Treatment should be aimed at alleviating symptoms and minimising the risk of long-term complications. Optimal control of glucose and other cardiovascular risk factors (e.g. 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, e.g. the benefits of tight glucose control must be weighed against any potential complications such as recurrent hypoglycaemia.^2,3

Patient education⁴

• 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.⁵ Suitable programmes are the X-PERT Diabetes Programme and the Diabetes Education and Self-management for Ongoing and Newly Diagnosed (DESMOND), see seperate Diabetes Education and Self-management Programmes article.
• Discuss diet and give dietary advice taking into account other factors, e.g. obesity, hypertension, renal impairment; offer referral to dietician.
• Encourage regular physical activity.
• Give advice and support on smoking cessation where appropriate.
• If appropriate, advise of need to contact DVLA to inform of diagnosis (see DVLA Medical Standards of Fitness to Drive.⁶)

Initial assessment and monitoring

• Check height, weight and calculate BMI; also measure waist circumference. Waist circumference is significantly associated with the risk of cardiovascular disease.^7,8
• Check smoking status and offer cessation advice as appropriate.
• Glucose control:
  • Offer self-monitoring of plasma glucose to a person newly diagnosed with type 2 diabetes only as an integral part of his or her self-management education.
    • Discuss its purpose and agree how it should be interpreted and acted upon.
    • Self-monitoring should be available to those on insulin, oral glucose-lowering treatment and to assess changes, e.g. change of treatment, acute illness, or for safety during activities such as driving.⁴
    • Urine glucose monitoring should be offered if blood glucose testing is unacceptable.
    See article Self-monitoring in Diabetes Mellitus.
  • Glycosylated haemoglobin (HbA1c):
    • Involve the person in decisions about their individual HbA1c target level, which may be above that of 6.5% set for people with type 2 diabetes in general.
    • Encourage the person to maintain their individual target, unless the resulting side-effects (including hypoglycaemia) or their efforts to achieve this, impair their quality of life.
    • Avoid pursuing highly intensive management to levels of less than 6.5%.
    • Check HbA1c routinely every 6 months but as frequently as 2 monthly, especially if changing treatment, poor control or intercurrent illness.⁴
    • HbA1c measurement is invalid in the presence of haemoglobinopathy or abnormal erythrocyte turnover.
• If blood pressure is <130/80 mmHg (with end-organ damage), monitor 4-6 monthly. Otherwise target BP is 140/80 mmHg which can be monitored annually.
• Renal monitoring: annual urine for albumin creatinine ratio (ACR); ideally a sample from the first passed urine of the day; creatinine and eGFR. If abnormal, see below under Monitoring for kidney damage.
• Serum lipids (see below); serum total and high-density lipoprotein cholesterol, fasting serum triglycerides.⁹
• Thyroid function tests (at diagnosis and annually).
• Eye: annual eye screening (including for example visual acuity, cataracts, diabetic retinopathy) and retinal photography.
• Neuropathic pain: ask at least once annually about symptoms of neuropathic pain.
• Feet: annual examination, including sensation (10 g monofilament or vibration), foot pulses, ulcers, foot deformity and footwear.

Dietary advice

See separate article Diabetes Diet And Exercise.

• Provide individualised and ongoing nutritional advice from a healthcare professional with specific expertise and competencies in nutrition.

Referral

The precise arrangements for referrals will depend on local service provisions and guidelines.

• Refer to a dietician as available and when indicated.
• Refer to local retinal screening service.⁹
• Refer people who have poor control of glucose or other cardiovascular risk factors despite optimal management in primary care.
• Refer people who present with complications of diabetes (e.g. nephropathy, retinopathy, cataracts, retinopathy).⁹
• Increased risk of foot ulcers (neuropathy or absent pulses or other risk factor) - arrange regular review, 3–6 monthly, by foot protection team.¹⁰
• High risk of foot ulcers (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) - arrange frequent review (1–3 monthly) by foot protection team.¹⁰
• Foot care emergency (new ulceration, swelling, discolouration) - refer to multidisciplinary foot care team within 24 hours.¹⁰
• Refer pregnant women with diabetes, or those planning a pregnancy, for specialist care.

There is a separate record on Managing Diabetes In General Practice.

Management of glucose control⁴

• See separate articles Diabetes, Oral Hypoglycaemic Agents and Exenatide and Insulin Regimens.
• The recommended steps for glucose control in the NICE guidance are:⁴
  1. Metformin
  2. Metformin and a sulfonylurea (consider substituting a DPP-4 inhibitor or a thiazolidinedione for the sulfonylurea if there is a significant risk of hypoglycaemia or a sulfonylurea is contra-indicated or not tolerated.)
  3. Add thiazolidinedione or insulin (exenatide may be considered at this stage if NICE criteria are met - see separate article above, and NICE guideline).
  4. Insulin and metformin and a sulfonylurea
  5. Increase insulin dose and intensify regimen over time

Follow-up

Blood pressure management⁴

See separate article Diabetes with Hypertension.

