Type 2 Diabetes
Stopping Smoking Consider referral to → smoking cessation
Set a → Consider referring for weight loss weight management BMI > 25 kg m² target of a 5-10% advice reduction
Control BP to <140/80mmHg See NHS Rotherham
(Monitor monthly if BP > 150/90mmHg) → hypertension guidelines
(<130/80mmHg if kidney, eye or cerebrovascular damage)
If microalbuminuria/ Ramipril 10mg daily . proteinuria present → Start at 1.25mg daily, titrate to the maximum tolerated dose.
(If ramipril is not tolerated consider Irbesartan 150mg increased to 300mg daily).
Aspirin 75mg daily If dyspepsia or increased risk or GI bleeding add Only if patient has had an MI or has → Lansoprazole 15mg daily. symptoms of cardiovascular disease If aspirin allergic consider Clopidogrel 75mg daily (Secondary prevention only). see antiplatelet guidelines.
Lipid Management in type 2 diabetes
Calculate 10 year CVD risk annually for all type 2
diabetes patients. Using QRISK
Is 10 year risk > 10%*
No Yes
Initiate Reassess in one year
Atorvastatin 20mg daily
Monitor lipid profile 3 months after initiation is there a > 40% reduction in non-HDL cholesterol
Yes No
• Maintain current statin • Discuss adherence and prescription timing of statin dose • Optimise diet and lifestyle measures
*Use clinical judgement if; • Consider increasing Atorvastatin if not already on •Over 40yrs of age? •Diabetic for more than 10 years? maximal dose •Established nephropathy? •Other CVD risk Factors?
Consider atorvastatin 20mg daily if CVD <
10%
Type 2 Diabetes
Before starting lipid therapy take at least 1 Refer for specialist advice if; lipid sample, this need not be fasting but Total cholesterol is above should include
• Total cholesterol Also Check 9mmol\litre Or non-HDL • HDL cholesterol • Smoking status cholesterol is above 7.5 • Alcohol status • non-HDL cholesterol mmol\litre. • BMI Triglyceride concentration • Triglycerides • Liver above 20mmol\litre Before transaminases • TSH (urgent referral) Consider familial hypercholesterolaemia and refer if Triglyceride concentration • Between 10 and 20mmol\litre, repeat • Total cholesterol more with a fasting sample after 5 days but than 7.5 mmol\litre • A family history of within 2 weeks) • Between 4.5 and 9.9 mmol\litre CVD risk premature coronary heart may be underestimated disease
Exclude common causes of secondary dyslipidaemia such as
• Excess alcohol • Uncontrolled diabetes • Hypothyroidism • Liver disease • Nephrotic syndrome
Always use Non-HDL cholesterol for all risk assessment calculations
= Total Cholesterol – HDL Cholesterol
HbA1C management pathway Recommended First Line Choices
Consider exercise and weight loss
Step 1 = Metformin 2g daily (or maximum tolerated) dose
Step 2 = Linagliptin 5mg daily
Consider referral to Step 3 Step 3 Diabetic specialist Empagliflozin 10-25mg Gliclazide increase up to nurses if after step 3 daily 160mg BD as necessary at maximum
tolerated doses HbA1C is still not at
Step 4 ? Step 4 ? target (HbA1c ≥ Gliclazide increase up to Empagliflozin 10-25mg 58mmol\l despite 160mg BD as necessary daily maximising triple therapy)
Refer to Diabetic Specialist Nurse for GLP1 + Insulin initiation
Type 2 Diabetes
Blood Glucose Management
pathway options
Step 1 HbA1c rises to Metformin 48mmol/mol despite Recommended first Repaglinide lifestyle measures line pathway
Step 2 HbA1c is greater Linagliptin Gliclazide Empagliflozin Pioglitazone than 58mmol/mol despite maximum tolerated metformin. Aim for 53mmol\mol
Step 3 HbA1c ≥ is Empagliflozin Linagliptin Gliclazide Gliclazide
greater than 58mmol/mol Or Or Or Or despite maximising Empagliflozin Linagliptin Empagliflozin step 2 options . Gliclazide Aim for 53mmol\mol Or Or
Pioglitazone Pioglitazone
Step 4
HbA1c ≥ is greater than Refer to Diabetes Specialist Nursing service for initiation of 58mmol/mol glucagon-like peptide 1 mimetic (GLP-1) or insulin. despite maximising step 3 options . 53mmol\m ol
Oral Diabetes treatment Pathways Recommended First Line Choice Step 1 Step 2 Step 3 Advantages /disadvantages HbA1c rises to HbA1c is greater than HbA1c is greater than 48mmol/mol despite 58mmol/mol despite 58mmol/mol despite lifestyle measures maximum tolerated maximising step 2 metformin. Aim for options . Aim for 53mmol\mol 53mmol\mol Metformin Linagliptin Empagliflozin
Recommended first line Initially 500mg once a day 5mg once a day 10mg once a day pathway for a least a week increasing to 25mg increasing to 500mg Consider using the once a day. twice a day for a week linagliptin+metformin Not recommended if Self Monitoring and to 500mg three times combination over 85 years of age. of Blood Glucose a week . Maximum dose preparation (SMBG) not 2g a day in divided doses (2.5mg\850mg) Reduce dose of necessary with (2.5mg\1000mg) One empagliflozin if eGFR this combination GI intolerance with tablet twice a day. ≤ 60ml\min metformin consider Stop empagliflozin if All drugs Metformin M\R if unable Linagliptin is weight eGFR ≤ 45ml\min associated with to tolerate ordinary neutral positive or tablets Empagliflozin is neutral Linagliptin and associated with cardiovascular Reduce metformin dose if pancreatitis = weight loss outcomes. eGFR ≤ 45ml\min increased risk Stop metformin if eGFR ≤ discontinue if severe Empagliflozin is 30ml\min abdominal pain associated with an increased incidence Metformin is associated If linagliptin of UTIs with weight loss unsuitable consider Empagliflozin or Empagliflozin; be Gliclazide or mindful of volume pioglitazone depletion especially in elderly and if diuretics are co-prescribed.
