Treatment should be aimed at alleviating symptoms and minimising the risk of long-term complications. Diabetes is a major risk factor for cardiovascular disease, which is the most common cause of death in people with diabetes. Optimal control of glucose and other cardiovascular risk factors (eg, smoking, sedentary lifestyle, hypertension, dyslipidaemia and obesity) is essential.
Management of type 2 diabetes has to be tailored to the individual needs and circumstances of each patient - eg, the benefits of tight glucose control must be weighed against any potential complications such as recurrent hypoglycaemia[2, 3].
- Structured patient education should be made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need.
- Suitable programmes are the X-PERT Diabetes Programme and the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) Programme. See the separate Diabetes Education and Self-management Programmes article.
- A study found that a single education and self-management structured programme for people with newly diagnosed type 2 diabetes mellitus did not show any benefit in biomedical or lifestyle outcomes at three years, although there were sustained improvements in some illness beliefs.
- Discuss diet and give dietary advice, taking into account other factors - eg, obesity, hypertension, and renal impairment; offer referral to a dietician.
- Encourage regular physical activity.
- Give advice and support on smoking cessation where appropriate.
- If appropriate, advise of the need to contact DVLA to inform them of the diagnosis - see DVLA Medical Standards of Fitness to Drive.
Initial assessment and monitoring
- Check height and weight and calculate BMI; also measure waist circumference. Waist circumference is significantly associated with the risk of cardiovascular disease.
- Check smoking status and offer cessation advice as appropriate.
See also the separate Diabetes Diet And Exercise article.
- Emphasise advice on healthy balanced eating that is applicable to the general population when providing advice to adults with type 2 diabetes.
- Encourage high-fibre, low-glycaemic-index sources of carbohydrate in the diet, such as fruit, vegetables, wholegrain and pulses.
- Include low-fat dairy products and oily fish.
- Control the intake of foods containing saturated and trans fatty acids.
- Integrate dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification, such as increasing physical activity and losing weight.
- For adults with type 2 diabetes who are overweight, set an initial body weight loss target of 5-10%. Lesser degrees of weight loss may still be of benefit and larger degrees of weight loss in the longer term will have advantageous metabolic impact.
- Limited substitution of sucrose-containing foods for other carbohydrate in the meal plan is allowable but avoid excess energy intake.
- Discourage the use of foods marketed specifically for people with diabetes.
HbA1c measurement and targets
In adults with type 2 diabetes, measure HbA1c levels at:
- Three- to six-monthly intervals (tailored to individual needs), until the HbA1c is stable on unchanging therapy
- Six-monthly intervals once the HbA1c level and blood glucose-lowering therapy are stable.
See the separate Glycated Haemoglobin (HbA1c) article for further information on when HbA1c is not valid. If HbA1c monitoring is invalid (eg, because of disturbed erythrocyte turnover or abnormal haemoglobin type), estimate trends in blood glucose control using one of the following:
- Self-monitoring glucose profiles.
- Total glycated haemoglobin estimation (if abnormal haemoglobins).
- Fructosamine estimation.
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 53 mmol/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 53 mmol/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 - eg, people with a reduced life expectancy
- For whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia - eg, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or who operate machinery as part of their job.
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.
Self-monitoring of blood glucose
See also the separate Self-monitoring in Diabetes Mellitus article.
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.
Consider short-term self-monitoring of blood glucose levels in adults with type 2 diabetes (and review treatment as necessary):
- When starting treatment with oral or intravenous corticosteroids or to confirm suspected hypoglycaemia.
- Be aware that adults with type 2 diabetes who have acute intercurrent illness are at risk of worsening hyperglycaemia. Review treatment as necessary.
See also the separate Antihyperglycaemic Agents used for Type 2 Diabetes and Insulin Regimens articles.
Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes. If metformin is contra-indicated or not tolerated, consider initial drug treatment with a dipeptidyl peptidase-4 (DPP-4) inhibitor or pioglitazone or a sulfonylurea.
