Blood glucose management in type 2 diabetes - NHS Cumbria

Blood Glucose Management in Type 2 DiabetesRefer patient to DESMONDHbA1c ≥ 6.5% after trial of lifestyle interventionsStep 1Metformin(increase dose gradually, see overleaf)GliclazideConsider Gliclazide if metformin is nottolerated or is contraindicatedHbA1c ≥ 6.5%HbA1c < 6.5%Monitor for deteriorationStep 2Metformin + GliclazideUse this combination unless there issignificant risk of hypoglycaemia (orits consequences) or gliclazide iscontraindicated or not tolerated.For options toreplace Gliclazide orMetformin shouldtreatment failureoccur, see overleafHbA1c ≥ 7.5%HbA1c

All newly diagnosed Type 2 diabetics should be referred to DESMOND.Diet is the usual initial therapy following diagnosis of type 2 diabetes,Drug therapy should be considered earlier for patients with marked symptoms and significant hyperglycaemia.Patients must inform DVLA / insurance company when commencing oral hypoglycaemic drugs.UKPDS demonstrated that tight control of blood glucose average HbA1c of 7.0% versus 7.9% is associated with a reduced risk ofmicrovascular complications.1st Choice MetforminMetformin is the only oral antidiabetic drug which has a proven survival advantage in overweight patients (BMI > 25) and gavegreater risk reductions than other therapies for both microvascular and macrovascular complications, with less weight gain.(UKPDS). Hypoglycaemia does not occur with Metformin therapy.Metformin is safe to use in the non-obese and shows the greatest reduction in HbA1c of all therapies. Step up Metformin every 10 –15 days over several weeks to minimise risk of gastrointestinal (GI) side effects.Renal function should be monitored, and the appropriateness of the dose and drug re-assessed if renal function deteriorates.Consider trial of extended-absorption Metformin if GI intolerability. Convert back to standard tablets after 3 months2nd Choice GliclazideEducate the patient about the possible risk of hypoglycaemia, particularly if he or she has renal impairment.Gliclazide should be taken before mealsOptions after poor control (HbA1c >7.5) with Metformin and Gliclazidea) Insulin• Human Isophane Insulin should be offered initially. See insulin guidance.b) Sitagliptin, Vildagliptin● Continue treatment with Sitagliptin or Vildagliptin only if there is a reduction of ≥ 0.5 percentage points in HbA1c in 6 months.They have been shown to reduce HbA1c levels, but, currently there is no data on morbidity, mortality or long-term adverse effectsc) Pioglitazone● Continue treatment with pioglitazone therapy only if there is a reduction of ≥ 0.5 percentage points in HbA1c in 6 months.● Glitazones can cause weight gain and fluid retention and reduce bone mineral density in post-menopausal women Do not start orcontinue therapy if the person has heart failure or is at higher risk of fracture.● Requires liver function monitoringd) Exenatide (Specialist Referral - Patients BMI>35)● Continue exenatide only if there is a reduction in HbA1c of ≥ 1.0 % and ≥ 3% of initial body weight in 6 months. Exenatide shouldbe used with caution in adults older than 75 years and if eGFR