Diagnosis

• n/a

Investigation

• Involve patient in HbA1c target setting, encourage maintenance unless impact QoL
• Target maybe above 48 mmol/mol, but inform any reduction towards target beneficial long term
• Measure HbA1c at 2–6-mth intervals, and 6 mthly when stable
• If pre-prandial well controlled but HbA1c high, self-monitor to detect hyperglycaemia
• If erythrocyte t/o abnormal use fructosamine to estimate (Not in T1DM)
• Self-monitoring plasma glucose: if on insulin, oral anti-diabetic therapy and hypoglycaemia, to assess impact of lifestyle and medication change, ensure safety while driving

Management

Conservative: Lifestyle / Non-pharmacological

• Diet: encourage high fibre low glycaemic index foods e.g. fruit, veg, wholegrains, pulses, low fat dairy and oily fish
• Integrate dietary advice with a personalised diabetes management plan
• If overweight, target wt loss of 5–10% may still be of benefit, greater loss long term will have advantageous metabolic impact

Pharmacological Therapy: Oral Glucose Control

• Biguanide (Metformin):
  • If overweight & blood glucose not controlled by lifestyle & diet, consider if not overweight
  • Step up over weeks to minimise GI S/Es, consider extended absorption Metformin
  • Review if eGFR < 45, stop if < 30
  • If inadequate continue Metformin add another oral glucose lowering drug (Sulphonylurea)
• Insulin Secretogogue (Sulphonylurea):
  • First line if person not overweight or cannot tolerate Metformin
  • Second line if inadequate control, usually added to Metformin
  • If still inadequate continue Sulphonylurea add another oral glucose lowering drug
• Acarbose: if unable to tolerate other oral glucose lowering drug
  • DPP-4 inhibitors (sitagliptin, vildagliptin)
  • Instead of Sulfonylurea as second-line therapy to first-line metformin when control inadequate (HbA1c > 48) and significant risk / consequence of hypoglycaemic events
  • Second line to Sulphonylurea if Metformin not tolerated
  • Third line if HbA1c > 58
• Thiozolidinedione (Pioglitazone) NB avoid in heart failure
  • Instead of Sulfonylurea as second-line therapy to first-line metformin when control inadequate (HbA1c > 48) and significant risk / consequence of hypoglycaemic events
  • Second line to Sulphonylurea if Metformin not tolerated
  • Third line if HbA1c > 58
  • Combine with insulin if on high dose insulin w/o adequate control
• GLP-1 Mimetic (Exanatide)
  • Third Line to Metformin, Sulphonylurea and BMI > 35, or insulin contra-indicated
• Insulin Therapy: bolus or pre-mix
  • Discuss benefits / risks if HbA1c > 58 mmol/mol, start if agrees
  • If markedly hyperglycaemic on dual therapy consider insulin vs third line OGL
  • Start with Metformin and Sulphonylurea, review Sulphonylurea if hypoglycaemia occurs
  • Begin with NPH at bed time or twice daily
  • Consider pre-mix if post prandial high or long acting if require carer
  • If hypoglycaemia switch from medium acting NPH to long acting (Glargine, Determir)
• Cardiovascular Management
  • Lifestyle advice if > 140/80 (130/80 if vascular pathology), and medication is not controlled
  • See Cardiovascular risk, Hypertension control CG127, and lipid modification CG181
  • Anti-thrombotics: Aspirin 75 mg if BP < 145/90 (or Clopidogrel if not tolerated)
• Management of Complications see T1DM Summary

NICE Source: CG87 Type 2 diabetes: The management of type 2 diabetes. Summary compiled by Dr D P Sheppard MBBS.