First intensification of drug treatment
If initial drug treatment with metformin has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider dual therapy with metformin combined with one of a DPP-4 inhibitor, pioglitazone or a sulfonylurea.
If metformin is contra-indicated or not tolerated and initial drug treatment has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider dual therapy with:
- DPP-4 inhibitor and pioglitazone; or
- DPP-4 inhibitor and a sulfonylurea; or
- Pioglitazone and a sulfonylurea.
Treatment with combinations of medicines including sodium-glucose cotransporter 2 (SGLT2) inhibitors may be appropriate for some people with type 2 diabetes.
December 2017 - Dr Hayley Willacy draws your attention to the recently published Scottish Intercollegiate Guidelines Network (SIGN) guidelines dealing with the management of glycaemic control in people with type 2 diabetes. These contain the following key recommendations:
- An HbA1c target of 7.0% (53 mmol/mol) is reasonable to reduce the risk of microvascular and macrovascular disease. A target of 6.5% (48 mmol/mol) may be appropriate at diagnosis. Targets should be set with individuals in order to balance benefits with harms, in particular hypoglycaemia and weight gain.
- Metformin should be considered as the first-line oral treatment option for people with type 2 diabetes.
- In individuals with type 2 diabetes and established cardiovascular disease, SGLT2 inhibitors with proven cardiovascular benefit (currently empagliflozin and canagliflozin) should be considered.
- For individuals with type 2 diabetes and established cardiovascular disease, GLP-1 receptor agonist therapies with proven cardiovascular benefit (currently liraglutide) should be considered.
Second intensification of drug treatment
Update from Dr Sarah Jarvis:
In October 2018, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) published a consensus report on management of hyperglycaemia in type 2 diabetes. Metformin remains the first-line treatment of choice. However, they now stratify recommended first-line options for second-line intensification of treatment according to comorbidities:
Compelling need to avoid hypoglycaemia - DPP-4 inhibitor, SGLT-2 inhibitor, pioglitazone or GLP-1 mimetic.
History of atherosclerotic CVD - SGLT-2 inhibitor or GLP-1 mimetic with proven heart benefit.
History of heart failure/chronic kidney disease - SGLT-2 inhibitor or, if not suitable, GLP-1 mimetic. (NB: in the UK, commencement of any SGLT-2 inhibitors is contra-indicated in patients with eGFR below 60. Dapagliflozin should be stopped if eGFR drops below 60, while empagliflozin or canagliflozin should be stopped if eGFR drops below 45.)
Compelling need to lose weight or avoid weight gain - SGLT-2 inhibitor or GLP-1 mimetic (or DPP-4 inhibitor if neither of these is suitable).
The National Institute for Health and Care Excellence (NICE) recommends that with some exceptions, GLP-1 mimetics should only be prescribed for people with a body mass index (BMI) over 35.
If dual therapy with metformin and another oral drug has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider:
- Triple therapy with either:
- Metformin, a DPP-4 inhibitor and a sulfonylurea; or
- Metformin, pioglitazone and a sulfonylurea.
- Alternatively, consider starting insulin-based treatment.
If triple therapy with metformin and two other oral drugs is not effective, is not tolerated or is contra-indicated, consider combination therapy with metformin, a sulfonylurea and a GLP-1 mimetic for adults with type 2 diabetes who:
- Have a BMI of 35 kg/m2 or higher (adjust accordingly for people from black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity or have a BMI lower than 35 kg/m2; and
- For whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities.
In adults with type 2 diabetes, if metformin is contra-indicated or not tolerated, and if dual therapy with two oral drugs has not continued to control HbA1c to below the person's individually agreed threshold for intensification, consider insulin-based treatment.
