Diabetes (Type 2) - Pennine GP Training



Diabetes (Type 2) 2019

Diagnosed with HbA1c 48 mmol/mol or above ( WHO 2011)

Diagnosis should be confirmed with a repeat HbA1c test, unless clinical symptoms and plasma glucose levels >11.1mmol/l are present in which case further testing is not required.

Note: Cannot use HbA1c for diagnosis in certain cases - children, pregnant, patients with haemoglobinopathy/anaemia (Hb 86 mmol/l BUT carry hypoglycaemia risk

Would need to counsel the patient about the symptoms of hypos, hypo management, hypos and driving and teach them how to use glucometer

pennine-gp-training.co.uk/res/2017-Hypo-leaflet.pdf

& driving leaflet link above

See our guidance below on further potential therapeutic interventions. If unsure please discuss management with the diabetes lead(s) within the practice.

9) If starting medication to complete the prescription exemption form for those patients under 60 years of age.

Management of Type 2 Diabetes overview

• Diet, exercise and education are the foundation

• Lowering glucose is important but BP & lipid control are often more effective interventions

Annual review of diabetes should include :

1) Weight (BMI & exercise status)

2) Smoking cessation (plus alcohol intake)

3) BP

4) Glycaemic control (HbA1c)

but also - Hypoglycaemic episodes ( ? awareness/need for external help with – see details at end of document)

- Driver esp if ? HGV/PSV

- Monitoring home blood glucose needed ? (HBGM)

Home Blood Glucose Monitoring Diary

5) Lipid management (non fasting Chol & Q risk)

6) & 7) Kidneys - Urinary albumin (ACR)

- Renal Function (U&Es/eGFR)

8) Eye examination (annual retinopathy screening)

9) Foot examination

Useful Patient information leaflets

Hypos   

Diabetes and driving

Diabetes and travel -

Sick day rules -

Targets at a glance

1) BMI >25 - Reinforce diet/lifestyle advice

Signpost to dietary advice e.g Carbs/Cals book &/or consider dietician referral

Consider referral to Weight/Exercise services via Better Living Team

Consider trial of Orlistat (if BMI>28) Target weight loss 5-10%

Bariatric surgery when all else fails (BMI >30 – note lower threshold than non diabetics)

A lot of focus recently on very low calorie diets/low carbohydrate diets resulting in significant weight loss to send ‘diabetes into remission’. Trials show promising results but as yet no long term data on relapse rates.

2) Smoking – increases CV (stroke/MI/PVD), amputation and nephropathy risks

Read code smoking cessation advice & offer help via ‘Yorkshire Smokefree’ stop smoking clinics where can access nicotine replacement therapies if needed.

3) BP 25% or creatinine rises by > 30% stop or back titrate treatment – see NICE guidelines. Don’t forget BNF cautions and contra indications.

4) Glycaemic control & HbA1c

Aim for HbA1c 58 on drug therapy

Continue medication at each stage if EITHER target achieved OR HbA1c falls more than 0.5% (5.5mmol/mol) in 3-6 months. Discontinue if medication ineffective.

If HbA1c is not at target, consider potential lifestyle changes, compliance issues before increasing medication

Individualise targets in order to balance benefits vs harms especially hypos & weight gain. Consider relaxing targets if older/frail/multiple comorbidities.

Note that HbA1c < 42 mmol/l in diabetics on oral hypoglycaemics is associated with increased morbidity and mortality.

HbA1c should be checked at least annually (NICE suggests 6 monthly) if at target

3-6 monthly if uptitrating to achieve a target

Initiating medication – Mono therapy

1st line - standard release Metformin with meals. If not tolerated, then switch to the MR form.

2nd line consider a DPP-4 inhibitor (‘gliptin’ or DPP4), Pioglitazone ( Pio or ‘glitazone’) or a sulphonylurea (SU) or Repaglinide

If monotherapy fails to get them to target then -

Dual therapy (1st intensification)

Metformin PLUS ONE of DPP-4/Pioglitazone/SU/Flozin

If hypo risk or weight gain undesirable opt for gliptin or a flozin

If Metformin not tolerated or CI consider

SU PLUS ONE of Pio/Flozin/DPP4

Or Pio & DPP4

Triple therapy (2nd intensification)

Metformin + SU + PLUS ONE of Pio/DPP4/Flozin

Metformin + Pio and Flozin

Metformin + SU and GLP agonist (injectable) or Insulin based therapy

SEE END for SUMMARY DIAGRAM for glycaemic control

Notes on medications

Metformin

Remains 1st line due to cardiovascular benefit.

Issues: Start slow 500mg od with/just after main meal & uptitrate by 500mg weekly. Max dose is usually 2g a day.

Caution in CKD - eGFR < 45 – review dose

- eGFR < 30 – STOP

So also stop if intercurrent illness (sick day rules).

Usually also stopped 48 hours prior to contrast radiological studies and not re-started until check U&Es confirm it is safe to do so, no earlier than 72 hours post procedure.

Advantages: Cheap, reduces CVD risk,weight neutral and no hypoglycaemia risk

Disadvantages: Metallic taste and diarrhoea are common but often settle. If not then try MR version with the main meal of the day.

Repaglinide

Issues : In NICE but not included in SIGN guidance & rarely used.

Essentially rapid acting SU used pre meals usually 0.5 to 4mg tds.

Licensed as monotherapy or in combination with Metformin only.

