Type 2 diabetes – all change

The latest National Institute for Health and Care Excellence (NICE) guidelines, out today, are for the management of type 2 diabetes – and they’ve been a long time coming. Its well over six years since the last version was published, and a great deal has changed since then. Apart from anything else, far more people have a vested interest than they did six years ago. The number of people affected by type 2 diabetes continues to skyrocket – over 3.2 million adults in the UK have a diagnosis of diabetes (about 6% of the population in England and 6.7% in Wales), and about 90% of them have type 2. In the USA, the figures are even higher – about 29.1 million (9.3% of the population) have diabetes, and over 90% of these have type 2.

Three years ago, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) produced new guidelines for type 2 diabetes, with a major shift in focus towards personalised care and targets. Gone was the ‘one size fits all’ target – the new guidelines were all about taking the whole person into account, especially where blood glucose control was concerned. Now the new NICE guidelines have followed suit. In fact, whether you live in the UK or the USA, pretty much every recommendation is the same now.

Keeping your blood glucose well controlled if you have diabetes is hugely important to reduce the risk of complications – heart attack and stroke levels are improving, but they are still by far the biggest killers among people with type 2 diabetes. And blood glucose, as well as cholesterol and blood pressure control, are key. High blood glucose is particularly toxic to the eyes, the kidneys and the nerves.

But high blood sugar takes many years to do really serious damage. And too-tight glucose control can sometimes do more harm than good. So the focus now is not just on good control, but on whether you fall into a ‘high-risk’ category where ‘good enough’ control is better than ‘perfect’. These high-risk categories include people who:

- Are older and frail

- Take lots of medicines that could interact with glucose-lowering ones

- Are at risk of falls

- Suffer from lots of other medical conditions

- Are at higher risk of the consequences of sudden drop in blood sugar, called ‘ hypos

- Drive or operate heavy machinery

- Have lost the ability to recognise early warning symptoms of ‘hypos’

Here are some of the key headlines for medicines and targets other than glucose control:

1) Aspirin is out for most people. If you have type 2 diabetes and haven’t had a heart attack or stroke, it’s no longer recommended that you take a 75 mg aspirin tablet every day

2) Your blood pressure should be below 140/80 mm Hg (millimetres of mercury) unless you have evidence of complications affecting your eyes, kidneys, heart of brain, in which case it should be below 130/80

3) Keeping your cholesterol levels down is still important, but targets will depend on whether you’ve had a heart attack.

For blood glucose targets, there’s quite a lot of tweaking. The measurements used are HbA1c – which gives an average of your blood glucose over the last few weeks. As a standard rule, the recommendations are that:

1) When you’re first diagnosed, you should be aiming for an HbA1c below 48 mmol/mol

2) If your level rises despite diet and lifestyle changes, you should start taking a medicine called Metformin (unless there’s a good medical reason you can’t)

3) If you haven’t started medication yet or you’re taking metformin, you should aim for an HbA1c below 48 mmol/mol

4) If your level rises on metformin to above 58 mmol/mol, your doctor and you should agree another tablet to add it, aiming to bring your HbA1c back to 53 mmol/mol

5) If you’re on two medicines and your HbA1c rises above 58 mmol/mol, your doctor and you should agree a third tablet (or occasionally insulin) to add it, aiming to bring your HbA1c back to 53 mmol/mol.

But don’t forget, all these targets are going to be personalised – so if you have other medical complications, your doctor may want to discuss levels that are best suited for you. Likewise, your doctor should be outlining all the drug options for you, so you can decide together which one is best for you.

Another really positive change as far as I and many other doctors are concerned is the move away from older drugs like sulfonylureas such as glicazide. These medicines have been around for decades, and while they’re effective at bringing blood sugar down, they almost invariably cause weight gain. They also carry a significant risk of low blood sugars or ‘hypos’, which are unpleasant at best and which can be life-threatening in severe cases. They may also increase the risk of heart attack and heart failure

Instead, the new guidelines offer a range of options as add-on treatment to metformin, including ‘gliptins’ and SGLT-2 inhibitors’. These newer medicines don’t cause weight gain (and can sometimes help with weight loss); have a very low risk of hypos; and are just as effective as older drugs at keeping blood sugar under control. Unless you’re taking other medicines that cause hypos, you won’t have to monitor your blood sugar with fingerprick tests while you’re taking them, either.

The last big focus of the new guidelines is on helping the patient take control. No matter how dedicated your medical team, they’re only there for a tiny proportion of your life. Taking charge of your own diet, lifestyle and weight has to be the best way to protect yourself against life-threatening complications. Your team will be with you every step of the way, but now it’s over to you!

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Egton Medical Information Systems Limited has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.