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A Resource for Glycaemic management in Diabetes
key messages
Drugs do not replace lifestyle advice at any stage
Lifestyle
• Individualise HbA1C target. Early tight control reduces later complications
Individual
Target
Hypoglycaemia is dangerous:
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Beware in elderly/RF/CVS risk
Sulphonylureas need education to avoid risk
Do not escalate Rx if hypoglycaemia present
Beware low HbA1C with insulin and sulphonylureas
Hypo
Advice
Newer agents have clear roles in appropriate patients as per NICE. They must
be reviewed at 6 months and stopped if not achieving targets.
NICE
Criteria
• eGFR matters – please check drug information
Drug
Information
Management
of Low eGFR
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Review date:
Version:
Useful resources
Coastal West Sussex Diabetic group
January 2014
No. 2
Disclaimer: The information given in this document is accurate at the time of publication. Any links to other websites or
documents contained in this resource does not constitute as an endorsement by the Diabetic Group or by Coastal West
Sussex Clinical Commissioning Group.
Quick Guide: Blood Glucose Lowering Therapy in
Type 2 DM
Diagnosis
Diet and lifestyle tried
HbA1C > 48 (6.5%)
• Symptomatic of
hyperglycaemia
requiring rapid
control / low BMI
• Metformin
contraindicated or
not tolerated
Lifestyle
Individual
Target
Metformin
At risk from
hypoglycaemia or
Gliclazide side effects not
tolerated / unacceptable
HbA1C > 48 (6.5%)
or individualised
target
Lifestyle
Individual
Target
Metformin +
Gliclazide
(Repaglanide if lifestyle
erratic)
Hypo
Advice
HbA1C > 58
(7.5%)
Individual
Target
NICE
Criteria
Metformin
+
Gliptin or Pioglitazone
Management
of Low eGFR
Individual
Target
Lifestyle
High BMI?
NICE
See NICE criteria for Criteria
GLP1 agonist use(refer DSN fpr initiation)
Insulin acceptable?
Start Insulin
Hypo
Insulin
Advice
Button
Consider Metformin
+/- Gliclazide
+ Exenatide or
Liraglutide
Intensify Insulin
+/- Metformin
+/- Pioglitazone
+/-Gliptin
Hypo
Advice
HbA1C > 58
(7.5%)
Lifestyle
Do not fit NICE
criteria for GLP1
agonist or Insulin
unacceptable
Consider triple
RX Metformin
Gliclazide +
Gliptin or
Pioglitazone
Monitor 6/12 Target
Hypo
Advice
HbA1C> 58
(7.5)
Target not met
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Drug
Information
Consider
Sulphonylurea
pathway
page 2
Insulin
Button
Change to insulin
Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009)
Hypo
Advice
Insulin
Start Insulin
Button
+/- Metformin
+/- Pioglitazone
+/- Gliptin
Sulphonylurea Pathway
Gliclazide
Hypo
Advice
Metformin tolerated
Return to Metformin
pathway (page1)
Consider stopping
Gliclazide if initial
response rapid
> HbA1C 52 (7%) or
individualised target
Poor initial
response
V low BMI
Exclude underlying
pathology
May need insulin,
(type1?) refer
Lifestyle
Individual
Target
Metformin not tolerated
or contraindicated then
consider Gliptin or
Pioglitazone
Gliclazide +
Gliptin or
Pioglitazone
> HbA1C 58 (7.5%) or
individualised target
Lifestyle
Individual
Target
Start
Insulin
Hypo
Advice
Intensify Insulin
regimen
Drug
Information
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Useful resources
Management
of Low eGFR
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Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009)
Lifestyle interventions
Education –
Type1 – needs a link
Type2 -needs a link
Care Planning with individualised Targe
• Year of Care Link
Diet
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Who should see the Dietitian?
Diet sheets
Diet advice – Click here to access the Eat well with DM2 DUK
web page
Weight – Needs updating
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Weight loss Help – click here to access the Why Weight page
on the GP website
– Why Weight: Tel 0300 123 0892
Exercise
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Exercise Referral
Smoking
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Stop Smoking advice: Tel 0300 100 1823
Mood Matters – MMG/TTT/Psychology
Self Help signposting – Wellbeing hub Contact numbers
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Hypoglycaemia Advice
• Hypoglycaemia IS DANGEROUS
Always enquire about mild symptoms
especially with HbA1C <7
Teach patients to actively pre-empt
low blood sugar & know how to
manage hypoglycaemia.
