Type 2 diabetes treatment and management

Type 2 diabetes treatment and management

Type 2 diabetes treatment should be aimed at alleviating symptoms and minimising the risk of long-term complications. Type 2 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.¹

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}

Patient education on type 2 diabetes⁴

• 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.

• One 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.⁵

• 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.⁶

The National Institute for Health and Care Excellence (NICE) has updated its guidance on type 2 diabetes to include information on periodontitis.⁴

All patients diagnosed with type 2 diabetes should be advised to get regular dental checks as their risk of periodontitis is high. This could lead to tooth loss. Periodontitis is a chronic inflammatory gum disease that destroys the supporting tissues of the teeth (the periodontium). Gingivitis is a milder form of periodontal disease but still causes inflammation in the gum, and if not treated it can lead to periodontitis.

Patients should be informed at their annual checks that they are at high risk of this condition and they need regular checks with their dentist.

If they have periodontitis, managing this condition will improve their blood glucose control and subsequently lower their risk of hyperglycaemia. Their dentist will also adjust their reviews in order to manage this condition appropriately.

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.⁷

• Check smoking status and offer smoking cessation advice as appropriate.

Dietary advice⁴

See also the separate Diabetes Diet And Exercise article.

• Emphasise advice on healthy balanced eating. Encourage high-fibre, low-glycaemic-index sources of carbohydrate in the diet, such as fruit, vegetables, whole grains and pulses. Include low-fat dairy products and oily fish, and 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% to 10%. Remember that lesser degrees of weight loss may still be of benefit, and that larger degrees of weight loss in the longer term will have advantageous metabolic impact.

• Advise adults with type 2 diabetes that limited substitution of sucrose-containing foods for other carbohydrate in the meal plan is allowable, but that they should take care to avoid excess energy intake.

• Discourage the use of foods marketed specifically for people with diabetes.

Glucose control⁴

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 Diabetes and Intercurrent Illness article.

HbA1c measurement and targets

In adults with type 2 diabetes, measure HbA1c levels at:

• 3- to 6-monthly intervals until the HbA1c is stable on unchanging therapy.

• 6-monthly intervals once the HbA1c level and blood glucose-lowering therapy are stable.

If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using one of the following:

• Plasma glucose profiles.

• Total glycated haemoglobin estimation (if abnormal haemoglobins).

• Fructosamine estimation.

Targets
Encourage the person to achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life.

• If 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, provide support 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.

• 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.

Self-monitoring of blood glucose

See also the separate Self-monitoring in Diabetes Mellitus article.

Currently self-monitoring of blood glucose levels for adults with type 2 diabetes is not routinely offered 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.

If adults with type 2 diabetes are self-monitoring their blood glucose levels, carry out a structured assessment at least annually.

Continuous glucose monitoring (CGM)
NICE has updated its guidance on the management of type 2 diabetes⁴ to recommend CGM (often referred to as 'flash' glucose monitoring) for adults with type 2 diabetes on multiple daily insulin injections if any of the following apply:

• They have recurrent hypoglycaemia or severe hypoglycaemia.

• They have impaired hypoglycaemia awareness.

• They have a condition or disability (including a learning disability or cognitive impairment) that means they cannot self-monitor their blood by capillary blood glucose monitoring but could use a CGM device (or have it scanned for them).

• They would otherwise be advised to self-measure at least eight times a day.

CGM should be provided by a team with expertise in its use, as part of supporting people to self-manage their diabetes. For more details on criteria to take into account, see the article on management of type 1 diabetes.

d-Nav insulin management app for type 2 diabetes⁸
This has been developed to help optimise insulin dosage for people with type 2 diabetes. The person's insulin treatment plan is entered by an appropriately trained healthcare professional through the d‑Nav website. The patient uses the device at home alongside a glucose meter or continuous glucose monitor. People would need a smartphone and regular internet access to use the device and get online updates.

One benefit of this system is that patients can get daily guidance about their insulin dosage, an option which is not possible within current primary care resources.

A study found an improvement of 1% in patients using the app compared to 0.3% a group using standard monitoring arrangements. There was no difference in the frequency of hypoglycaemia.

Drug treatment⁴

See also the separate Antihyperglycaemic Agents used for Type 2 Diabetes and Insulin Regimens articles.

Discuss with adults with type 2 diabetes the benefits and risks of drug treatment and what options are available. Base the choice of drug treatments on:

• The person's individual clinical circumstances - eg, comorbidities, contra-indications, weight, and risks from polypharmacy.

• The individual's preferences and needs.

