Clickmanagement of type II diabetes (NIDDM)
  
         
 
 
  

The principles of management of a type 2 diabetic are outlined (1,2):


diabetic diet
monitoring of diabetic control 
for each individual, a target (DCCT aligned) should be set between 6.5% and 7.5%, based on the risk of macrovascular and microvascular complications. In general, the lower target HbA1c is preferred for people at significant risk of macrovascular complications, but higher targets are necessary for those at risk of iatrogenic hypoglycaemia (1)
if the diabetes fails to come under control oral hypoglycaemics may be used with the choice of agent dependent upon the patient
metformin 
in people who are overweight (body mass index > 25.0 kg/m^2) and whose blood glucose is adequatel controlled using lifestyle interventions alone, metformin should normally be used as the first-line glucose-lowering therapy
metformin should be considered as an option for first-line or combination therapy for people who are not overweight
dose of metformin should be reviewed if the serum creatinine exceeds 130 micromol/litre or the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73-m2 
stop the metformin if the serum creatinine exceeds 150 micromol/litre or the eGFR is below 30 ml/minute/1.73-m2
insuliin secretagogues 
insulin secretagogues include the sulphonylureas and the rapid-acting insulin secretagogues (nateglinide and repaglinide) 
a sulfonylurea should be considered as an option for first-line glucose-lowering therapy if: 
person is not overweight 
person does not tolerate metformin (or it is contraindicated) or 
a rapid response to therapy is required because of hyperglycaemic symptoms 
a sulfonylurea should be added as second-line therapy when blood glucose control remains or becomes inadequate with metformin 
continue with a sulfonylurea if blood glucose control remains or becomes inadequate and another oral glucose-lowering medication is added
a sulfonylurea with a low acquisition cost (but not glibenclamide) should be prescribed when an insulin secretagogue is indicated 
when drug concordance is a problem, offer a once-daily, long-acting sulfonylurea 
a person being treated with an insulin secretagogue, particularly if renally impaired, should be educated about the risk of hypoglycaemia
consider offering a rapid-acting insulin secretagogue to a person with an erratic lifestyle
clnicians and those using an insulin secretagogue should be aware of the risk of hypoglycaemia and be alert to it
PPAR-gamma agonists (including the thiazolidininediones) 
see linked item
alpha-glusidase inhibitors 
acarbose may be considered as an alternative glucose-lowering therapy in people unable to use other oral drugs
insulins 
the disease may progress so that in time insulin is required. Also non-insulin dependant patients may become insulin dependant during, for example, periods of infective illness. This temporary requirement for insulin is thought to be related to an increase in diabetogenic hormones.
insulin should be offered to people with diabetes with inadequate blood glucose control on optimised glucose-lowering drugs
see linked item for more details
anti-obesity drugs 
orlistat, when used in concordance with NICE guidance, may be considered as part of a weight-loss strategy for people with type 2 diabetes
blood pressure control
below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular disease) (2)
statin therapy is particularly effective in type II diabetics (3) - see details in linked item below 
antiplatelet treatment (4)
NICE recommend that aspirin 75mg should be given to people with type 2 diabetes if they have:
manifest CVD (i.e. secondary prevention),
or no overt CVD but a 10-year coronary event risk >15% (i.e. primary prevention), providing systolic BP is reduced and maintained to 145mmHg or below (and diastolic pressure < 90 mmHg)
note however, trials of antiplatelet treatment specifically in people with diabetes are limited, and results are disappointing. Also clopidogrel should not be used routinely in patients with type 2 diabetes who require antiplatelet treatment. It is significantly more expensive than aspirin, and there is no evidence to suggest that it has any advantages over aspirin in a diabetic population
Reference:

(1) NICE (September 2002). Management of type 2 diabetes. Management of blood glucose. 
(2) NICE (May 2008).Type 2 diabetes The management of type 2 diabetes
(3) Heart Protection Study Collaborative Group (2003). MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet; 361: 2005-16.
(4) MeReC Bulletin (2004); 15 (1):1-4.