Type 2 diabetes: the management of type 2 diabetes continued

Patient education

• Structured education is an integral part of diabetes care, and patients and carers should be informed of this. Offer it, preferably through a group education programme, to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review. Offer an alternative of equal standard to people unable or unwilling to participate in group education sessions

Patient education programmes

• Programmes should:
  • meet the quality criteria laid down by the Department of Health and Diabetes UK Patient Education Working Group (see ‘Structured patient education in diabetes: report from the Patient Education Working Group’. Available from )
  • meet the local cultural, linguistic, cognitive and literacy needs
  • provide appropriate resources to support the educators, who should be properly trained and allowed time to develop and maintain their skills
• Ensure:
  • all members of the diabetes healthcare team are familiar with local programmes
  • programmes are integrated with the care pathway
  • people with type 2 diabetes and their carers have the opportunity to contribute to the design and provision of local programmes

Dietary advice

• Provide in a form that is sensitive to the person’s needs, culture and beliefs, being sensitive to their willingness to change, and effects on their quality of life
• Integrate with diabetes management plan, including other aspects of lifestyle modification, such as increasing physical activity
• Include in discussion:
  • general advice for healthy eating:
    • include high-fibre, low-glycaemic index sources of carbohydrate
    • include low-fat dairy products and oily fish
    • control the intake of foods containing saturated fats and trans fatty acids
  • limited substitution of sucrose containing foods for other carbohydrate is allowable, but care should be taken to avoid excess energy intake
  • discourage use of foods marketed specifically for people with diabetes

• Action
• • provide individualised and ongoing nutritional advice from a healthcare professional with specific expertise and competencies in nutrition
  • Individualise recommendations for carbohydrate and alcohol intake, and meal patterns – aim to reduce risk of hypoglycaemia, particularly if using insulin or insulin secretagogues
  • iInitial body weight loss target = 5–10% in an overweight person:
    • lesser amounts are still beneficial
    • losing more weight in the longer term has metabolic benefits

• Special circumstances:
• • a meal-planning system providing consistency in the carbohydrate content of meals should be implemented for inpatients with type 2 diabetes

Type 2 diabetes: the management of type 2 diabetes continued

Assessment of blood glucose control

HbA_1c

• Include in discussion:
  • individual HbA1c target level, which may be above the general target of 6.5%
  • encouragement to maintain target unless resulting side effects or efforts to achieve this impair quality of life
  • how any reduction in HbA1c towards agreed target benefits future health
• Action:
  • offer therapy (lifestyle and medication) to help achieve and maintain HbA1c target
  • measure using high-precision methods and report results in DCCT-aligned units
  • if HbA1c remains above target, but pre-meal self-monitoring levels remain well controlled (<7.0 mmol/litre), consider self-monitoring to detect postprandial hyperglycaemia (>8.5 mmol/litre), and manage to below this level if detected
• Monitoring:
  • 2–6 monthly (according to individual needs) until stable on unchanging therapy*
  • 6-monthly once blood glucose level and blood glucose-lowering therapy are stable
• Further investigation:
  • seek advice from a team with specialist expertise in diabetes or clinical biochemistry if there are unexplained discrepancies between HbA1c and other glucose measurements
• Special circumstances:
  • if HbA1c result is invalid,^† estimate trends in blood glucose control using one of the following:
    • fructosamine estimation
    • quality-controlled plasma glucose profiles
    • total glycated haemoglobin estimation (if abnormal haemoglobins)

Self-monitoring

• Self-monitoring of plasma glucose should be available:
  • to those on insulin treatment
  • to those on oral glucose-lowering medications to provide information on hypoglycaemia
  • to assess changes in glucose control resulting from medications and lifestyle change
  • to monitor changes during intercurrent illness
  • to ensure safety during activities, including driving
• Include in discussion:
  • the purpose of self-monitoring
  • how to interpret and act on the results
• Action
• • offer to a person newly diagnosed only as an integral part of self-management education
• Monitoring
• • assess at least annually, and in a structured way:
    • self-monitoring skills
    • the quality and frequency of testing
    • how the results are used
    • the impact on quality of life
    • the continued benefit
    • the equipment used
• Special circumstances
• • discuss urine glucose monitoring if plasma monitoring is found to be unacceptable