Oral Diabetes treatment Pathways Alternative Options Step 1 Step 2 Step 3 Advantages /disadvantages HbA1c rises to HbA1c is greater than HbA1c is greater 48mmol/mol despite 58mmol/mol despite than 58mmol/mol lifestyle measures maximum tolerated despite maximising metformin. Aim for step 2 options . Aim 53mmol\mol for 53mmol\mol
Metformin Linagliptin Gliclazide
Initially 500mg once a day 5mg once a day Initially 40-80mg SMBG for a least a week daily, increase up to necessary with increasing to 500mg Consider using the 160mg once a day. gliclazide see twice a day for a week linagliptin+metformin Doses higher than SMBG guidelines and to 500mg three times combination 160mg must be a week . Maximum dose preparation given as divided Hypoglycaemia 2g a day in divided doses (2.5mg\850mg) doses. Maximum with gliclazide (2.5mg\1000mg) One dose 320mg a day. GI intolerance with tablet twice a day. All drugs metformin consider Gliclazide is associated with Metformin M\R if unable Linagliptin is weight associated with positive or to tolerate ordinary neutral significant weight neutral tablets gain cardiovascular Linagliptin and outcomes Reduce metformin dose if pancreatitis = A 2-4kg weight gain eGFR ≤ 45ml\min increased risk is recognised as a Stop metformin if eGFR ≤ discontinue if severe consequence of 30ml\min abdominal pain sulphonylurea therapy; in some Metformin is associated If linagliptin patients this may with weight loss unsuitable consider exceed 10kg. Empagliflozin or Patients should be Gliclazide or re-assessed and pioglitazone dietary compliance reaffirmed before initiation
Sulphonylureas are considered to be cardiovascular neutral
Oral Diabetes treatment Pathways Alternative Options Step 1 Step 2 Step 3 Advantages HbA1c rises to HbA1c is greater than HbA1c is greater /disadvantages 48mmol/mol despite 58mmol/mol despite than 58mmol/mol lifestyle measures maximum tolerated despite maximising metformin. Aim for step 2 options . Aim 53mmol\mol for 53mmol\mol
Metformin Repaglinide SMBG necessary with repaglinide Initially 500mg once a day Adult 18-74 years see SMBG for a least a week initially 500 guidelines increasing to 500mg micrograms a day- twice a day for a week adjusted according to Hypoglycaemia and to 500mg three times response at intervals with repaglinide. a week . Maximum dose of 1-2 weeks . 2g a day in divided doses Repaglinide is Maximum dose 16mg only licensed as GI intolerance with a day 4mg maximum monotherapy or metformin conside as a single dose. with metformin, Metformin M\R if unable if moving to a to tolerate ordinary Doses to be taken 30 third agent tablets minutes before main repaglinide has meals. to be Reduce metformin dose if discontinued and eGFR ≤ 45ml\min an alternative Stop metformin if eGFR ≤ established 30ml\min before a third agent can be Metformin is associated added. with weight loss
Step 2 alternatives to Linagliptin Empagliflozin SMBG not necessary 10mg once a day increasing to 25mg once a day. Not recommended if over 85 years of age.
Reduce empagliflozin if eGFR ≤ 60ml\min Stop empagliflozin if eGFR ≤ 45ml\min
Empagliflozin is associated with weight loss
Empagliflozin is associated with an increased incidence of UTIs (Common 1 in 10 to 1in 100)
Empagliflozin; be mindful of volume depletion especially in elderly and if diuretics are co-prescribed (uncommon side effect between 1 in 100 to 1 in 1000)
The sodium glucose co-transporters 2 inhibitors are all new drugs and their adverse effect profiles are still developing. Drugs within this class have been recently implicated in causing acute kidney injury especially if used in combination with other drugs known to cause acute kidney injury (ACE, ARBs, NSAIDS Diuretics) also there have been reports of lower limb amputations associated with SGLT2 use Empagliflozin has to date been implicated with these issues
Empagliflozin has demonstrated a cardioprotective effect.