Advantages: Cheap, safe in CKD and useful for patients with erratic eating habits

Disadvantages: high risk of hypos, weight gain, limited licensing and avoid if liver disease

Sulphonylureas ‘SU’ e.g gliclazide, glimepiride

Issues: Taken 10 to 15 mins prior to the meal

Gliclazide -Start with 40mg bd & uptitrate 2 weekly – max 160mg bd

If a driver, consider HBGM and counsel re hypoglycaemia symptoms/management & DVLA guidance

Advantages: Highly effective esp for rapid symptom control

Disadvantages: High hypo risk – increased if renal impairment & with longer acting SUs so caution.

Weight gain

Avoid in severe hepatic impairment

DPP-4 inhibitors/ ‘Gliptins’ e.g linagliptin, alogliptin,sitagliptin

Issues: Not titrated just started at most appropriate dose according to eGFR.

Linagliptin 5mg od is only one that doesn’t need dose adjustment for renal impairment.

Warn patient risk small but if gets severe abdo pain, stop Rx and see doctor same day re ? pancreatitis AND document warning in records.

Advantages: Weight neutral, once daily/well tolerated, hypos not an issue

Disadvantages: Expensive, risk of pancreatitis/don’t use if pmh of pancreatitis, dose adjustments for renal impairment apart from linagliptin

Pioglitazone

Issues: Once daily, dose 15 to 45 mg (up titrate every 3 months and stop if HbA1c not improved on max Rx ).

Avoid if PMH of heart failure, bladder cancer or undiagnosed haematuria

Advantages: cheap and once daily, some cardioprotective benefits demonstrated

Disadvantages : weight gain/fluid retention, CI in heart failure

Increased osteoporotic fracture risk, caution diabetic maculopathy

CI if bladder cancer – caution if risk factors >50, smoker, worker in rubber/dye industry

SGLT2 inhibitors/ ‘Flozins’ e.g canagliflozin, empagliflozin,dapagliflozin

Rapidly becoming the favourite 2nd line drug after metformin for various reasons but cannot initiate if eGFR < 60.

Issues : Canagliflozin 100mg then 300mg after a month if tolerated

In combination with SUs or insulin can cause hypos, so step down insulin or SU dose temporarily when initiating Rx.

Need to inform all about S+S of DKA ( N&V, abd pain, excess thirst, fatigue, confusion/SOB) & clinicians to test for ketones even if blood sugar only mildly elevated

Sick day rules – i.e stopping when intercurrent illness also really important.

Advantages : once daily, aids weight loss /BP reduction.

CV/renal benefits with empagliflozin & canagliflozin so use recommended for those with established CVD.

Disadvantages : expensive, cannot use if renal impairment

increased genital infections - mainly thrush due to glycosuria, increased risk of euglycaemic DKA , increased amputation risk

GLP-1 agonists e.g liraglutide, exenatide, dulaglutide,lixisenatide, semaglutide

Issues: Need referral to DSN to initate as injectable - various types from twice daily to once weekly – once daily liraglutide currently favoured.

Consider this option especially if their BMI > 35 and if patient will not accept insulin or it would cause occupational issues.

Continue GLP -1 only if the person has a reduction in HbA1c of ≥ 11mmol/l and ≥ 3% of initial body weight in 6 months.

Advise patient (& document in record) to see GP promptly if severe abdominal pain/vomiting.

Advantages: Weight loss, hypoglycaemia not a concern,CV/renal benefits with liraglutide so recommended in those with established CVD

Disadvantages: Very expensive, injectable

Main SE resulting in discontinuation is N&V/anorexia

Risk of pancreatitis

Contra-indicated if PMH pancreatitis or severe inflammatory bowel disease, thyroid cancer/MEN. Avoid in gastroparesis.

Need dose adjustment for renal impairment.

Self monitoring of blood glucose (SMBG)

Not needed in all

Consider short term when commencing SUs, those planning pregnancy or suspected hypos/erratic sugar control

Consider long term if on insulin, drivers/machine operators on medications with high hypoglycaemia risk or those with comorbidities that put them at raised hypo risk. These patients will need correct/adequate strips and lancets on repeat.

5) Lipids & CVD risk management

Aim for 40% fall in non HDL cholesterol (previous QoF target of chol < 5 has been retired as not in line with NICE)

Type 2 diabetics – Annual Q risk and if risk > 10% commence Atorvastatin 20mg for primary prevention.

(NB if have CKD would offer them statin regardless)

Just for info - Type 1 diabetics get offered a statins at age 40 if disease duration > 10 years, established nephropathy or other CV risk factors

Atorvastatin 80mg for secondary prevention if established CVD.

Note: SIGN guidance is simpler! suggesting statin at 40 regardless of risk

6) & 7) – Kidneys – eGFR and ACR

eGFR – annual eGFR >60 = normal otherwise CKD needs coding dependent on values and monitoring is as per CKD protocol.

Annual ACR (Albumin Creatinine Ratio). Normal < 3

(Urinary PCI is sometimes used if consistently high ACRs).

If new onset microalbuminuria or proteinuria is present (ACR >3) exclude UTI and repeat twice more (within 3 to 4 months) to ensure not rapidly progressive nephropathy. Read Code microalbuminuria on their Problem Page & Summary.

NB: Nephropathy is strongly associated with retinopathy - If retinopathy is not present /resistant HT/ microscopic haematuria then look for a non-diabetes cause of renal disease & consider renal referral.

• Offer ACE I /ARB if ACR>3 & DM&CKD

• Atorvastatin 20mg for those CKD 3 & below

• Try to keep BP 58

BMI >35 ( 33 in Asians) or BMI ................
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