Type 2 Diabetes

NICE criteria for diagnosis 

 Prediabetes: HbA1c - 42 to 47mmol/mol (6 to 6.4%) 

 Diabetes: HbA1c - 48mmol/mol or higher (6.5%) on 2 independent occasions OR fasting plasma glucose – 7mmol/L or higher on 2 independent occasions 

👉 HbA1c diagnosis should not be used in the following instances:  rapid blood sugar increase/ increased red cell turnover/ pregnancy/ anaemia/ haemoglobinopathies ❌ 

👉 Where possible a second test should be performed to confirm accuracy 

 Gestational Diabetes: oral glucose tolerance test (after 75g load): 

👉 Fasting: 5.1mmol/L or higher 

👉 1 hour: 10mmol/L or higher ⏱ 

👉 2 hour: 8.5mmol/L or higher ⏱ 

Management 

 Blood Pressure Target:  

👉 Diagnostic thresholds – Clinic BP greater than 140/90, fit ABPM, and if ABPM is greater than 135/85, diagnose hypertension

 Treatment Target: 

👉 Clinic BP less than 140/90 if patient is over 80 years old (y/o) OR clinic bp less than 150/90 if patient is 80 y/o or older  

 Cholesterol Target:  

👉 40% decrease in non-high-density-lipoprotein (non-HDL) cholesterol (to prevent both primary and secondary type 2 diabetes prevention) 

 HbA1c Target:  

👉 Intensify lifestyle treatment if HbA1C is above 48/6.5% OR intensify all treatment if HbA1c is above 58/7.5% 

Treatment 

 Lifestyle changes: 

👉 Refer patient to an educational programme when diagnosed 

👉 Annually reinforce the importance of diet/lifestyle management 

👉 In overweight patients: aim to reduce weight by 5 to 10% ⬇ 

👉 Ask male patients if they have experienced erectile dysfunction, annually (if so, review CVD risk factors/offer treatments such as PDE5 inhibitor if lifestyle changes alone are ineffective) 👨

 Blood Pressure:  

👉 Follow hypertension guidelines presented by NICE (2019) 

👉 1st line: patients of all ages/ethnicities should be given an ACE inhibitor (ARB if ACE cannot be tolerated) 💊

👉 2nd line: 2 of the following should be given – ACE, CCB, thiazide-like diuretic 💊

👉 3rd line: ACE + CCB + thiazide-like diuretic 💊

👉 4th line: if potassium is less than or equal to 4.5, add spironolactone to the treatment OR if potassium is greater than 4.5, add alpha/beta blocker to the treatment 💊

 Lipids: 

👉 Primary prevention – 20mg of Atorvastatin if QRISK is 10% or higher (reduce non-HDL cholesterol 40%) 💊

👉 Secondary prevention – 80mg of Atorva (reduce non-HDL cholesterol 40%) 💊

👉 Aspirin/antiplatelets - Do NOT use unless CVD already diagnosed 💊

 Glycaemic control:  

👉 Intensify treatment if HbA1c is greater than 48/6.5% when lifestyle changes are being used as the only form of management OR intensify treatment if HbA1c is greater than 58/7.5% when any drug therapy is being used as management ⬆ 

👉 Targets following intensification of treatment: 48/6.5% for patient on monotherapy with metformin/gliptin/piogitazone OR 53/7% for patients on any other treatments 💊

👉 Treatment should be patient specific to ensure the patient’s lifestyle improves

👉 Patient should only monitor their own levels if they are on insulin for example 

 Foot care: 

👉 Annually examine to identify risk factors (neuropathy [treated with 10mg of monofilament]/ischaemia/ulceration, callouses, infection, gangrene/deformity [Charcot’s arthropathy]) 

👉 If more than 1 of the risk factors are present, refer the patient 

 Autonomic neuropathy: 

👉 Hypo unawareness 

👉 Urinary incontinence 💧

👉 Gastrointestinal tract symptoms (gastroparesis, treated with erythromycin/diarrhoea) 

 Peripheral neuropathy: 

👉 Tightly controlling glycaemic levels reduces neuropathy progression 

👉 Treat neuropathy according to NICE guidelines  

 Renal: 

👉 Follow NICE CKD guidelines 

 Eyes: 

👉 Annual screening of eyes 👁

Hypertension in Type 2 Diabetes 

 NICE 2019 guidance: hypertension in patients with type 2 diabetes is now treated in the same way as people without diabetes

👉 Clinic BP higher than 140/90, fit ABPM, and if ABPM is greater than 135/85 - diagnose hypertension 

👉 BP should be measured when patient is sitting and standing to identify postural hypertension

👉 Antihypertensive drug treatment - offer to patients with stage 2 hypertension, discuss with patients with stage 1 hypertension who have a greater than 10% 10-year CVD risk, consider it for patients who are under 60 y/o with stage 1 hypertension but have a less than 10% 10-year CVD risk 💊

👉 Initiate treatment with an ACE inhibitor 💊

👉 Aim is to get clinic BP below 140/90 (or 150/90 if the patient is 80 y/o or older) ⬇