1. Clickmanagement of type II diabetes (NIDDM)

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

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  11. diabetic diet

  12. monitoring of diabetic control 

  13. 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)

  14. if the diabetes fails to come under control oral hypoglycaemics may be used with the choice of agent dependent upon the patient

  15. metformin 

  16. 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

  17. metformin should be considered as an option for first-line or combination therapy for people who are not overweight

  18. 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 

  19. stop the metformin if the serum creatinine exceeds 150 micromol/litre or the eGFR is below 30 ml/minute/1.73-m2

  20. insuliin secretagogues 

  21. insulin secretagogues include the sulphonylureas and the rapid-acting insulin secretagogues (nateglinide and repaglinide) 

  22. a sulfonylurea should be considered as an option for first-line glucose-lowering therapy if: 

  23. person is not overweight 

  24. person does not tolerate metformin (or it is contraindicated) or 

  25. a rapid response to therapy is required because of hyperglycaemic symptoms 

  26. a sulfonylurea should be added as second-line therapy when blood glucose control remains or becomes inadequate with metformin 

  27. continue with a sulfonylurea if blood glucose control remains or becomes inadequate and another oral glucose-lowering medication is added

  28. a sulfonylurea with a low acquisition cost (but not glibenclamide) should be prescribed when an insulin secretagogue is indicated 

  29. when drug concordance is a problem, offer a once-daily, long-acting sulfonylurea 

  30. a person being treated with an insulin secretagogue, particularly if renally impaired, should be educated about the risk of hypoglycaemia

  31. consider offering a rapid-acting insulin secretagogue to a person with an erratic lifestyle

  32. clnicians and those using an insulin secretagogue should be aware of the risk of hypoglycaemia and be alert to it

  33. PPAR-gamma agonists (including the thiazolidininediones) 

  34. see linked item

  35. alpha-glusidase inhibitors 

  36. acarbose may be considered as an alternative glucose-lowering therapy in people unable to use other oral drugs

  37. insulins 

  38. 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.

  39. insulin should be offered to people with diabetes with inadequate blood glucose control on optimised glucose-lowering drugs

  40. see linked item for more details

  41. anti-obesity drugs 

  42. orlistat, when used in concordance with NICE guidance, may be considered as part of a weight-loss strategy for people with type 2 diabetes

  43. blood pressure control

  44. below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular disease) (2)

  45. statin therapy is particularly effective in type II diabetics (3) - see details in linked item below 

  46. antiplatelet treatment (4)

  47. NICE recommend that aspirin 75mg should be given to people with type 2 diabetes if they have:

  48. manifest CVD (i.e. secondary prevention),

  49. 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)

  50. 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

  51. Reference:

  52. 

  53. (1) NICE (September 2002). Management of type 2 diabetes. Management of blood glucose. 

  54. (2) NICE (May 2008).Type 2 diabetes The management of type 2 diabetes

  55. (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.

  56. (4) MeReC Bulletin (2004); 15 (1):1-4.