Glucose Control In Type 2 Diabetes

1 Management of Type 2 Diabetes First produced: June 2009 Updated: July 2018 Review date: June 2020 Page 1 of 36 Management of Type 2 Diabetes in adults Key messages: Education and lifestyle advice are fundamental to patient management, as is overall consideration to the patient s risk of macrovascular complications and microvascular complications ( glycaemic Control , blood pressure management, smoking status, and cholesterol)). A structured education programme for adults with type 2 Diabetes is an integral part of Diabetes care and should be offered to patients and family members/carers.

2 (For further details of local programmes see appendix 9). An individualised approach to Diabetes care should be tailored to the needs and circumstances of the adult with type 2 Diabetes in association with patient (considerations include life expectancy, risks from polypharmacy, comorbidities etc). An adult with type 2 Diabetes should be involved in the discussion about target setting. NICE recommends that if 2 drugs in the same class are appropriate, to choose the option with the lowest acquisition cost.

3 Metformin is the most cost effective of the initial therapy treatments, and is suitable for most adults with type 2 Diabetes . Metformin is contraindicated or not tolerated in approximately 15% of individuals but there is little evidence, for some adults, to guide management strategies on treatment combinations that do not include metformin (NICE NG28). Evidence for combination treatments beyond second intensification is limited (when 2 or more non-insulin based treatment combinations fail to adequately Control blood Glucose levels).

4 There is limited emerging evidence in relation to the long-term effects of blood Glucose lowering therapies, particularly newer agents in terms of efficacy and adverse events (for example, cardiovascular outcomes). Evidence from a meta-analysis looking at the association between the newer blood Glucose lowering therapies (SGLT2 inhibitors, GLP1 agonists and DPP4i (gliptins)) with all-cause mortality, suggests SGLT-2 inhibitors or GLP-1 agonists were associated with better all-cause mortality outcomes than DPP-4 inhibitors.

5 When moving patients to the newer agents, prescribers should consider this evidence, but individual treatment circumstances should be taken into account. A HBA1c reduction of 5mmol/mol ( ) is considered clinically important. At each review re-assess the person s needs and circumstances and think about stopping any medicines that are not effective at 6 months. NICE recommend for continued therapy with DPP4i (gliptins) /pioglitazone / SGLT2i must show HbA1c reduction mmol/mol ( ) in 6 months Routine self- monitoring of blood Glucose is not recommended except for particular circumstances.

6 Insulin use, 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. Do not offer antiplatelet therapy for adults with type 2 Diabetes mellitus without cardiovascular disease. Driving advice: this should be an individualised decision by the clinician, using the DVLA guidance ( ) and advice from Patient decision aids can help patients think about their options for controlling their blood Glucose to try to reduce the long-term risks of Diabetes .

7 NICE patient decision aids can be found here. DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) Management of Type 2 Diabetes First produced: June 2009 Updated: July 2018 Review date: June 2020 Page 2 of 36 Document updates Date updated Key ACEI angiotensin converting enzyme inhibitor ARB angiotensin receptor blockers BMI body mass index CCB calcium channel blocker DPP4i Dipeptidyl peptidase-4 inhibitor ( gliptin ) DVLA Driver and Vehicle Licensing Agency eGFR Estimated glomerular filtration rate GI gastro-intestinal GLP1 Glucagon-like peptide-1 mimetic HbA1c Glycated haemoglobin HF heart failure Met metformin NG National guidance PDE5i phosphodiesterase type 5 inhibitor Pio pioglitazone SGLT2i sodium- Glucose contransporter 2 inhibtor Reference NICE NG28 Type 2 Diabetes in adults.

8 Management (2015) SIGN 154 Pharmacological management of glycaemic Control in people with type 2 Diabetes (2017) Zheng SL, Roddick AJ, Aghar-Jaffar R, et al. Association between use of sodium- Glucose co-tranporter-2 inhibitors, glucagon-like peptide-1 agonists, and dipeptidyl peptidase 4 inhibitors with all-cause mortality in patients with type 2 Diabetes . JAMA. 2018;319(15):1580-1591. Consultee Dr Frances Game Consultant Diabetes & Endocrinology RDH Dr Robinson Consultant Endorcrinologist CRH Derbyshire Medicines Management Guideline Group NICE define Interventions that should be used - strong recommendation Offer as an intervention which will do more good than harm and be cost effective, for the vast majority of patients.

9 Interventions that could be used: Consider as an intervention which will do more good than harm for most patients and be cost effective, but other options may be similarly cost effective Management of Type 2 Diabetes First produced: June 2009 Updated: July 2018 Review date: June 2020 Page 3 of 36 Contents Page number Antihypertensive drug treatment - type 2 Diabetes 4 Treatment algorithm for type 2 Diabetes in adults 5 Treatment algorithm for type 2 Diabetes if metformin is contra-indicated or not tolerated 6 Scope of guidance 7 Management of Diabetes requires a multifactorial approach in its management 7 Young adults 8 Factors to consider when setting a HbA1c target between the clinician and patient 8 Targets 8 Management strategies Individualised care

10 Patient education Dietary advice Physical activity Bariatric surgery blood pressure management Lipid management Anti-platelet therapy 9 9 9 9 9 9 10 10 HbA1c measurement 10 Self- monitoring of blood Glucose 10 blood Glucose testing for people with Diabetes who drive 10 Preconception advice 10 Oral hypoglycaemic agents Metformin Metformin MR Gliclazide Pioglitazone DPP-4 inhibitors (gliptins) (alogliptin, linagliptin, sitagliptin, saxagliptin & vildagliptin) SGLT2 inhibitors (canagliflozin, dapagliflozin & empagliflozin) GLP1 agonists (lixisenatide, liraglutide & exenatide) Weekly GLP1 agonists (albiglutide, dulaglutide & exenatide) 11 11 11 12 13 13 14 16 17 Drug therapy & renal and hepatic impairment 18 Insulin therapy in type 2 Diabetes Table 1: various insulin s available and their properties Table 2: traffic light classification for high strength insulin s Table 3.