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A Resource for Glycaemic management in Type 2 DM Drugs do not replace lifestyle advice at any stage Lifestyle • Individualise HbA1C target. Early tight control reduces later complications Individual Target Hypoglycaemia is dangerous: • • • • Beware in Elderly/RF/CVS risk Sulphonureas need education to avoid risk Do not escalate Rx if hypoglycaemia present Beware low HbA1C with insulin and sulphonureas 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 Take me to the Quick Guide Authors: Review date: Version: Useful resources Coastal West Sussex Diabetic group September 2012 No. 1 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 Diet and lifestyle tried HbA1C > 48 (6.5%) Individual Target • Symptomatic of hyperglycaemia requiring rapid control / low BMI • Metformin Contraindicated or not tolerated Lifestyle 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 Drug Information NICE Criteria Metformin + Sitagliptin or Pioglitazone Management of Low eGFR Individual Target Lifestyle High BMI? See NICE criteria for GLP1 agonist use Insulin acceptable? Start Insulin Hypo Insulin Advice Button Monitor 6/12 Target Hypo Advice NICE Criteria Hypo Advice Insulin Button Change to insulin Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009) Lifestyle Consider triple RX Metformin Gliclazide + Sitagliptin or Pioglitazone HbA1C> 58 (7.5) Target not met Useful resources HbA1C > 58 (7.5%) Do not fit NICE criteria for GLP1 agonist or Insulin unacceptable Consider Metformin +/- Gliclazide + Exenatide or Liraglutide Intensify Insulin +/- Metformin +/- pioglitazone +/- sitagliptin Home Consider Sulphonylurea pathway page 2 Hypo Advice Insulin Start Insulin Button +/- Metformin +/- pioglitazone +/- sitagliptin Sulphonylurea Pathway Gliclazide Metformin tolerated Return to Metformin pathway (page1) Consider stopping Gliclazide if initial response rapid Hypo Advice Individual Target > HbA1C 52 (7%)or individualised target Lifestyle Poor initial response V low BMI Exclude underlying pathology May need insulin, (type1?) refer Metformin not tolerated or contraindicated then consider Sitagliptin or Pioglitazone Gliclazide + Sitagliptin or Pioglitazone Individual Target > HbA1C 58 (7.5%) or individualised target Lifestyle Start Insulin Hypo Advice Intensify Insulin Regimen Drug Information Home Useful resources Management of Low eGFR Take me back to the quick guide, page 1 Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009) Lifestyle interventions Diet • Who should see the Dietitian? • Diet sheets • Diet advice – Click here to access the Eat well with DM2 DUK web page Weight • Weight loss Help – click here to access the Why Weight page on the GP website – Why Weight: Tel 0300 123 0892 Exercise • Exercise Referral Smoking • Stop Smoking advice: Tel 0300 100 1823 Desmond Education Care Plan with Individualised Target • Example Diabetic Care Plan Home Take me back to the quick guide 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 • Driving and hypoglycaemia advice • Medical standards of fitness to drive Home Take me back to the quick guide Individualised Target Aim 48-53 (6.5-7%) Aim 58 (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 Macro-vascular complication When setting a target HBA1C): • 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/l or 6.5%) holds better long-term outcome Home Take me back to the quick guide Insulin • Insulin should be initiated by qualified practitioners only. Dietician 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 Home Take me back to the quick guide NICE Criteria DPP-4 inhibitors (Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin) • • 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 • Discuss the benefits of GLP1 agonist to allow the person to make an informed decision. Consider starting in: • BMI ≥ 35 kg/m2 in people of European descent and there are problems associated with high weight, or • BMI < 35 kg/m2 and insulin is unacceptable because of occupational implications or weight loss would benefit other co-morbidities. 6 month review • 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) • • • • 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 Home Take me back to the quick guide 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/ Home Take me back to the quick guide Useful Resources Diagnostic criteria • • WHO. Quick summary chart Referral protocols • • • Dietitian DSN Footcare clinic Information Leaflets For the patient: • Diet sheets • Driving and the new medical standards for people with diabetes • Footcare instructions • Hypoglycaemia dietary advice For the Clinician • Mood Management Referral • Preconception Consultation • Emergency Hypoglycaemia Treatment Useful Websites • HBA1C conversion chart • Link to safe use of insulin on NHS Diabetes website • Click here to access the DVLA Guide to Medical Standards of fitness to drive • Click here to access the Map of Medicine • Click here to access the NICE pathway for a Diabetes overview • Click here to access Diabetes UK • Click here to access DUK – Understanding Diabetes • Click here to access Diabetes Bible Contact Details • Hospital contact details – – Home Worthing Diabetes Centre 01903 285044 (9am – 3pm, Mon - Fri) St Richards Diabetes Centre 01243 831614 (8am - 5pm, Mon - Thu) Take me back to the quick guide