Flowchart for the management of blood glucose in type 2 diabetes mellitus

Revised October 2009, approved January 2010
Flowchart for the Management of Blood Glucose in Type 2
Flowchart for the Management of Blood Glucose in Type 2
Diabetes Mellitus
Aim for target HbA1c 6.5-7.5% (or agreed individualised targets)
Target set based on macrovascular and microvascular complications. Higher target if at risk of hypoglycaemia.
Avoid intensive management to HbA1c < 6.5%
Lifestyle changes – diet, alcohol, p Diabetes Mellitus
hysical activity, smoking cessation, refer to DESMOND (see box 3)
A1c can be
2-6 monthly HbA1c – target?
monitored 6 monthly once
stable.
BMI < 22
BMI >22
or very symptomatic (polyuria, polyd
or significant weight loss
or ketones
Creatinine > 150µmol/l or eGFR < 40ml/min
specialist care
Metformin
Sulphonylurea
BOX 2: Metformin and the kidney
- Do not start metformin if eGFR <40ml/min – seek specialist advice. - Review metformin dose if Cr>130µmol/l or 2-6 monthly
HbA1c – target?
- Stop/avoid metformin if Cr>150µmol/l or eGFR 2-6 monthly
Keep HBA1c above 6.5%
but below 7.5% - see
HbA1c – target?
- Patients with advanced cardiac disease may
point 9, box 3
be at risk of sudden deterioration of renal function. BOX 3: GENERAL COMMENTS
Add sulphonylurea
1. Increase medication stepwise to maximum tolerated dose. 2. Educate patient to self-titrate metformin over several weeks to e risk of gastro-intestinal (GI) side effects. If metformin not tolerated despite slow titration & taking after meals, consider 2-6 monthly
3. Monitor for side effects of medication. If at any step patient cannot HbA1c – target?
tolerate drug or drug is contraindicated, move to the next step (see Keep HBA1c above
6.5% but below 7.5% -
see point 9, box 3
4. Metformin may be considered in obese patients even if HbA1c 5. Consider a sulphonylurea first line if not overweight or a rapid therapeutic response is required due to hyperglycaemic symptoms 6. Consider a rapid-acting insulin secretagogue for those with erratic 7. Consider sitagliptin or a glitazone if significant risk of hypoglycaemia 8. Consider acarbose for patients unable to use other oral CONSIDER ADDING EITHER:
9. The ACCORD and ADVANCE studies7 found intensive glucose control (HbA1c <6.5%) did not offer any advantage with regard to major CV events. NICE cautions against the use of highly intensive Sitagliptin (this is the gliptin on the local management strategies to achieve levels of <6.5%. 10. The full version of the NICE guideline1 notes that as glitazones If needed, seek specialist advice via telephone on worked in combination with metformin, fixed-dose combination products would be suitable for use where there were no cost implications or where improved drug adherence issues increase cost OR REFER FOR:
 Insulin therapy
11. DESMOND: Diabetes Education and Self Management for Ongoing
Exenatide
Newly Diagnosed - a structured education programme.
ORAL HYPOGLYCAEMICS - Refer to product literature for full list of doses, cautions, contraindications, and drug interactions3.
Recommended dose range (BNF Sept 2008)
Cost of 4 weeks treatment (£)
Comments
Contraindicated in renal impairment – caution in patients at risk of sudden deterioration in Metformin Start at 500mg daily and titrate dose 2-6 weekly normal Max 3g daily, most physicians limit dose to 2.5g daily Doses in company literature may differ to BNF doses. release Doses are normally taken with meals (breakfast, lunch, dinner) Metformin normal release is first line choice
NICE recommend a trial of metformin M/R in patients unable to tolerate & continue Metformin Initially 500mg once daily, increased every 10-15 days, max. 2g Not suitable if normal release dose is greater than 2g daily 2g daily-------------------------£12.28 Patients taking less than 2g daily of normal release can start on release (M/R) same daily dose of M/R  Avoid sulphonylureas where possible in severe hepatic and renal impairment and in acute porphyria. Educate patient about risks of hypoglycaemia, particularly if he or she has renal impairment Gliclazide Initially 40-80mg daily, titrate according to response. Max. 320 Up to 160mg daily can be taken as a single dose, with breakfast. Doses higher than this should be divided Glipizide Initially 2.5-5mg daily, Titrate dose according to response. Max. Doses are taken just before breakfast or lunch. Up to 15mg daily can be taken as a single dose. Divide higher doses. GLITAZONES – initiation on specialist advice only (e.g via telephone) - this may be a GP with a specialist interest or a diabetologist.  Contraindicated in hepatic impairment, patients with heart failure (HF) or a history of HF. Incidence of HF is increased when glitazones are combined with insulin; rosiglitazone is not licensed for use with insulin4. Closely monitor patients during treatment with insulin and a glitazone for signs and symptoms of fluid retention, including weight gain or oedema. Rosiglitazone contra-indicated in acute coronary syndrome and is not
recommended in patients with ischaemic heart disease and/or peripheral arterial disease5. Rosiglitazone might be associated with a small increased risk of cardiac ischaemia, particularly in combination with insulin;
rosiglitazone should be used in patients with previous or current ischaemic heart disease only after careful evaluation of individual risk. Glitazones should be avoided in patients with high cardiovascular risk e.g.:
estimated risk of future MI > 20% in 10 years; past history of cardiovascular disease/ankle oedema, suboptimal blood pressure or lipid control, microalbuminuria6.
