pragmatic algorithm for the management of glycaemic (glucose) control 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))

NICE suggest targets for management of type 2 diabetes as (1)

Targets

  • for adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%)

  • for adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53mmol/mol (7.0%)

  • 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

  • if adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example, deteriorating renal function or sudden weight loss

HbA1c lower than target:

  • If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example, deteriorating renal function or sudden weight loss

Metformin is the usual first line therapy in type 2 diabetes management. Therapy is considered in terms of whether a patient is tolerant or intolerant to metformin.

Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless:

  • the person is on insulin or
  • there is evidence of hypoglycaemic episodes or
  • the person is on 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. For more information, see the NICE guideline on diabetes in pregnancy

Notes:

  • 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 reviewed 09/2021

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