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Advice about diet – diet lifestyle adherence to drug treatment
Indivdualised hba1c target- Preferences Co-morbidities Risks from polypharmacy and tight control Ability to achieve longer term risk reduction benefits Measure Hba1c 3-6 monthly as appropriate If Hba1c lower than target and no hypoglycaemia –> encourage to maintain it
Choose drugs based on- Effectiveness Safety Tolerability Individual clinical circumstances Preferences and needs Licensing and cost
Self- monitoring of blood glucose –Do not routinely offer self monitoring unless ○ on insulin ○ on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery ○ pregnant or planning to become pregnant ○ evidence of hypoglycaemic episodes
Adults who can take metformin .Hba1c rises to 48 mmol.mol ( 6.5 % ) on lifestyle interventions.Try modified-release metformin if standard metformin not tolerated
Hba1c rises to 58 ( 7.5 % ) → First intensification-Consider dual therapy ○ Metformin + DPP4inhibitor ○ Metformin + Pioglitazone ○ Metformin + Sulphonylurea ○ Metformin + SGLT- 2 inhibitor * SGLT-2i * – dapagliflazocin ,canagliflazocin and empagliflazocin are recommended as options in dual Rx with metformin under certain conditions , as options in triple Rx and in combination with insulin. They can also be used as monotherapy in adults who cannot take or tolerate metformin. Warn about risk of diabetic ketoacidosis in people who take SGLT2-i or shortly after stopping. MHRA guidance advices testing for raised ketones in people with symptoms of diabetic ketoacidosis even if plasma glucose levels are near normal.
Pioglitazone –NICE advices caution with Pioglitazone as it can be associated with increased risk of significant side effects as heart failure bladder cancer bone fracture. MHRA guidance 2011 advices that safety and efficacy should be reviewed after 3-6 months and only continue if beneficial
Second intensification if Hba1c rises to 58 ( 7.5 % )-Consider triple therapy with ○ Metformin + DPP-4i + SU ○ Metformin + pioglitazone + SU ○ Metformin + pioglitazone or an SU + SGLT-2i Insulin based treatment
NICE advices adding a GLP1 mimetic if triple therapy not effective or contraindicated. Metformin + SU + GLP 1 mimetic if BMI 35 or higher and any specific psychological or other medical problems associated with obesity or BMI lower than 35 and for whom insulin Rx would have significant occupational implications or Weight loss would benefit other sig obesity related comorbidities
People who cannot tolerate metformin-Hba1c rises to 48 mmol.mol ( 6.5 % ) on lifestyle interventions-Use one of the following ○ DPP4-i , pioglitazone or an SU ○ SGLT-2i instead of a DPP4-i if an SU or pioglitazone is not appropriate If on DPP4-i , SGLT-2i or pioglitazone → aim for Hba1c of 48 ( 6.5 % ) If on SU- aim for Hba1c of 53 ( 7 % )
Hba1c rises to 58 ( 7.5 % ) → First intensification-Offer dual therapy with ○ DPP-4i + pioglitazone ○ DPP-4i + SU ○ pioglitazone + SU
Second intensification if Hba1c rises to 58 ( 7.5 % ) insulin based treatment
Insulin based treatment –When starting insulin use a structured programme Continue metformin and review the need for other agents Offer NPH insulin once or twice a day Consider starting both NPH and a short acting insulin as ○ separately or ○ pre-mixed biphasic human insulin particularly if Hba1c is 75 ( 9.0 % ) or higher NICE advice for people ○ who needs assistance with inj ○ recurrent symptomatic hypoglycemia ○ would need twice daily NPH in combination with oral hypoglycaemics -Long acting insulins eg glargine ( Lantus ) or detemir ( Levemir )
For people who ○ prefer injecting immediately before a meal ○ hypoglycemia is a problem or ○ blood sugar level rises markedly after meal- short acting insulin analogue Insulin + GLP1 → only under specialist care advice Monitor people on insulin for the need to change the regimen SGLT2-i can be combined with insulin
LINKS AND RESOURCES
For patients
Diabetes Org UK has a huge section covering all aspects related to diabetes for patients-a must for who can access this online treasure https://www.diabetes.org.uk/professionals/information-support-for-your-patients/education-information
Diabetes co UK – growing resource https://www.diabetes.co.uk/
American Diabetes Association – living with diabetes for patients in the US https://www.diabeteseducator.org/living-with-diabetes
Diet sheet Type 2 diabetes from the Association of British Dietitians https://www.bda.uk.com/foodfacts/diabetestype2.pdf
A 26 page diet guide from safefood.eu on Type 2 diebetes https://www.safefood.eu/SafeFood/media/SafeFoodLibrary/Documents/Publications/Consumer/Diabetes-Type-2-Booklet-July-12.pdf
What can I eat from ADA https://www.diabetes.org/blog/what-can-i-eat
Diabetes risk calculators
ADA https://www.diabetes.org/risk-test
Diabetes UK https://riskscore.diabetes.org.uk/start
Diabetes Australia https://www.diabetesaustralia.com.au/risk-calculator
MedIndia https://www.medindia.net/patients/calculators/diabetes-risk-assessment-calculator.asp
QDiabetes https://qdiabetes.org/
Type 2 diabetes structured programmes
Desmond https://www.desmond-project.org.uk/
X-Pert https://www.xperthealth.org.uk/
Bertie ( type 1 ) https://www.bertieonline.org.uk/
Dafne ( type 1 ) http://www.dafne.uk.com/
Diabetes Hypo Program https://www.hypoprogram.com/
Driving and Type 1 diabetes DVLA https://www.gov.uk/diabetes-driving
Healthcare professional resources
All NICE guidelines on diabetes https://www.nice.org.uk/guidance/conditions-and-diseases/diabetes-and-other-endocrinal–nutritional-and-metabolic-conditions/diabetes/products?ProductType=Guidance&Status=Published
SIGN diabetes collection https://www.sign.ac.uk/sign-116-and-154-diabetes.html
ADA and the European Association for the study of Diabetes ( EASD ) type 2 diabetes guideline 2018 http://diabetologia-journal.org/wp-content/uploads/2018/09/EASD-ADA.pdf
International Diabetes federation Global Guideline for Type 2 diabetes https://www.idf.org/e-library/guidelines/79-global-guideline-for-type-2-diabetes
Australian Diabetes Society Algorithm Type 2 diabetes http://t2d.diabetessociety.com.au/plan/
References
- Management of type 2 diabetes in adults : summary of updated NICE guidance BMJ 2016 ; 353 : i1575
- Type 2 diabetes in adults : management NICE guideline NG 28 Published December 2015 Last updated May 2017