Type 2 diabetes: the management of type 2 diabetes continued

Blood glucose-lowering therapy

• Metformin
  • step up metformin over several weeks to minimise risk of gastrointestinal (GI) side effects
  • consider trial of extended-absorption metformin if GI tolerability prevents the person continuing with metformin
  • review metformin dose if serum creatinine >130 μmol/litre or estimated glomerular filtration rate (eGFR) <45 ml/minute/1.73-m²
  • stop metformin if serum creatinine>150 μmol/litre or the eGFR <30 ml/minute/1.73-m²
  • prescribe metformin with caution for those at risk of a sudden deterioration in kidney function, and those at risk of eGFR falling to <45 ml/minute/1.73-m²
  • if the person has mild to moderate liver dysfunction or cardiac impairment, discuss benefits of metformin so due consideration can be given to its cardiovascular-protective effects before any decision is made to reduce the dose
• Sulfonylureas
  • prescribe a sulfonylurea with a low acquisition cost (not glibenclamide) when an insulin secretagogue is indicated
  • educate the person about the risk of hypoglycaemia, particularly if he or she has renal impairment
• DPP-4 inhibitors (sitagliptin, vildagliptin):
  • continue DPP-4 inhibitor therapy only if there is a reduction of ≥0.5 percentage points in HbA_1c in 6 months
  • discuss the benefits and risks of a DPP-4 inhibitor with the person, bearing in mind that a DPP-4 inhibitor might be preferable to a thiazolidinedione if:
    • further weight gain would cause significant problems, or
    • athiazolidinedione is contraindicated, or
    • the person had a poor response to or did not tolerate a thiazolidinedione in the past
• Thiazolidinediones (pioglitazone)
  • continue thiazolidinedione therapy only if there is a reduction of ≥0.5 percentage points in HbA_1c in 6 months
  • discuss the benefits and risks of a thiazolidinedione with the person, bearing in mind that a thiazolidinedione might be preferable to a DPP-4 inhibitor if:
    • the person has marked insulin insensitivity, or
    • a DPP-4 inhibitor is contraindicated, or
    • the person had a poor response to or did not tolerate a DPP-4 inhibitor in the past
  • do not start or continue a thiazolidinedione if the person has heart failure or is at higher risk of fracture
  • when selecting a thiazolidinedione, take into account the most up-to-date advice from regulatory authorities, cost, safety and prescribing issues
• Exenatide
  • continue exenatide only if the person has a reduction in HbA_1c of ≥1.0 percentage point and ≥3% of initial body weight in 6 months
  • discuss the benefits of exenatide to allow the person to make an informed decision
• Acarbose
  • consider acarbose for a person unable to use other oral glucose-lowering medications
• Starting insulin therapy
  • if other measures do not keep HbA_1c to <7.5% (or other agreed target), discuss benefits and risks of insulin treatment
  • initiate with a structured programme (see Key priorities for implementation)
  • begin with human NPH insulin taken at bedtime or twice daily according to need
  • alternatively, consider a once-daily long-acting insulin analogue (insulin detemir, insulin glargine) if:
    • the person needs help with injecting insulin and a long-acting insulin analogue would reduce injections from twice to once daily, or
    • the person’s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes, or
    • the person would otherwise need twice-daily basal insulin injections plus oral glucose-lowering drugs, or the person cannot use the device to inject NPH insulin
  • consider twice-daily biphasic human insulin (pre-mixed) (particularly if HbA_1c ≥9.0%). A once-daily regimen may be an option
  • consider pre-mixed preparations of insulin analogues (including short-acting insulin analogues) rather than pre-mixed human insulin preparations if:
    • immediate injection before a meal is preferred, or
    • hypoglycaemia is a problem, or
    • blood glucose levels rise markedly after meals
  • consider switching to a long-acting insulin analogue (insulin detemir, insulin glargine) from NPH insulin if the person:
    • does not reach target HbA_1c because of
    • hypoglycaemia, or
    • has significant hypoglycaemia with NPH
    • insulin irrespective of HbA_1c level, or
    • cannot use the delivery device for NPH insulin but could administer a long-acting insulin analogue, or
    • needs help to inject insulin and could reduce the number of injections with a long-acting analogue
  • review use of sulfonylurea if hypoglycaemia occurs with insulin plus sulfonylurea
• Intensifying the insulin regimen
  • monitor those using basal insulin regimens (NPH or a long-acting analogue [glargine]) for need for mealtime or pre-mixed insulin
  • monitor those using pre-mixed insulin once or twice daily for need for further preprandial injection or eventual change to mealtime plus basal regimen
• Insulin delivery devices
  • offer education to a person who requires insulin about using an injection device (usually a pen injector and cartridge or a disposable pen) that they and/or their carer find easy to use
  • if a person has a manual or visual disability and requires insulin, offer an appropriate device or adaptation that can be used successfully
  • appropriate local arrangements should be in place for the disposal of sharps

