Management of type 2 diabetes in adults: NICE Guideline

NICE has released its updated version of guidelines on the management of type 2 diabetes in adults. It focuses on patient education, dietary advice, managing cardiovascular risk, managing blood glucose levels, and identifying and managing long-term complications.

Following are the key recommendations:

Patient Education

• Offer structured education to adults with type 2 diabetes and/or their family members or carers (as appropriate) at and around the time of diagnosis, with annual reinforcement and review. Explain to people and their carers that structured education is an integral part of diabetes care.


• Ensure the patient-education programme provides the necessary resources to support the educators, and that educators are properly trained and given time to develop and maintain their skills.


• Offer group education programmes as the preferred option. Provide an alternative of equal standard for a person unable or unwilling to participate in group education.


• Ensure that the patient-education programmes available meet the cultural, linguistic, cognitive and literacy needs within the local area.


• Ensure that all members of the diabetes healthcare team are familiar with the patient-education programmes available locally, that these programmes are integrated with the rest of the care pathway, and that adults with type 2 diabetes and their family members or carers (as appropriate) have the opportunity to contribute to the design and provision of local programmes.

Dietary Advice

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


• Provide dietary advice in a form sensitive to the person’s needs, culture and beliefs, being sensitive to their willingness to change and the effects on their quality of life.


• Emphasise advice on healthy balanced eating that is applicable to the general population when providing advice to adults with type 2 diabetes. Encourage high-fibre, low-glycemic-index sources of carbohydrate in the diet, such as fruit, vegetables, whole grains and pulses; include low-fat dairy products and oily fish, and control the intake of foods containing saturated and trans fatty acids.


• Integrate dietary advice with a personalised diabetes management plan, including
  other aspects of lifestyle modification, such as increasing physical activity and losing weight.


• For adults with type 2 diabetes who are overweight, set an initial body weight loss
  target of 5-10%. Remember that lesser degrees of weight loss may still be of benefit, and that larger degree of weight loss in the longer term will have advantageous metabolic impact.


• Individualise recommendations for carbohydrate and alcohol intake, and meal patterns. Reducing the risk of hypoglycaemia should be a particular aim for a person using insulin or an insulin secretagogue.


• Advise adults with type 2 diabetes that limited substitution of sucrose-containing foods for other carbohydrates in the meal plan is allowable, but that they should take care to avoid excess energy intake.


• Discourage the use of foods marketed specifically for people with diabetes.


• When adults with type 2 diabetes are admitted to hospital as inpatients or to any other care settings, implement a meal planning system that provides consistency in the carbohydrate content of meals and snacks.

Blood Pressure Management

• Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive
  lifestyle advice.


• For an adult with type 2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and medications used. Make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems.


• Repeat blood pressure measurements within:
  
  
  
  • 1 month if blood pressure is higher than 150/90 mmHg
  
  
  • 2 months if blood pressure is higher than 140/80 mmHg
  
  
  • 2 months if blood pressure is higher than 130/80 mmHg and there is kidney, eye or cerebrovascular damage.
  
  
  
  


• Provide lifestyle advice if blood pressure is confirmed as being consistently above 140/80 mmHg (or above 130/80 mmHg if there is kidney, eye or cerebrovascular
  damage).


• Monitor blood pressure every 1-2 months, and intensify therapy if the person is already on antihypertensive drug treatment until the blood pressure is consistently below 140/80 mmHg.


• First-line antihypertensive drug treatment should be a once-daily, generic angiotensin-converting enzyme (ACE) inhibitor.


• A calcium-channel blocker should be the first-line antihypertensive drug treatment for a woman for whom, after an informed discussion, it is agreed there is a possibility of her becoming pregnant.


• For a person with continuing intolerance to an ACE inhibitor (other than renal deterioration or hyperkalaemia), substitute an angiotensin II-receptor antagonist for the ACE inhibitor.


• Do not combine an ACE inhibitor with an angiotensin II-receptor antagonist to treat hypertension.


• If the person’s blood pressure is not reduced to the individually agreed target with first-line therapy, add a calcium-channel blocker or a diuretic (usually a thiazide or thiazide-related diuretic). Add the other drug (that is, the calcium-channel blocker or diuretic) if the target is not reached with dual therapy.


• If the person’s blood pressure is not reduced to the individually agreed target with triple therapy, add an alpha-blocker, a beta-blocker or a potassium-sparing diuretic.


• Monitor the blood pressure of a person who has attained and consistently remained at his or her blood pressure target every 4-6 months. Check for possible adverse effects of antihypertensive drug treatment – including the risks from
  unnecessarily low blood pressure.

Antiplatelet Therapy

• Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.

Blood Glucose Management

HbA1c measurement and targets

Measurement

• In adults with type 2 diabetes, measure HbA1c levels at:
  
  
  
  • 3-6 monthly intervals, until the HbA1c, is stable on unchanging therapy
  
  
  • 6-monthly intervals once the HbA1c level and blood glucose-lowering therapy are stable.
  
  
  
  


• Use methods to measure HbA1c that have been calibrated according to the International Federation of Clinical Chemistry (IFCC) standardisation.


• If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using one of the following:
  
  
  
  • quality-controlled plasma glucose profiles
  
  
  • total glycated haemoglobin estimation (if abnormal haemoglobins)
  
  
  • fructosamine estimation
  
  
  
  


• Investigate unexplained discrepancies between HbA1c and other glucose measurements.

Targets

• Involve adults with type 2 diabetes in decisions about their individual HbA1c target. Encourage them to achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life.


