Type 2 diabetes mellitus is a significant cause of morbidity and mortality, both in the U.K. and worldwide. This prevalence of this devastating illness is increasing, partially due to rising rates of obesity, but also as a consequence of an ageing population.
The management of type 2 diabetes focused on the alleviation of symptoms and the minimisation of the risks of developing long-term side effects. Diabetes is a major risk factor for the development of cardiovascular disease, and a patient-centred approach, aiming for optimal blood glucose control, and modification of other cardiovascular risk factors is essential.
All patients should be offered structured education at the time of the initial diagnosis and then on an ongoing basis as needed after that. A number of excellent self-management courses are available, including the X-PERT Diabetes Programme, and the DESMOND Programme.
NICE recommend that the personalised diabetes management plan should include dietary advice as well as other aspects of lifestyle modification, such as increasing physical activity and losing weight.
Blood pressure management
The current NICE guidance on blood pressure management in patients with type 2 diabetes is as follows:
- Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage).
- Monitor blood pressure every 1-2 months, and intensify therapy if the person is already on antihypertensive drug treatment, until the blood pressure is consistently below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage).
The choice of drug for patients with type 2 diabetes is as follows:
- In non-black patients, an ACEi or an ARB should be the first-line drug. Thiazide-like diuretics should be used second-line and CCBs as the third-line choice.
- In black patients of African or Caribbean family origin monotherapy is not recommended. A combination of an ACEi or ARB plus a thiazide-like diuretic or a CCB should be used.
- If BP is not adequately controlled using triple therapy, consider the addition of an alpha- or beta-blocker, or spironolactone.
- In diabetic women of child-bearing age CCBs are the first-line drug of choice. Nifedipine is the recommended drug in pregnancy.
Blood glucose management
An HbA1c target of 7.0% (53 mmol/mol) among people with type 2 diabetes is reasonable to reduce the risk of microvascular and macrovascular disease. A target of 6.5% (48 mmol/mol) may be appropriate at diagnosis. Targets should be set with individuals in order to balance benefits with harms, in particular hypoglycaemia and weight gain.
The current NICE guidance recommends that in adults with type 2 diabetes if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher, the following action should be taken:
- Reinforce advice about diet, lifestyle and adherence to drug treatment, and;
- Support the person to aim for an HbA1c level of 53 mmol/mol (7.0%), and;
- Intensify drug treatment.
Do not routinely offer self‑monitoring of blood glucose levels for adults with type 2 diabetes, unless:
- The person is on insulin, or;
- There is evidence of hypoglycaemic episodes, or;
- The person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery; or
- The person is pregnant or is planning to become pregnant.
FreeStyle Libre is a recently introduced novel technology that has been strongly supported by Diabetes UK. It is a flash glucose monitoring system that measures interstitial fluid glucose levels via a sensor that is applied to the skin. It can be used as an alternative to routine finger-prick blood glucose testing and can produce near-continuous readings, which can be accessed on demand. A smartphone app is also available to scan the sensor.
FreeStyle Libre is designed to be used by people with either type 1 or type 2 diabetes who require multiple daily injections or use an insulin pump. The main advantages of FreeStyle Libre are:
- Reduced requirement for finger prick readings
- Easily viewed continuous readings for patients
- Allows tracking of blood glucose trends
Some finger-prick testing will still be necessary, particularly before driving and in the event of hypoglycaemic episodes or with intercurrent illness.
As of November 2017, Freestyle Libre is available on the NHS in some areas (depending on local approval). To get it on prescription the patient must meet certain criteria, such as having to test blood glucose levels more than 8 times a day and/or the patient experiencing disabling hypos.
If the HbA1c is > 48 mmol/mol with lifestyle modification alone, then drug treatment is recommended. The current NICE and SIGN guidelines both advise that standard-release metformin is used as the initial drug treatment for adults with type 2 diabetes.
If metformin is contraindicated or not tolerated, initial drug treatment with one of the following should be considered:
- A dipeptidyl peptidase‑4 (DPP‑4) inhibitor, or;
- A thiazolidinedione (pioglitazone), or;
- A sulfonylurea.
In patients that are symptomatically hyperglycaemic, a sulphonylurea or insulin should be considered.
The NICE recommendations for intensification of drug therapy are as follows:
1st intensification of drug treatment if HbA1c > 58 mmol/mol. Consider dual therapy, aiming for an HbA1c target of 53 mmol/mol, with one of:
- Metformin plus pioglitazone
- Metformin plus sulfonylurea
- Metformin plus dipeptidyl peptidase-4 (DPP4) inhibitor
- Metformin plus sodium-glucose co-transporter 2 (SGLT2) inhibitor
2nd intensification of drug treatment if HbA1c > 58 mmol/mol. Consider triple therapy, aiming for an HbA1c target of 53 mmol/mol, with one of:
- Metformin plus pioglitazone plus sulfonylurea
- Metformin plus sulfonylurea plus DPP4 inhibitor
- Metformin plus pioglitazone, or sulfonylurea, plus SGLT2 inhibitor
- Insulin-based treatment
If triple therapy is ineffective, not tolerated, or contraindicated consider a glucagon-like peptide-1 (GLP1) analogue as follows:
- Metformin plus sulfonylurea plus GLP1 analogue, if BMI >35, or if BMI <35 and insulin has significant implications and weight loss would benefit obesity-related conditions
- Only continue with GLP1 analogue if HbA1c is lowered by 11 mmol/mol and there is >3% weight loss in 6 months
The November 2017 SIGN guideline on the pharmacological management of glycaemic control in Type 2 diabetes provides an excellent treatment algorithm, which further helps decision making on which drug should be used at each stage. This is shown below:
Thank you to the joint editorial team of MRCGP Exam Prep for this article.
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