 Glitazones should not be started or continued in those at high risk of fracture.  Only consider triple therapy with metformin and sulphonylurea in patients where insulin is inappropriate (limited role due to likely failing insulin release at this stage)  Monitor liver function before treatment, and then periodically thereafter e.g. two months after initiation, then at 6 months, then 6 monthly after that. Do not initiate treatment if ALT >2.5 X upper limit of normal (ULN) or any evidence of liver disease. During therapy, if ALT increases to 3 X ULN, reassess liver enzymes ASAP. If ALT remains >3 X ULN, discontinue therapy.  May be preferable to sitagliptin if there is marked insulin insensitivity, sitagliptin is contra-indicated, or a poor response or intolerance to sitagliptin was observed in the past.  Continue glitazone only if there is a reduction of ≥0.5% in HbA1c in 6 months 15-30mg once daily, increased to a max. of 45mg daily In patients administered rosiglitazone in combination with a sulphonylurea, an increase in rosiglitazone to 8 mg/day should be undertaken cautiously following appropriate clinical evaluation to assess the patient's risk of developing adverse reactions relating to fluid Rosiglitazone Initially 4mg daily, when used in combination with metformin, the retention. This should also be borne in mind for pioglitazone2. dose can be increased to 8mg daily (in 1 or 2 divided doses) GLIPTINS – initiation on specialist advice only (e.g via telephone) - this may be a GP with a specialist interest or a diabetologist. NOTE: Sitagliptin is on the local hospital (GSTFT, KCH and UHL) joint formulary
 Continue gliptin only if there is a reduction of ≥0.5% in HbA1c in 6 months  Only consider triple therapy with metformin and sulphonylurea in patients where insulin is inappropriate  May be of particular benefit in patients where significant weight gain has occurred/expected with insulin (or insulin refused) and in whom exenatide is contra-indicated or refused  May be preferable to glitazones in patients where weight gain would cause significant problems, or a glitazone is contra-indicated or not tolerated/poor response Avoid in moderate to severe renal impairment (CrCl<50ml/min) References:
1. NICE Type 2 Diabetes, May 2009 available via WHEN TO REFER PATIENTS:
2. Expert opinions of diabetologists and diabetes nurses from Guy’s and St Thomas’ foundation Trust and King’s Col ege Hospital Foundation Trust Acutely unwell patients (these patients may require insulin urgently, refer to specialist service) 3. Summary of Product Characteristics for metformin and metformin MR, sulphonylureas, glitazones and sitagliptin available via 4. Personal communication with GlaxoSmithKiine Medical Information Department 30.12.09 5. Prescribing and Clinical Effectiveness Newsletter, Derbyshire PCT. October 2009. available at: Patients with advanced cardiac disease or hepatic impairment 6. Southwark PCT Medicines Update: Guidance on the use of glitazones, October 2007 Referral for insulin start in those with sub-optimal control on maximal tolerated oral agents. 7. NPCi blog on ACCORD and ADVANCE studies, available at: 4. Pregnant women, urgent referral to diabetes antenatal clinic Guideline produced by Lambeth and Southwark Diabetes Prescribing Workstream. Revised October 2009. For information and group details please contact Devika Sennik, PCT Pharmacist, Southwark PCT, Tel 020 7525 3253

Source: http://www.londondiabetes.nhs.uk/resources/guidelines/FINALApprovedglycaemiccontrolGL2010.pdf