Type 2 diabetes mellitus - the management of glycaemic control

Management of type 2 diabetes mellitus (T2DM) can reduce symptoms of hyperglycaemia and reduce long-term complications. The aim of this hot topic is to ensure that these are prescribed safely. For further information on prescribing for Type 2 Diabetes see Type 2 Diabetes Mellitus - quality prescribing strategy: improvement guide 2024 to 2027.

Should be considered essential, for treatment of symptomatic hyperglycaemia.

People with T2DM can achieve remission by diet control, weight management and lifestyle changes, but frequently people require pharmacological treatment. Reduction in hyperglycaemia, to prevent the long-term complications is important,²⁰² but equal emphasis is placed on reducing cardiovascular and renal risk, independent of glycaemic control.²⁰³

Glycaemic control is a balance between minimising complications of hyperglycaemia and the risk of hypoglycaemia (with particular risk of falls and hospitalisation, in those who are frail). The figure below shows characteristics and considerations that individuals and clinicians can consider together to assess “what matters to me” when determining individual glycaemic control.

Individualisation of glycaemic control^203,206,204

Click on the image to view a larger version

Some individuals with diabetes and health inequalities will require additional support to manage their long-term conditions due to an increased risk of poorer medication adherence and complications associated with diabetes.

Lifestyle management is the fundamental aspect of diabetes care.

Weight loss can delay the onset of type 2 diabetes²⁰⁵ and can also lead to remission.²⁰⁶

First line pharmacological treatment is metformin,²⁰⁷ due to:

• reduction in cardiovascular events and death
• beneficial effects on HbA1c
• being weight neutral
• reduced risk of hypoglycaemia

unless:

• intolerance due to gastrointestinal side effects, which can be minimised by gradual dose increase and by modified release preparations
• reduced renal function (reduce dose if eGFR<45ml/min, or stop if less than 30ml/min)
• lactic acidosis

Managing cardiovascular risk:

• Primary and secondary prevention of cardiovascular disease (CVD) should be addressed, e.g. statins, antihypertensives, smoking, obesity.
• Newer classes of blood glucose lowering agents, in addition to improved glycaemic control, have positive outcomes for those with, or at risk of, major adverse cardiovascular events (MACE), hospitalisation for heart failure (hHF), cardiovascular death and chronic kidney disease (CKD) progression.

If the individual with T2DM has:

• existing atherosclerotic cardiovascular disease (ASCVD), chronic heart failure:
  • sodium-glucose co-transporter 2 inhibitors (SGLT-2i) and glucagon-like peptide-1 agonists (GLP-1RA), should be recommended, independent of glycaemic control.
• consider use of SGLT-2i and GLP-1RA²⁰⁸ if there are cardiovascular risk factors:
  • Adults over 40 years: ASSIGN 2.0 more than 10%
  • Adults under 40 years: a clinically assessed elevated lifetime risk of cardiovascular disease (defined as the presence of one or more cardiovascular risk factors):
    • hypertension
    • dyslipidaemia
    • smoking
    • obesity
    • family history (in a first-degree relative) of premature cardiovascular disease (males less than 45 years, females less than 55 years)
• chronic kidney disease (eGFR<60 ml/min/1.73m²)
  • check albumin to creatinine ratio (ACR) to determine appropriate medication (see table below).

Treatment options in CKD

Please note that the table above may need to be scrolled horizontally or vertically in order to view all information, depending on your device.

Prescribing choices

These are preventative interventions with outcomes realised over 10 or more years. See Numbers Needed to Treat (NNT) for individual NNTs. Consider risks of side effects which may outweigh the benefits of therapy.