Gliclazide SMBG is necessary if Initially 40-80mg daily, increase up to 160mg once a day. Doses higher than 160mg gliclazide is used must be given as divided doses maximum dose 320mg a day. in combination with all other Weight Gain drugs. Gliclazide is associated with significant weight gain. A 2-4kg weight gain is recognised as a consequence of sulphonylurea therapy; in some patients this may exceed 10kg. See NHS Patients should be re-assessed and dietary compliance reaffirmed before initiation Rotherham CCG SMBG guidelines. CVS Risk Sulphonylureas are considered to be cardiovascular neutral
Pioglitazone SMBG not necessary Although included in the NICE diabetes guidance a prescriber needs to have a clear rational for initiating pioglitazone, after considering the other available agents and the established adverse side effect profile of pioglitazone
Initially 15-30mg once daily. Maximum dose 45ng once a day
CVS Risk Pioglitazone associated with negative cardiac outcomes. Pioglitazone increased incidence of heart failure and is contraindicated in existing heart failure
Weight gain Pioglitazone associated with significant weight gain
Points to consider Pioglitazone is associated with; Atypical fractures Increased incidence of bladder cancers, advise patients before starting, investigate all haematuria, dysuria, or urinary urgency, Assess patients risk of bladder cancer before starting Pioglitazone check liver function before starting and at each review Rare cases of elevated liver enzymes and hepatocellular dysfunction have occurred in post-marketing experience. Although in very rare, cases with fatal outcome has been reported, causal relationship has not been established.
Oral Diabetes treatment Pathways Alternative Options If Metformin not tolerated Step 1 Step 2 Step 3 Advantages /disadvantages HbA1c rises to HbA1c is greater than HbA1c is greater 48mmol/mol despite 58mmol/mol despite than 58mmol/mol lifestyle measures maximum tolerated despite maximising metformin. Aim for step 2 options . Aim 53mmol\mol for 53mmol\mol Linagliptin Empagliflozin Gliclazide SMBG necessary with 5mg once a day 10mg once a day Initially 40-80mg gliclazide see increasing to 25mg daily, increase up to SMBG guidelines Linagliptin is weight once a day. 160mg once a day. neutral Not recommended if Doses higher than Hypoglycaemia over 85 years of age. 160mg must be with gliclazide Linagliptin and given as divided pancreatitis discontinue if Reduce empagliflozin doses maximum All drugs severe abdominal pain if eGFR ≤ 60ml\min dose 320mg a day. associated with Stop empagliflozin if positive or eGFR ≤ 45ml\min Gliclazide is neutral associated with cardiovascular significant weight Empagliflozin is outcomes gain associated with A 2-4kg weight gain been reported weight loss is recognised as a consequence of
Empagliflozin is sulphonylurea associated with a therapy; in some patients this may increased incidence of exceed 10kg. UTIs? Patients should be re-assessed and Empagliflozin; be dietary compliance mindful of volume reaffirmed before depletion especially in initiation elderly and if diuretics Sulphonylureas are are co-prescribed. considered to be cardiovascular neutral
Oral Diabetes treatment Pathways Alternative Options If Metformin not tolerated Step 1 Step 2 Step 3 Advantages /disadvantages HbA1c rises to HbA1c is greater than HbA1c is greater 48mmol/mol despite 58mmol/mol despite than 58mmol/mol lifestyle measures maximum tolerated despite maximising metformin. Aim for step 2 options . Aim 53mmol\mol for 53mmol\mol Linagliptin l Empagliflozin Gliclazide SMBG necessary with 5mg once a day 10mg once a day Initially 40-80mg gliclazide see increasing to 25mg daily, increase up to SMBG guidelines Linagliptin is weight once a day. 160mg once a day. neutral Not recommended if Doses higher than Hypoglycaemia over 85 years of age. 160mg must be with gliclazide Linagliptin and given as divided pancreatitis discontinue if Reduce empagliflozin doses maximum All drugs severe abdominal pain if eGFR ≤ 60ml\min dose 320mg a day. associated with Stop empagliflozin if positive or eGFR ≤ 45ml\min neutral Gliclazide is cardiovascular Empagliflozin is associated with outcomes associated with significant weight been reported weight loss gain. A 2-4kg weight gain Empagliflozin is is recognised as a associated with an consequence of increased incidence sulphonylurea of UTIs? therapy; in some patients this may Empagliflozin; be exceed 10kg. mindful of volume Patients should be depletion especially in re-assessed and elderly and if diuretics dietary compliance are co-prescribed. reaffirmed before initiation
Sulphonylureas are considered to be cardiovascular neutral