• Emergency treatment of
hypoglycaemia
• Ongoing management / advice for
hypoglycaemia
• Patient leaflet – management advice
on hypoglycaemia
• Driving and hypoglycaemia advice
• Medical standards of fitness to drive
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Individualised Target
Aim Hb1C 48-53mmol/mol
(6.5-7%)
Aim HbA1C 58mmol/mol
(7.5% or higher)
Younger patient
Older patient
Newer diagnosis
Long standing diabetes
Low risk of hypoglycaemia
Multiple hypoglycaemic
agents
No co-morbidities
Cardiovascular risk
Micro-vascular complications
When setting a target HBA1C):
Macro-vascular
complication
• Involve the person in decisions about their individual HbA1C target level, see above
• Encourage the person to maintain their individual target unless the resulting side effects
(including hypoglycemia) or their efforts to achieve this impair their quality of life
• Offer therapy (lifestyle and medication) to help achieve and maintain the HbA1C target
level
• Inform a person with a higher HbA1C that any reduction in HbA1C towards the agreed
target is advantageous to future health
• Avoid pursuing highly intensive management to levels of less than 48mmol/l or 6.5 %.
However in early disease tight control (HbA1C 48mmol/mol or 6.5%) holds
better long-term outcome
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Insulin
• Insulin should be initiated by qualified
practitioners only. Dietitian input should also
be sought at the same time
• Aims of treatment with insulin
• Leaflets:
– Sick day rules
– Implication of Ketone levels
– Simple dose adjustment instructions:
• QDS / Basal Bolus
• BD / pre-mix
– Hypoglycaemia awareness (advice see
hypoglycaemia page) Hypo
Advice
• Link to safe use of insulin on NHS Diabetes
website
• Download the Insulin Passport
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NICE Criteria
DPP-4 inhibitors (Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin)
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Continue DPP-4 inhibitor therapy only if there is a reduction of ≥ 0.5
percentage points in HbA1c in 6 months.
Discuss the benefits and risks of a DPP-4 inhibitor with the person, bearing in mind
that a DPP-4 inhibitor might be preferable to a Thiazolidinedione if:
– further weight gain would cause significant problems, or
– a Thiazolidinedione is contraindicated, or the person had a poor response to
or did not tolerate a Thiazolidinedione in the past.
GLP1 agonists (Exenatide/ Liraglutide)
These should only be initiated by the team with special interest in
practice
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Discuss the benefits of GLP1 agonist to allow the person to make an informed
decision.
Consider starting in:
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BMI ≥ 35 kg/m2 in people of European descent and there are problems associated
with high weight, or
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BMI < 35 kg/m2 and insulin is unacceptable because of occupational implications or
weight loss would benefit other co-morbidities.
6 month review
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Continue GLP1 Therapy only if the person has a reduction in HbA1C of ≥ 1.0
percentage point and ≥ 3% of initial body weight in 6 months.
Thiazolidinedione (Pioglitazone)
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Continue Thiazolidinedione therapy only if there is a reduction of ≥ 0.5 percentage
points in HbA1c in 6 months.
Discuss the benefits and risks of a Thiazolidinedione with the person, bearing in
mind that a Thiazolidinedione might be preferable to a DPP-4 inhibitor if:
– the person has marked insulin insensitivity, or
– a DPP-4 inhibitor is contraindicated, or
– the person had a poor response to or did not tolerate a DPP-4 inhibitor in the
past.
Do not start or continue a Thiazolidinedione if any suspicion or risk of bladder
cancer/ frank haematuria if the person has heart failure or is at higher risk of
fracture.
When selecting a Thiazolidinedione, take into account the most up-to-date advice
from regulatory authorities, cost, safety and prescribing issue
Click here to access the full NICE guidance
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Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009)
Management of Low eGFR
Prescribers should always check the latest product information in the
relevant data sheet by visiting http://www.medicines.org.uk/emc/
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Useful Resources
Diagnostic criteria
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WHO.
Quick summary chart
Referral protocols
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Dietitian
DSN
Footcare clinic
Information Leaflets
For the patient:
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Diet sheets
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Driving and the new medical standards for people with diabetes
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Footcare instructions
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Hypoglycaemia dietary advice
For the Clinician
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Mood Management Referral – needs link
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Preconception Consultation
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Emergency Hypoglycaemia Treatment
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Guidelines for Blood Glucose Meter testing use – Type1
Type2
Useful Websites
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HBA1C conversion chart
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Link to safe use of insulin on NHS Diabetes website
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Click here to access the DVLA Guide to Medical Standards of fitness to drive
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Click here to access the Map of Medicine
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Click here to access the NICE pathway for a Diabetes overview
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Click here to access Diabetes UK
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Click here to access DUK – Understanding Diabetes
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Click here to access Diabetes Bible
Contact Details
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Hospital contact details
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Worthing Diabetes Centre 01903 285044 (9am – 4pm, Mon - Fri)
St Richards Diabetes Centre 01243 831614 (9am - 4pm, Mon - Fri)
Email [email protected]
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