• If kidney, eye or cerebrovascular damage, set a blood pressure target <130/80 mmHg; for others set a target <140/80 mmHg.
• The stages of treatment for raised blood pressure in people with type 2 diabetes are:
  1. Advise on lifestyle measures.
  2. Offer ACE inhibitor (titrate dose); for people of African-Caribbean descent, offer ACE inhibitor plus diuretic or calcium channel blocker (CCB).
     • If there is a possibility of the person becoming pregnant, start with a CCB.
     • If continuing intolerance to ACE inhibitor (other than renal deterioration or hyperkalaemia), change to an angiotensin II receptor blocker.
  3. Add CCB or diuretic (usually bendroflumethiazide, 2.5 mg daily).
  4. Add other drug (diuretic or CCB).
  5. Add alpha blocker, beta blocker or potassium-sparing diuretic.

Management of blood lipids⁴

See separate article Hyperlipidaemia.

• Review CV risk status annually, including risk factors such as features of metabolic syndrome and waist circumference, and full lipid profile (including HDL-C and TG). Consider to be at high CV risk unless all of the following apply:
  • Not overweight (tailor with body weight-associated risk assessment according to ethnic group)
  • Normotensive (<140/80 mmHg in absence of antihypertensive therapy)
  • No microalbuminuria
  • Non-smoker
  • No high-risk lipid profile
  • No history of CV disease
  • No family history of CV disease.
• Estimate CV risk from UKPDS risk engine annually if assessed as not at high CV risk.¹¹
• Consider generic simvastatin (to 40 mg) or a statin of similar efficacy and cost if:
  • Age under 40 years and poor CV risk factor profile.
  • Age 40+ years and CV risk >20% over 10 years.
• Assess lipid profile and modifiable risk factors 1–3 months after starting therapy. Continue to monitor annually:
  • If high CV risk and TG = 2.3–4.5 mmol/litre despite statin, consider adding fibrate.
  • Treat to achieve total cholesterol <4.0 mmol/litre (HDL-C 1.4 mmol/litre or below) or LDL-C <2.0 mmol/litre.
• If target is not reached:
  • Increase simvastatin to 80 mg daily
  • Consider intensifying therapy with a more effective statin or ezetimibe if there is existing or newly diagnosed CV disease (HDL-C should not exceed 1.4mmol/litre) or increased albumin excretion rate.
• If becoming pregnant is a possibility, discuss issues surrounding statin use and agree next step with the woman.
• High serum triglyceride (TG):
  • Assess possible secondary causes (including poor glycaemic control) and treat if identified.
  • If TG remains >4.5 mmol/litre (despite optimised glycaemic control), offer fibrate (if acute need, may be necessary to start fibrate before statin).
  • If lifestyle measures and fibrate therapy have proved to be ineffective, consider a trial of highly-concentrated, licensed omega-3 fish oils.

Anti-thrombotic therapy

The NICE guideline recommends offering low-dose (75 mg) daily aspirin (or clopidogrel if clear aspirin intolerance) if:⁴

• Age 50+ years and BP <145/90 mmHg, or
• Age <50 years and significant other CV risk factors
• Secondary prevention of cardiovascular disease

However a very recent multicentre, randomised, double-blind, placebo-controlled trial did not find evidence to support the use of aspirin or antioxidants in the primary prevention of cardiovascular events and mortality in people with diabetes.¹²

Monitoring for kidney damage⁴

See separate article Diabetic Nephropathy.

• Arrange annual albumin creatinine ratio (ACR) estimation ideally on first-pass urine sample, measure serum creatinine and estimated GFR.
• If abnormal ACR (in absence of proteinuria/UTI): repeat test at next two clinic visits and within 3–4 months; microalbuminuria is confirmed if at least one out of two or more results is also abnormal.
• Suspect renal disease other than diabetic nephropathy and consider further investigation or referral if ACR is raised and:
  • No significant or progressive retinopathy, or
  • BP is particularly high or resistant to treatment, or
  • Heavy proteinuria (ACR > 100 mg/mmol) but ACR previously documented as normal, or significant haematuria, or
  • GFR has worsened rapidly, or
  • The person is systemically ill.
• If diabetic nephropathy is confirmed, offer ACE inhibitor with dose titration; substitute an angiotensin 2 receptor blocker if ACE inhibitors are poorly tolerated.
• Maintain BP < 130/80 mmHg if abnormal ACR.

