management if patient tolerant of metformin in type 2 diabetes

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Confirm diagnosis of type 2 diabetes

  • refer to practice nurse for baseline assessments for diabetes - feet, urine, BMI; refer for retinal screening
  • refer for DESMOND or equivalent
  • metformin is generally the first line treatment in type 2 diabetes. Consider a sulphonylurea (or occasionally insulin) as first line if phenotype is unusual for type 2 diabetic (thin type 2 diabetic - this may represent a patient presenting with latent autoimmune diabetes of adulthood (LADA) (see notes))

The European Association for the Study of Diabetes (EASD)/American Diabetes Association (ADA) have developed guidance where there is a consideration of (1):

  • the glycaemic lowering properties of particular medication AND
  • the cardiovascular risk of the type 2 diabetic patient being treated

In this context the EASD/ADA guidance defines use of glucose lowering medication in either of two populations *:

  • those of high high cardiovascular risk (CVrisk) (type 2 diabetics with either established atherosclerotic cardiovascular disease (ASCVD) or chronic kidney disease) (CKD) OR
  • type 2 diabetics with no ASCVD or CKD

The EASD/ADA guidance takes forward the principles used in the 2015 NICE guidance - again with metformin the first line treatment of choice. However the EASD/ADA guidance gives relevance to the reduction in CV risk seen with certain agents in patients with type 2 diabetes.

The guidance for management of type 2 diabetics with ASCVD and/or CKD is as below:

 

In type 2 diabetics without CKD or ASCVD then the guidance is as below:

* there are also flow charts relating to use of glucose lowering medication where weight reduction is a principle aim, and guidance where cost is a particular consideration.

Notes:

  • in the EASD/ADA guidance there is no specific intensification targets stated. However if these algorithms were to be applied with particular intensification targets pre-specified, it would seem reasonable (2) - if applied in England and Wales, to use the intensification advice as per NICE (3):
    • in adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
      • reinforce advice about diet, lifestyle and adherence to drug treatment and
      • support the person to aim for an HbA1c level of 53mmol/mol (7.0%)
      • and intensify drug treatment

    • consider relaxing the target HbA1c level on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes:
      • who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
      • for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job
      • for whom intensive management would not be appropriate, for example, people with significant comorbidities

    • in the context of the EASD/ADA algorithms then this would be mean - in general - the intensification target at each level would be an HbA1c level of 58 mmol/mol (ie if HbA1c above 58 mmol/mol then consider intensification as per flow charts) - however this target would be relaxed on a case-by-case basis as described above

  • LADA
    • patients with LADA are relatively 'insulin deficient' rather than 'insulin resistant'. These patients do not have the classic type 2 diabetic phenotype. These patients are likely to require insulin earlier in their management compared to 'insulin resistant' diabetics. Caution is required in management of these patients because insulin therapy may be indicated from diagnosis of diabetes in these patients if presenting with persistently high blood glucose values

Reference:

Last edited 02/2022