• The effectiveness of the drug treatments in terms of metabolic response and cardiovascular and renal protection.

• Safety and tolerability of the drug.

• Monitoring requirements.

• The licensed indications or combinations available.

• Cost (if two drugs in the same class are appropriate, choose the option with the lowest acquisition cost).

Rescue therapy at any phase of treatment
If an adult with type 2 diabetes is symptomatically hyperglycaemic, consider insulin or a sulfonylurea, and review treatment when blood glucose control has been achieved.

Initial drug treatment
Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes.
Gradually increase the dose of standard-release metformin over several weeks to minimise the risk of gastrointestinal side-effects in adults with type 2 diabetes.

If an adult with type 2 diabetes experiences gastrointestinal side-effects with standard-release metformin, consider a trial of modified-release metformin.

In adults with type 2 diabetes, review the dose of metformin if the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73m²:

• Stop metformin if the eGFR is below 30 ml/minute/1.73m².

• Prescribe metformin with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR falling below 45 ml/minute/1.73m².

In adults with type 2 diabetes, if metformin is contra-indicated or not tolerated, assess the cardiovascular risk using a recognised risk scoring system such as QRISK®3.

Based on the cardiovascular risk assessment for the person with type 2 diabetes:

• If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.

• If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.

• When starting an adult with type 2 diabetes on dual therapy with metformin and an SGLT2 inhibitor as first-line therapy, introduce the drugs sequentially, starting with metformin and checking tolerability. Start the SGLT2 inhibitor as soon as metformin tolerability is confirmed.

• For first-line drug treatment in adults with type 2 diabetes, if metformin is contra-indicated or not tolerated and if they do not have chronic heart failure, established atherosclerotic cardiovascular disease or are at high risk fo developing cardiovascular disease, consider:

  • A DPP‑4 inhibitor; or

  • Pioglitazone; or

  • A sulfonylurea; or

  • An SGLT2 inhibitor for people who meet the criteria in the NICE technology appraisal guidance on canagliflozin, dapagliflozin and empagliflozin as monotherapies or ertugliflozin as monotherapy or with metformin for treating type 2 diabetes.⁹

Before starting an SGLT2 inhibitor, check whether the person may be at increased risk of diabetic ketoacidosis (DKA) - for example if:

• They have had a previous episode of DKA.

• They are unwell with intercurrent illness.

• They are following a very low-carbohydrate or ketogenic diet.

NICE has also updated the guidance to reflect new recommendations for the use of SGLT2 inhibitors in people with diabetes and chronic kidney disease - see the article on diabetic nephropathy for full details.

Further intervention

Introduce drugs used in combination therapy in a stepwise manner, checking for tolerability and effectiveness of each drug.

For adults with type 2 diabetes, if monotherapy has not continued to control HbA1c to below the person's individually agreed threshold for further intervention, consider adding:

• A DPP‑4 inhibitor; or

• Pioglitazone; or

• A sulfonylurea; or

• An SGLT2 inhibitor for people who meet the criteria in NICE's technology appraisal guidance on canagliflozin in combination therapy, ertugliflozin as monotherapy or with metformin, or dapagliflozin or empagliflozin in combination therapy.⁹

For adults with type 2 diabetes, if dual therapy with metformin and another oral drug has not continued to control HbA1c to below the person's individually agreed threshold for further intervention consider either:

• Triple therapy by adding a DPP‑4 inhibitor, pioglitazone or a sulfonylurea or an SGLT2 inhibitor for people who meet the criteria in NICE's technology appraisal guidance on canagliflozin in combination therapy, dapagliflozin in triple therapy, empagliflozin in combination therapy, or ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor;⁹ or

• Starting insulin-based treatment (see the section on insulin-based treatments).

If triple therapy with metformin and two other oral drugs is not effective, not tolerated or contra-indicated, consider triple therapy by switching one drug for a GLP‑1 mimetic for adults with type 2 diabetes who:

• Have a body mass index (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.

Only continue GLP-1 mimetic therapy if the person with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in six months).

In adults with type 2 diabetes, only offer a GLP-1 mimetic in combination with insulin with specialist care advice and ongoing support from a consultant-led multidisciplinary team.

Insulin-based type 2 diabetes treatments

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.

• Self-monitoring.

• Dose titration to target levels.

• Dietary understanding.

• DVLA's Assessing fitness to drive: a guide for medical professionals.

• 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:

• Offer NPH insulin injected once or twice daily according to need.