Type 2 diabetes: the management of type 2 diabetes continued

Blood glucose lowering therapy

Type 2 diabetes: the management of type 2 diabetes continued

Blood pressure management

Targets

• See algorithm below
• If kidney, eye or cerebrovascular damage, set a target <130/80 mmHg
• Others, set a target <140/80 mmHg
• If on antihypertensive therapy at diagnosis of diabetes
  • review BP control and medication use
  • make changes only if BP is poorly controlled or current medications are inappropriate because of microvascular complications or metabolic problems
• If the person’s BP reaches and consistently remains at the target
  • monitor every 4–6 months and check for possible adverse effects of antihypertensive therapy (including those from unnecessarily low blood pressure)

Blood pressure management

Type 2 diabetes: the management of type 2 diabetes continued

Management of blood lipids

• See algorithm below
• Review CV risk status annually:
  • assess risk factors, including features of metabolic syndrome and waist circumference
  • note changes in personal or family CV history
  • perform full lipid profile (including HDL-C and TG) – also perform after diagnosis and repeat before starting lipid-modifying therapy
• If history of elevated serum TG, perform full fasting lipid profile (including HDL-C and TG)
• Consider to be at high CV risk unless all of the following apply:
  • not overweight (tailor with body-weight-associated risk assessment according to ethnic group)
  • normotensive (<140/80 mmHg in absence of antihypertensive therapy)
  • no microalbuminuria
  • non-smoker
  • no high-risk lipid profile
  • no history of CV disease
  • no family history of CV disease
• Estimate CV risk from UKPDS risk engine annually if assessed as not at high CV risk (see www.dtu.ox.ac.uk)

Type 2 diabetes: the management of type 2 diabetes continued

Kidney damage

• Monitoring:
  • annually, regardless of presence of nephropathy:
    • arrange albumin:creatinine ratio (ACR) estimation on first-pass urine sample (or spot sample if necessary)
    • measure serum creatinine
    • estimate GFR
• Further investigation
  • if abnormal ACR^‡ (in absence of proteinuria/urinary tract infection):
    • repeat test at next two clinic visits and within 3–4 months
    • microalbuminuria is confirmed if at least one out of two or more results is also abnormal^‡
• Interpretation:
  • suspect renal disease other than diabetic nephropathy and consider further investigation/ referral if ACR is raised and:
    • no significant or progressive retinopathy, or
    • blood pressure (BP) is particularly high or resistant to treatment, or
    • heavy proteinuria (ACR>100 mg/mmol) but ACR previously documented as normal, or
    • significant haematuria, or
    • GFR has worsened rapidly, or
    • the person is systemically ill
• Action:
• • if diabetic nephropathy confirmed, offer ACE inhibitor with dose titration to maximum dose (unless not tolerated)
  • substitute an angiotensin II receptor (A2RB) if ACE inhibitors are poorly tolerated
  • maintain BP <130/80 mmHg if abnormal ACR (see Blood pressure management)
• Include in discussion:
• • significance of abnormal albumin excretion rate (AER) and trend
  • if becoming pregnant is a possibility: relative risks and benefits of ACE inhibitor so an informed decision can be made