• Offer lifestyle advice and drug treatment to support adults with type 2 diabetes to achieve and maintain their HbA1c target.


• For adults with type 2 diabetes managed either by lifestyle and diet or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%).


• In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
  
  
  
  • reinforce advice about diet, lifestyle and adherence to drug treatment and
  
  
  • support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and
  
  
  • intensify drug treatment
  
  
  
  


• Consider relaxing the target HbA1c level on a case-by-case basis, with particular
  consideration for people who are older or frail, for adults with type 2 diabetes:
  
  
  
  • who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
  
  
  • for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job.
  
  
  • for whom intensive management would not be appropriate, for example, people with significant comorbidities.
  
  
  
  


• If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example, deteriorating renal function or sudden weight loss.

Self-monitoring of blood glucose

• Take the Driver and Vehicle Licensing Agency (DVLA) guide, At a glance guide to
  the current medical standards of fitness to drive, into account when offering self-monitoring of blood glucose levels for adults with type 2 diabetes.


• Do not routinely offer self-monitoring of blood glucose levels for adults with type 2
  diabetes unless:
  
  
  
  • the person is on insulin or there is evidence of hypoglycaemic episodes or
  
  
  • the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery or
  
  
  • the person is pregnant or is planning to become pregnant.
  
  
  
  


• Be aware that adults with type 2 diabetes who have the acute intercurrent illness are at risk of worsening hyperglycaemia. Review treatment as necessary.

Drug treatment

• For adults with type 2 diabetes, discuss the benefits and risks of drug treatment, and the options available. Base the choice of drug treatment on:
  
  
  
  • the effectiveness of the drug treatment(s) in terms of metabolic response
  
  
  • safety and tolerability of the drug treatment(s)
  
  
  • the person’s individual clinical circumstances, for example, comorbidities, risks from polypharmacy
  
  
  • the person’s individual preferences and needs
  
  
  • the licensed indications or combinations available
  
  
  • cost
  
  
  
  

Initial drug treatment

• Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes.


• Gradually increase the dose of standard-release metformin over several weeks to minimise the risk of gastrointestinal side effects in adults with type 2 diabetes.


• If an adult with type 2 diabetes experiences gastrointestinal side effects with standard-release metformin, consider a trial of modified-release metformin.

First intensification of drug treatment

• treatment with metformin has not continued to control HbA1c to below the person’s individually agreed threshold for intensification, consider dual therapy with:
  
  
  
  • metformin and a DPP-4 inhibitor or
  
  
  • metformin and pioglitazone or
  
  
  • metformin and a sulfonylurea.
  
  
  
  


• Treatment with combinations of medicines including sodium-glucose cotransporter 2 (SGLT-2) inhibitors may be appropriate for some people with type 2 diabetes.

Second intensification of drug treatment

• In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, and if dual therapy with 2 oral drugs has not continued to control HbA1c to below the person’s individually agreed threshold for intensification, consider insulin-based treatment.


• In adults with type 2 diabetes, only offer a GLP-1 mimetic in combination with insulin with specialist care advice and ongoing support from a consultant-led multidisciplinary team.


• Treatment with combinations of medicines including SGLT-2 inhibitors may be appropriate for some people with type 2 diabetes.

Insulin-based treatments

• When starting insulin therapy in adults with type 2 diabetes, continue to offer metformin for people without contraindications or intolerance. Review the continued need for other blood-glucose-lowering therapies.


• Monitor adults with type 2 diabetes who are on a basal insulin regimen (NPH insulin, insulin detemir or insulin glargine for the need for short-acting insulin before meals.


• Monitor adults with type 2 diabetes who are on pre-mixed (biphasic) insulin for the need for a further injection of short-acting insulin before meals or for a change to a basal-bolus regimen with NPH insulin or insulin detemir or insulin glargine if blood glucose control remains inadequate.

Managing Complications

Gastroparesis

• Think about a diagnosis of gastroparesis in adults with type 2 diabetes with erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses.

Autonomic neuropathy

• Think about the possibility of contributory sympathetic nervous system damage for adults with type 2 diabetes who lose the warning signs of hypoglycaemia.


• Think about the possibility of autonomic neuropathy affecting the gut in adults with type 2 diabetes.


• Investigate the possibility of autonomic neuropathy affecting the bladder in adults with type 2 diabetes who have unexplained bladder-emptying problems.


• In managing autonomic neuropathy symptoms, include specific interventions indicated by the manifestations.

Erectile dysfunction

• Offer men with type 2 diabetes the opportunity to discuss erectile dysfunction as part of their annual review.


• Assess, educate and support men with type 2 diabetes who have problematic
  erectile dysfunction, addressing contributory factors such as cardiovascular disease as well as possible treatment options.


• Consider a phosphodiesterase-5 inhibitor to treat problematic erectile dysfunction in men with type 2 diabetes, initially choosing the drug with the lowest acquisition cost and taking into account any contraindications.

Eye disease

• Arrange or perform eye screening at or around the time of diagnosis. Arrange a repeat of structured eye screening annually.


• Explain the reasons for, and success of, eye screening systems to adults with type 2
  diabetes, so that attendance is not reduced by lack of knowledge or fear of the outcome.


• Use mydriasis with tropicamide when photographing the retina, after prior informed agreement following discussion of the advantages and disadvantages. Discussions should include precautions for driving.


• Use a quality-assured digital retinal photography programme using appropriately trained staff.

To read the full guidelines visit: www.nice.org.uk