• SGLT-2i contra-indications/cautions (not exhaustive):
• people 75 years and older are at increased risk of volume depletion
• not recommended for initiation when eGFR <15 ml/min/1.73m²
• have less glucose-lowering efficacy when eGFR <45 ml/min/1.73m²
• should be avoided in those with factors predisposing to diabetic ketoacidosis (DKA)/euglycaemic diabetic ketoacidosis (eDKA)²⁰⁹
  • pancreatic insufficiency
  • drug or alcohol abuse disorder
  • a low/ultra-low carbohydrate or keto diet
  • excessive alcohol consumption
• frequent bacterial urinary tract infections or genitourinary yeast infection
• low bone density or high risk for falls/fractures
• foot ulceration

Continue diabetic medication when:

• symptomatic hyperglycaemia needs to be treated. Alternative treatments may need to be considered
• additional benefits (of SGLT-2i or GLP-1RA) are present

Reduced renal function:

• metformin
• SGLT-2is
• GLP-1RAs
• Dipeptidyl peptidase 4 inhibitors (DPP-4i)
• in addition to ACEI, ARBs, diuretics and NSAIDs

Frailty:²¹⁰

• Increasing frailty increases the risk of hypoglycaemia (and therefore falls and hospitalisation)
• Consider less stringent targets (see individualised targets below)

Other:

• Dual prescribing of DPP-4i and GLP-1RA – stop DPP-4i, as no benefit from dual prescribing
• Less effective antidiabetic medication, e.g. pioglitazone, DPP-4i, sulfonylureas (unless for symptomatic control of hyperglycaemia). Note that sometimes HbA1c may be within target range, but these agents may not be contributing to HbA1c target reduction
• Medication Sick Day Guidance

Stop: if an antidiabetic medication is no longer indicated or safe. There is no need to down titrate.

Immediate dose reduction: when renal impairment requires a dose reduction or altered HbA1c target.

Always reinforce lifestyle modifications.

Specific areas/situations where medication may need to be introduced or increased

1. If target HbA1c is not achieved
2. If comorbidities, such as ASCVD, HF, CKD, even if HbA1c within target range

Action: Consider additional therapies in line with medication effectiveness section.

Key points to discuss with the individual:

Does the person understand the outcomes of the review, including risk and benefits?

• Increase in therapy may be to improve glycaemic control, have positive long-term outcomes in ASCVD/HF/CKD, or both
• Treatment may be reduced due to risk of adverse effects, renal impairment or individualised treatment, especially if frail.

Is drug therapy tailored to the individual?

• Consider frailty
• What is the impact of comorbidities such as poor mental health?

Agree the plan

• Non-pharmacological and lifestyle management is a fundamental aspect of diabetes care and includes: diabetes self-management education and support; nutritional advice; physical activity; smoking cessation counselling; psychosocial care

• self management/support tools
• decision aids for healthcare professionals
  • Type 2 Diabetes Mellitus - quality prescribing strategy: improvement guide 2024 to 2027
  • My Diabetes My Way website
  • Diabetes UK website
  • NHS inform website – type 2 diabetes

National Therapeutic Indicators (NTIs) use prescription data in specific areas to provide a measure of prescribing activity for comparison across NHS Boards, Health and Social Care Partnerships (HSCPs), GP clusters and GP practices.

NTIs are available to view online.

NTIs benchmark prescribing across set parameters and are presented in a variety of ways. Examining variation over time can indicate where improvements in prescribing can be made. The indicator detail provides further information and suggested actions.

Indicators for this hot topic include:

• Individuals with T2DM prescribed a SGLT-2i/GLP-1RA and existing therapy suggestive of atherosclerotic cardiovascular disease (ASCVD). See the chart below.
• Antidiabetic drugs (metformin %) - Number of people prescribed metformin: this should have a high percentage
• Antidiabetic drugs (polypharmacy %) - Number of people prescribed three or more categories of diabetes medication
• Falls, fractures, delirium (sulfonylureas %) - Number of people aged 75 years and over prescribed sulfonylureas

Individuals with T2DM prescribed a SGLT-2i/GLP-1RA and existing therapy suggestive of atherosclerotic cardiovascular disease (ASCVD)

(Click on image to enlarge)