Eye screening

• Monitoring:
  • arrange or perform eye screening at or around the time of diagnosis
  • use a quality-assured digital retinal photography programme with appropriately trained staff
  • repeat structured eye surveillance annually, unless findings require other action
  • perform visual acuity testing as a routine part of eye surveillance programmes
• Include in discussion:
  • reasons for and success of eye surveillance systems
  • before appointment for eye surveillance: advantages and disadvantages of mydriasis with tropicamide for retinal photography, and precautions for driving
• Further investigation:
  • emergency review by ophthalmologist for:
    • sudden loss of vision
    • rubeosis iridis
    • pre-retinal or vitreous haemorrhage
    • retinal detachment
• Rapid review by ophthalmologist for new vessel formation
• Refer to ophthalmologist if:
  • there are features of maculopathy, including:
    • exudate or retinal thickening within one disc diameter of the centre of the fovea
    • circinate or group of exudates within the macula^§
    • any microaneurysm or haemorrhage within one disc diameter of the centre of the fovea, if associated with a best visual acuity of 6/12 or worse
  • there are features of pre-proliferative retinopathy^|, including:
    • any venous beading
    • any venous loop or reduplication
    • any intraretinal microvascular abnormalities
    • multiple deep, round or blot haemorrhages
  • any unexplained drop in visual acuity

Type 2 diabetes: the management of type 2 diabetes continued

Neuropathic pain management

• For the managment of diabetic neuropathic pain see 'Neuropathic pain: the pharmacological management of neuropathic pain in adults in non-specialist settings' (NICE clinical guideline 96)

Other neuropathic complications

Gastroparesis

• Consider gastroparesis in adult with:
  • erratic blood glucose control, or
  • unexplained gastric bloating or vomiting
• Action:
  • consider trial of metoclopramide, domperidone or erythromycin for an adult with gastroparesis
• Further investigation:
  • consider referral to specialist services if:
    • differential diagnosis is in doubt, or
    • persistent or severe vomiting occurs

Erectile dysfunction:

• Review with men annually
  • provide assessment and education for a man with erectile dysfunction to address contributory factors and treatment options
• Action:
  • if no contraindications, offer a phosphodiesterase-5 inhibitor
• Further investigation:
  • if phosphodiesterase-5 inhibitor is ineffective, discuss next step and refer as appropriate for:
    • medical treatment
    • surgery
    • psychological support
• Foot problems
  • see ‘Type 2 diabetes: prevention and management of foot problems’ (NICE clinical guideline 10)

Other signs of possible autonomic neuropathy

• Loss of warning signs for hypoglycaemia
  • consider contributory sympathetic nervous system damage
  • investigate further and offer specific interventions
• Unexplained diarrhoea, particularly at night:
  • consider autonomic neuropathy affecting gut
  • investigate further and offer specific interventions
• Unexplained bladder-emptying problems:
  • consider autonomic neuropathy affecting bladder
  • investigate further and offer specific interventions

Depression

• Refer to the recommendations in ‘Depression: management of depression in primary and secondary care’ (NICE clinical guideline 23)

^* Use measurements taken at intervals of <3 months to indicate direction of change, rather than a new steady state
^† Disturbed erythrocyte turnover and abnormal haemoglobin type make HbA_1c results invalid
^‡ Abnormal ACR = ACR >2.5 mg/mmol for men and >3.5 mg/mmol for women
^§ The macula is defined here as a circle centred on the fovea, with a diameter the distance between the temporal border of the optic disc and the fovea
^| If cotton wool spots are present, look carefully for the features; cotton wool spots themselves do not define pre-proliferative retinopathy

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
guidance.nice.org.uk/CG87

National Institute for Health and Care Excellence. Type 2 diabetes: the management of type 2 diabetes. Quick Reference Guide. May 2009

First included: Jun 08 (updated: Jul 09).