Only offer a GLP-1 mimetic in combination with insulin with specialist care advice and ongoing support from a consultant-led multidisciplinary team. Treatment with combinations of medicines including SGLT2 inhibitors may be appropriate for some people with type 2 diabetes.
When starting insulin therapy in adults with type 2 diabetes, use a structured programme employing active insulin dose titration that encompasses:
- Injection technique, including:
- Rotating injection sites and avoiding repeated injections at the same point within sites.
- Continuing telephone support.
- Dose titration to target levels.
- Dietary understanding.
- DVLA guidance.
- Management of hypoglycaemia.
- Management of acute changes in plasma glucose control.
- Support from an appropriately trained and experienced healthcare professional.
When starting insulin therapy in adults with type 2 diabetes, continue to offer metformin for people without contra-indications or intolerance. Review the continued need for other blood glucose-lowering therapies.
Start insulin therapy for adults with type 2 diabetes from a choice of a number of insulin types and regimens. See also the separate Insulin Regimens article.
Blood pressure control
See also the separate Diabetes with Hypertension article.
Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventative lifestyle advice.
Repeat blood pressure measurements within:
- One month if blood pressure is higher than 150/90 mm Hg.
- Two months if blood pressure is higher than 140/80 mm Hg.
- Two months if blood pressure is higher than 130/80 mm Hg and there is kidney, eye or cerebrovascular damage.
Provide lifestyle advice (diet and exercise) if blood pressure is confirmed as being consistently above 140/80 mm Hg (or above 130/80 mm Hg if there is kidney, eye or cerebrovascular damage). See the separate Diabetes Diet and Exercise article. Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mm Hg (below 130/80 mm Hg if there is kidney, eye or cerebrovascular damage).
Monitor blood pressure every 1-2 months and intensify therapy if the person is already on antihypertensive drug treatment, until the blood pressure is consistently below 140/80 mm Hg (below 130/80 mm Hg if there is kidney, eye or cerebrovascular damage).
- First-line antihypertensive drug treatment should be a once-daily angiotensin-converting enzyme (ACE) inhibitor. Exceptions to this are people of African or Caribbean family origin, or women for whom there is a possibility of becoming pregnant.
- The first-line antihypertensive drug treatment for a person of African or Caribbean family origin should be an ACE inhibitor plus either a diuretic or a calcium-channel blocker.
- A calcium-channel blocker should be the first-line antihypertensive drug treatment for a woman for whom there is a possibility of her becoming pregnant.
- For a person with continuing intolerance to an ACE inhibitor (other than renal deterioration or hyperkalaemia), substitute an angiotensin II-receptor antagonist for the ACE inhibitor.
- Do not combine an ACE inhibitor with an angiotensin II-receptor antagonist to treat hypertension.
- If the person's blood pressure is not reduced to the individually agreed target with first-line therapy, add a calcium-channel blocker or a diuretic (usually a thiazide or thiazide-related diuretic). Add the other drug (that is, the calcium-channel blocker or diuretic) if the target is not reached with dual therapy.
- If the person's blood pressure is not reduced to the individually agreed target with triple therapy, add an alpha-blocker, a beta-blocker or a potassium-sparing diuretic (the last with caution if the person is already taking an ACE inhibitor or an angiotensin II-receptor antagonist).
- Monitor the blood pressure of a person, who has attained and consistently remained at his or her blood pressure target, every 4-6 months.
Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.
- Renal monitoring: see the separate Diabetic Nephropathy article.
- Serum lipids: see the separate Hyperlipidaemia and Lipid-regulating Drugs (including Statins) articles.
- TFTs (at diagnosis and annually).
- Eye: see the separate Diabetic Retinopathy and Diabetic Eye Problems article.
- Neuropathic pain: see the separate Neuropathic Pain and its Management and Neuropathic Joints (Charcot Joints) articles.
- Feet: see the separate Diabetic Neuropathy and Diabetic Foot articles.
