Management of Type 2 Diabetes

Effective management of people with type 2 diabetes must be based on support, education and motivation. 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 cessation, sedentary lifestyle, hypertension, hyperlipidaemia and obesity) is essential.

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.

• Type 2 diabetes is seen most frequently in those over the age of 40, although is becoming more frequent in all age groups including children and young adults.
• It is more common in certain ethnic minority groups e.g. those from India and Africa.
• Over 1.3 million people are known to have diabetes in the UK, and 85% of these have type 2 diabetes.¹

• Type 2 diabetes is a disease of gradual onset which may have only non-specific symptoms in the initial stages and is frequently diagnosed at routine screening or screening for non-specific symptoms such as tiredness.
• Patients with type 2 diabetes will only complain of polyuria and polydipsia late in the disease history, more frequently they are picked up at routine screening.
• A diagnosis of diabetes may be made in the presence of classical symptoms such as polyuria and polydipsia if:²
  • A random blood glucose ≥ 11.1mmol/l (200 mg/dl) OR
  • A fasting blood glucose ≥ 7.0 mmol/l (126 mg/dl)
• In the absence of classical symptoms if:
  • 2 fasting plasma glucose samples ≥ 7.0 mmol/l (126 mg/dl) OR
  • 2 random blood glucose levels of ≥ 11.1mmol/l (200 mg/dl) OR
  • 1 fasting level ≥7.0 mmol/l AND EITHER 1 random level of ≥11.1 mmol/l OR a level of ≥ 11.1 mmol/l (200 mg/dl), 2 hours post 75g of glucose (oral glucose tolerance test)

• The successful management of the diabetic patient is dependent on working in partnership with the patient, and all members of the team responsible for the various elements of their care.
• Before a management plan can be agreed, an initial assessment of the health and lifestyle of the patient must be undertaken with particular reference to:³
  • History
    • Symptoms of potential complications e.g. deterioration in eyesight
    • Other medical conditions
    • Drug history, current medications
    • Family history
    • Occupation and social history e.g. level of exercise, type of diet, smoking history, use of alcohol and "recreational drugs"
    • Prior knowledge of, attitudes to, and concerns about diabetes
  • Examination
    • General examination
    • Height/ weight/ BMI
    • Examination of feet (e.g.ulcers, loss of sensation)
    • Examination of eyes (e.g. cataracts, diabetic retinopathy)
    • Blood pressure measurement
    • Examination of peripheral pulses

The following investigations should be performed routinely:

• Urine protein (diabetic nephropathy: albumin loss of > 300mg/day)
• If no measurable protein on urine dipstick testing, test for urine albumin excretion (microalbuminuria: albumin loss of 30-300mg/day).
• Glycosylated haemoglobin (HbA1c)
• Renal function and electrolytes
• Serum cholesterol

Non-drug^1,3,4

• 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.
• Self monitoring should be taught if the patient is clear about the purpose.
• Patient education and advice should be made available on an ongoing basis.

Drug Treatment⁴

All decisions concerning treatment should be made with the patient in partnership, as patients who make informed shared decisions concerning their management are more likely to adhere to any given regime.

• Step 1: Metformin:
  • May be used as a first line treatment for all patients other than those with serious renal impairment.
  • Metformin should be used as first line treatment in all patients who are overweight as in this group it reduces all diabetes related end points beyond that which can be explained by glycaemic control alone.⁵
  • For those for whom metformin is contraindicated or who are not overweight, a sulphonylurea such as glibenclamide is an alternative first line agent.
• Step 2:
  • If glucose control is inadequate with metformin alone, an insulin secretagogue such as glibenclamide should be added to the regime.
  • Patients with more erratic lifestyles may benefit from the addition of a rapid-acting secretagogue such as nateglinide or repaglinide.
  • Patients taking any form of secretagogue medication should be warned of the possibility of hypoglycaemic episodes.
• Step 3:
  • In patients who are unable to tolerate a metformin/secretagogue regime, or in whom blood glucose remains high despite such a regime, a glitazone should be added, or substituted.
  • This group of drugs should only be initiated by a physician experienced in treating type 2 diabetes and should always be used in combination with metformin or with a sulphonylurea if metformin not appropriate.
  • The "glitazones" are contraindicated in patients receiving treatment with insulin, any history of liver disease, cardiac failure or severe renal impairment; liver function should be monitored every 8 weeks for the first year of treatment.
• Step 4:
  • Ascarbose may be used in patients unable to use any of the above regimes.
• Step 5:
  • Patients who are not adequately controlled on oral hypoglycaemic agents may be treated with insulin. In these patients, the first line agent, either metformin or a sulphonylurea, should also be continued.
• Other drug treatment:
  • Orlistat may be considered to help weight loss in patients with type 2 diabetes.⁴
  • Thiazides and/or ACE inhibitors should be used to control hypertension. In the presence of microalbuminuria or proteinuria ACE inhibitors should be used as first line agents.⁴
  • Low dose aspirin and statins are now standard treatment from diagnosis (to counteract increased cardiovascular risk).⁴

Review assessment

• All patients with type 2 diabetes should have glycaemic control reviewed at 2-6 monthly intervals.⁴
• Other aspects of diabetes should be reviewed every 6-12 months and should include:
  • Glycaemic control and any perceived problems.
  • Reinforce need for lifestyle measures.
  • Height, weight and calculate BMI.
  • HbA1c (check every 2-6 months, aim for level of 6.5%-7.5%).
  • Full lipid profile.
  • Level of urinary albumin/protein.
  • Renal function (eGFR) and electrolytes.
  • BP measurement (Maintain below 130/80).
  • Examination of eyes for signs of retinopathy and cataracts.
  • Examination of feet for ulceration /sensation/peripheral pulses.
  • Examination of injection sites if appropriate.
  • If male, ask about impotence.