Glycaemic Control
Important Notes
Individual patient circumstances may dictate deviation from the pathways outlined at the supervising clinician's discretion.
Those who are pregnant or aged 16 and under should be under Specialist care.
Some individuals with type 2 diabetes will progress to insulin more quickly than outlined according to their circumstances. Particular circumstances in which insulin treatment would be considered are:
- presentation with ketoacidosis
- post myocardial infarction
- symptoms suggesting marked insulin deficiency.
The importance of good glycaemic control is emphasised here but for some individuals the cost of achieving this outweigh the benefits. Individualisation of treatment goals is therefore appropriate. Difficult cases should be discussed with the specialist team.
Actions of Type 2 Drugs:
Here is a brief outline of the role of oral medication. . It is intended as a guide with the algorithm making clinical suggestions at appropriate times:
Metformin: Reduces glucose production and insulin resistance. First choice in overweight patients. Avoid if eGFR < 30.
Sulphonylureas: Increases Insulin production. First choice in thin patients. Teach BGM to avoid hypoglycaemia. Associated with weight gain in obese patients. Avoid longacting agents (glibenclamide etc) in elderly and renal impairment.
Glitazones. Reduces insulin resistance. Associated with weight gain and fluid retention. Do not use if history consistent with heart failure or fracture risk greater than 10%. (to work out fracture risk: www.shef.ac.uk/FRAX/ , use calculator tool for UK). Rosiglitazone shown to reduce progression to next step in early phase of disease compared to SUs. Pioglitazone beneficial in patients with vascular disease (of other drugs only metformin has same benefit), avoid Rosiglitazone in IHD.
Gliptins: Change hormonal response within the gut. Weight neutral and not associated with hypoglycaemia. No long term outcome data. Consider later in overweight patients.
GLP1 Analogues: Injectible and effect gut hormones. Associated with weight loss. Consider on Metformin +/- others who have BMI> 35 with poor control.
Acarbose; Reduces carbohydrate absorbtion from the gut. Weight neutral. Gastric side effects restrict use.
For some obese insulin resistant individuals the pathway may suggest that progression to insulin is required when this may have to be balanced against the risk of weight gain. In most cases improved control with insulin therapy probably outweighs the risks of weight gain with insulin, but attention to treatment of obesity should be considered in all these individuals and may warrant a delay in starting insulin treatment. The diabetes team are very happy to discuss these difficult cases or review them.
NICE guidelines on type 2 diabetes May 2008. http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11983
http://guidance.nice.org.uk/CG87 for recent partial update.