Eye screening⁴

See separate article Diabetic Retinopathy and Other Eye Problems.

• Arrange or perform eye screening at or around the time of diagnosis.
• Use a quality-assured digital retinal photography programme with appropriately trained staff. Repeat structured eye surveillance annually, unless findings require other action.
• Perform visual acuity testing as a routine part of eye surveillance programmes.
• Emergency review by ophthalmologist for:
  • Sudden loss of vision
  • Rubeosis iridis
  • Pre-retinal or vitreous haemorrhage
  • Retinal detachment.
• Rapid review by ophthalmologist for new vessel formation.
• Refer to ophthalmologist if:
  • There are features of maculopathy, including:
  • Exudate or retinal thickening within one disc diameter of the centre of the fovea
  • Circinate or group of exudates within the macula
  • Any microaneurysm or haemorrhage within one disc diameter of the centre of the fovea, if associated with a best visual acuity of 6/12 or worse
  • There are features of pre-proliferative retinopathy, including:
    • Any venous beading
    • Any venous loop or reduplication
    • Any intraretinal microvascular abnormalities
    • Multiple deep, round or blot haemorrhages
    • Any unexplained drop in visual acuity

Management of foot problems

See separate articles Diabetic Neuropathy and Diabetic Foot.

Neuropathic pain management

See separate article Neuropathic Pain and its Management.

• Ask about neuropathic symptoms at diagnosis and at every review.
• If required, offer a tricyclic drug, starting at low doses and titrate as tolerated.
• If symptoms not adequately controlled, offer trial of cheapest (at maximum dose) of duloxetine, gabapentin or pregabalin; stop if ineffective at maximally tolerated dose; try another of the drugs if side-effects limit dose titration.⁴
• If symptoms still not adequately controlled, consider trial of opiate analgesia.
• If symptoms controlled, consider reducing dosage or stopping therapy following discussion and agreement with person concerned.
• If symptoms remain uncontrolled, discuss with the person and seek assistance of local chronic pain management team.

Other management issues

Assessment of the Established Diabetic is covered separately:

• People with diabetes should be offered influenza vaccination and pneumococcal vaccination.
• Managing diabetes and intercurrent illness is covered in the separate record Diabetes and Intercurrent Illness.
• Depression screening; early detection, support and effective management.
• There is a separate record on Precautions with Diabetic Patients Undergoing Surgery.
• Be alert for the potential development of metabolic syndrome.
• Management of features of autonomic neuropathy, e.g. gastroparesis, erectile dysfunction, loss of warning signs for hypoglycaemia, unexplained diarrhoea (especially at night) and unexplained bladder-emptying problems.

Prevention

This covered in detail in the Prevention of Type 2 Diabetes Mellitus record.

Document references

1. No authors listed; Intensive diabetes management: implications of the DCCT and UKPDS. Diabetes Educ. 2002 Sep-Oct;28(5):735-40.
2. Gerstein HC, Miller ME, Byington RP, et al; Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008 Jun 12;358(24):2545-59. Epub 2008 Jun 6. [abstract]
3. 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 12;358(24):2560-72. Epub 2008 Jun 6. [abstract]
4. Type 2 diabetes - newer agents (partial update), NICE Clinical Guideline (May 2009); Type 2 diabetes - newer agents for blood glucose control in type 2 diabetes
5. Diabetes (types 1 and 2) - patient education models, NICE Technology Appraisal (2003); The clinical effectiveness and cost effectiveness of patient education models for diabetes
6. At a Glance Guide to the Current Medical Standards of Fitness to Drive, Driver and Vehicle Licensing Agency, Swansea
7. Dobbelsteyn CJ, Joffres MR, MacLean DR, et al; A comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. The Canadian Heart Health Surveys. Int J Obes Relat Metab Disord. 2001 May;25(5):652-61. [abstract]
8. 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 Apr;28(7):850-6. Epub 2007 Apr 2. [abstract]
9. Diabetes Type 2, Clinical Knowledge Summaries (2009)
10. Type 2 diabetes: Prevention and management of foot problems, NICE Clinical Guideline (January 2004)
11. UKPDS Risk Engine; available on the website of the Oxford Centre for Diabetes, Endocrinology and Metabolism.
12. Belch J, MacCuish A, Campbell I, et al; The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ. 2008 Oct 16;337:a1840. doi: 10.1136/bmj.a1840. [abstract]

Internet and further reading

• Diabetes UK
• National Diabetes Information Clearing House

Acknowledgements