• Consider starting both NPH and short-acting insulin (particularly if HbA1c is 75 mmol/mol [9.0%] or higher), administered either separately or as a pre-mixed (biphasic) human insulin preparation.

Consider, as an alternative to NPH insulin, using insulin detemir or insulin glargine if:

• The person needs assistance from a carer or healthcare professional to inject insulin, and use of insulin detemir or insulin glargine would reduce the frequency of injections from twice to once daily; or

• The person's lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes; or

• The person would otherwise need twice-daily NPH insulin injections in combination with oral glucose-lowering drugs.

Consider pre-mixed (biphasic) preparations that include short-acting insulin analogues, rather than pre-mixed (biphasic) preparations that include short-acting human insulin preparations, if:

• A person prefers injecting insulin immediately before a meal; or

• Hypoglycaemia is a problem; or

• Blood glucose levels rise markedly after meals.

Consider switching to insulin detemir or insulin glargine from NPH insulin in adults with type 2 diabetes:

• Who do not reach their target HbA1c because of significant hypoglycaemia; or

• Who experience significant hypoglycaemia on NPH insulin irrespective of the level of HbA1c reached; or

• Who cannot use the device needed to inject NPH insulin but who could administer their own insulin safely and accurately if a switch to one of the long-acting insulin analogues was made; or

• Who need help from a carer or healthcare professional to administer insulin injections and for whom switching to one of the long-acting insulin analogues would reduce the number of daily injections.

Monitor adults with type 2 diabetes who are on a basal insulin regimen (NPH insulin, insulin detemir or insulin glargine) for the need for short-acting insulin before meals (or a pre-mixed [biphasic] insulin preparation).

Monitor adults with type 2 diabetes who are on pre-mixed (biphasic) insulin for the need for a further injection of short-acting insulin before meals or for a change to a basal bolus regimen with NPH insulin or insulin detemir or insulin glargine, if blood glucose control remains inadequate.

When starting an insulin for which a biosimilar is available, use the product with the lowest acquisition cost.

Ensure the risk of medication errors with insulins is minimised by following Medicines and Healthcare products Regulatory Agency (MHRA) guidance on minimising the risk of medication error with high strength, fixed combination and biosimilar insulin products, which includes advice for healthcare professionals when starting treatment with a biosimilar.¹⁰

See also the separate Insulin Regimens article.

Blood pressure control¹¹

See also the separate Diabetes and Hypertension article.

Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Measure standing as well as seated blood pressure in people with hypertension and with type 2 diabetes.

Offer and reinforce preventative lifestyle advice.

Salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin-II receptor blockers.

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have diabetes. Stage 1 hypertension is defined as clinic blood pressure 140/90 mm Hg to 159/99 mm Hg, and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mm Hg to 149/94 mm Hg.

• Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who have type 2 diabetes.

• If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of one of the following drugs in addition to step 1 treatment: CCB or a thiazide-like diuretic.

• If hypertension is not controlled in adults taking step 2 treatment, offer a combination of: an ACE inhibitor or ARB, a CCB and a thiazide-like diuretic.

Antiplatelet therapy

Do not offer antiplatelet therapy (aspirin or clopidogrel) for type 2 diabetes treatment without cardiovascular disease.⁴

Other monitoring

• 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.

Gastroparesis⁴

Consider 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.

For adults with type 2 diabetes who have vomiting caused by gastroparesis:

• There is not 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, but prescribers must take into account its safety profile, in particular its cardiac risk and potential interactions with other medicines.

For treating vomiting caused by gastroparesis in adults with type 2 diabetes:

• Consider alternating use of erythromycin and metoclopramide.

• Consider domperidone only in exceptional circumstances (if domperidone is the only effective treatment) and in accordance with MHRA guidance.

If gastroparesis is suspected, consider referral to specialist services if the differential diagnosis is in doubt, or persistent or severe vomiting occurs.

Autonomic neuropathy⁴

Consider the possibility of contributory sympathetic nervous system damage for adults with type 2 diabetes who lose the warning signs of hypoglycaemia.

Consider 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.

Erectile dysfunction⁴

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 (ED) article.

Other type 2 diabetes 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 for Patients with Diabetes Undergoing Surgery article.

• Be alert for the potential development of metabolic syndrome.

See also the articles on Diabetic Foot, Diabetic Neuropathy, Diabetic Retinopathy and Diabetic Eye Problems, Diabetic Nephropathy and Diabetic Amyotrophy.

Referral

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.¹²

Type 2 diabetes prevention

This is covered in detail in the separate Prevention of Type 2 Diabetes article.