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 

πŸ‘‰ HbA1c diagnosis should not be used in the following instances:  rapid blood sugar increase/ increased red cell turnover/ pregnancy/ anaemia/ haemoglobinopathies βŒ 

πŸ‘‰ Where possible a second test should be performed to confirm accuracy 


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

πŸ‘‰ Fasting: 5.1mmol/L or higher 

πŸ‘‰ 1 hour: 10mmol/L or higher β± 

πŸ‘‰ hour: 8.5mmol/L or higher β± 




Management 


 Blood Pressure Target 

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



 Treatment Target

πŸ‘‰ 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 

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


 HbA1c Target 

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

 

Treatment 


 Lifestyle changes: 

πŸ‘‰ Refer patient to an educational programme when diagnosed 

πŸ‘‰ Annually reinforce the importance of diet/lifestyle management 

πŸ‘‰ In overweight patients: aim to reduce weight by 5 to 10% β¬‡ 

πŸ‘‰ 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) πŸ‘¨


 Blood Pressure:  

πŸ‘‰ Follow hypertension guidelines presented by NICE (2019) 

πŸ‘‰ 1st line: patients of all ages/ethnicities should be given an ACE inhibitor (ARB if ACE cannot be tolerated) πŸ’Š

πŸ‘‰ 2nd line: 2 of the following should be given – ACE, CCB, thiazide-like diuretic πŸ’Š

πŸ‘‰ 3rd line: ACE + CCB + thiazide-like diuretic πŸ’Š

πŸ‘‰ 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 πŸ’Š


 Lipids: 

πŸ‘‰ Primary prevention – 20mg of Atorvastatin if QRISK is 10% or higher (reduce non-HDL cholesterol 40%) πŸ’Š

πŸ‘‰ Secondary prevention – 80mg of Atorva (reduce non-HDL cholesterol 40%) πŸ’Š

πŸ‘‰ Aspirin/antiplatelets - Do NOT use unless CVD already diagnosed πŸ’Š


 Glycaemic control:  

πŸ‘‰ 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 β¬† 

πŸ‘‰ 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 πŸ’Š

πŸ‘‰ Treatment should be patient specific to ensure the patient’s lifestyle improves

πŸ‘‰ Patient should only monitor their own levels if they are on insulin for example 


 Foot care: 

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

πŸ‘‰ If more than 1 of the risk factors are present, refer the patient 


 Autonomic neuropathy: 

πŸ‘‰ Hypo unawareness 

πŸ‘‰ Urinary incontinence πŸ’§

πŸ‘‰ Gastrointestinal tract symptoms (gastroparesis, treated with erythromycin/diarrhoea) 


 Peripheral neuropathy: 

πŸ‘‰ Tightly controlling glycaemic levels reduces neuropathy progression 

πŸ‘‰ Treat neuropathy according to NICE guidelines  


 Renal: 

πŸ‘‰ Follow NICE CKD guidelines 


 Eyes: 

πŸ‘‰ Annual screening of eyes πŸ‘

 

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

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

πŸ‘‰ BP should be measured when patient is sitting and standing to identify postural hypertension

πŸ‘‰ 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 πŸ’Š

πŸ‘‰ Initiate treatment with an ACE inhibitor πŸ’Š

πŸ‘‰ Aim is to get clinic BP below 140/90 (or 150/90 if the patient is 80 y/o or older) β¬‡ 


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