Think about a diagnosis of gastroparesis in adults with type 2 diabetes with erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses. There is no strong evidence that any available antiemetic therapy is effective. Some people have had benefit with domperidone, erythromycin or metoclopramide. The strongest evidence for effectiveness is for domperidone. If gastroparesis is suspected, consider referral to specialist services if the differential diagnosis is in doubt or if persistent or severe vomiting occurs.
Think about the possibility of contributory sympathetic nervous system damage for adults with type 2 diabetes who lose the warning signs of hypoglycaemia. Think about the possibility of autonomic neuropathy affecting the gut in adults with type 2 diabetes who have unexplained diarrhoea that happens particularly at night.
When using tricyclic drugs and antihypertensive drug treatments in adults with type 2 diabetes who have autonomic neuropathy, be aware of the increased likelihood of side-effects such as orthostatic hypotension. Investigate the possibility of autonomic neuropathy affecting the bladder in adults with type 2 diabetes who have unexplained bladder-emptying problems.
In managing autonomic neuropathy symptoms, include specific interventions indicated by the manifestations (for example, for abnormal sweating or nocturnal diarrhoea).
See also the separate Autonomic Neuropathy article.
Offer men with type 2 diabetes the opportunity to discuss erectile dysfunction as part of their annual review. Consider a phosphodiesterase-5 inhibitor to treat problematic erectile dysfunction in men with type 2 diabetes, initially choosing the drug with the lowest acquisition cost and taking into account any contra-indications. Refer men with type 2 diabetes to a service offering other medical, surgical or psychological management of erectile dysfunction if treatment (including a phosphodiesterase-5 inhibitor, as appropriate) has been unsuccessful.
See also the separate Erectile Dysfunction article.
Other management issues
See the separate Assessment of the Patient with Established Diabetes article.
- People with diabetes should be offered influenza vaccination and pneumococcal vaccination.
- Managing diabetes and intercurrent illness is covered in the separate Diabetes and Intercurrent Illness article.
- Depression screening; early detection, support and effective management.
- See the separate Precautions with Patients with Diabetes Undergoing Surgery article.
- Be alert for the potential development of metabolic syndrome.
The precise arrangements for referrals will depend on local service provisions and guidelines Most patients with type 2 diabetes can be managed within primary care but referrals such as to podiatry, the multidisciplinary footcare team and the local retinal screening programme, may be required. Referral to a diabetes specialist may be required depending on the development of complications, comorbidity and any difficulties with controlling glucose, lipids or blood pressure.
Refer pregnant women with diabetes, or those planning a pregnancy, for specialist care.
This is covered in detail in the separate Prevention of Type 2 Diabetes article.
Further reading and references
Management of diabetes; Scottish Intercollegiate Guidelines Network - SIGN (March 2010 - updated Sept 2013)
Diabetes and High HbA1c Information Prescription; Diabetes UK
Lorber D; Importance of cardiovascular disease risk management in patients with type 2 diabetes mellitus. Diabetes Metab Syndr Obes. 2014 May 237:169-83. doi: 10.2147/DMSO.S61438. eCollection 2014.
Gerstein HC, Miller ME, Byington RP, et al; Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008 Jun 12358(24):2545-59. Epub 2008 Jun 6.
Patel A, MacMahon S, Chalmers J, et al; Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008 Jun 12358(24):2560-72. Epub 2008 Jun 6.
Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care; BMJ 2012 344 doi: http://dx.doi.org/10.1136/bmj.e2333
Assessing fitness to drive: guide for medical professionals; Driver and Vehicle Licensing Agency
de Koning L, Merchant AT, Pogue J, et al; Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies. Eur Heart J. 2007 Apr28(7):850-6. Epub 2007 Apr 2.
Type 2 diabetes in adults: management; NICE Guidelines (December 2015, updated May 2017)
Pharmacological management of glycaemic control in people with type 2 diabetes; SIGN 154 (Dec 2017)
Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period; NICE Clinical Guideline (February 2015)
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