A Resource for Glycaemic management in Diabeteskey messages

Hypoglycaemia is dangerous:

• Beware in elderly/RF/CVS risk• Sulphonylureas need education to avoid risk• Do not escalate Rx if hypoglycaemia present• Beware low HbA1C with insulin and sulphonylureas

• Individualise HbA1C target. Early tight control reduces later complications

Newer agents have clear roles in appropriate patients as per NICE. They must be reviewed at 6 months and stopped if not achieving targets.

• eGFR matters – please check drug information

Drugs do not replace lifestyle advice at any stage

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LifestyleLifestyle

IndividualTarget

IndividualTarget

Hypo AdviceHypo Advice

NICE CriteriaNICE

Criteria

Drug Information

Drug Information

Management of Low eGFRManagement of Low eGFR

Author: Coastal West Sussex Diabetic groupReview date: January 2014Version: No. 2

Disclaimer: The information given in this document is accurate at the time of publication. Any links to other websites or documents contained in this resource does not constitute as an endorsement by the Diabetic Group or by Coastal West Sussex Clinical Commissioning Group.

Diet and lifestyle triedHbA1C > 48 (6.5%)

Metformin

HbA1C > 48 (6.5%) or individualised target

Metformin + Gliclazide

(Repaglanide if lifestyle erratic)

HbA1C > 58 (7.5%)

Insulin acceptable?

Intensify Insulin+/- Metformin

+/- Pioglitazone+/- Sitagliptin

Start Insulin

• Symptomatic of hyperglycaemia requiring rapid control / low BMI• Metformin contraindicated or not tolerated

At risk from hypoglycaemia or

Gliclazide side effects not tolerated / unacceptable

HbA1C > 58 (7.5%)

Metformin

+

Sitagliptin or Pioglitazone

Consider Sulphonylurea

pathway page 2

Consider Sulphonylurea

pathway page 2

High BMI?See NICE criteria for GLP1 agonist use-

(refer DSN fpr initiation)

Consider Metformin +/- Gliclazide + Exenatide or

Liraglutide

Monitor 6/12 Target

Target not met

Change to insulin

Do not fit NICE criteria for GLP1 agonist or Insulin

unacceptable

Consider triple RX Metformin Gliclazide +

Sitagliptin or Pioglitazone

HbA1C> 58 (7.5)

Start Insulin+/- Metformin

+/- Pioglitazone+/- Sitagliptin

Quick Guide: Blood Glucose Lowering Therapy in Type 2 DM

Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009)

Hypo AdviceHypo Advice

NICE CriteriaNICE

Criteria

Hypo AdviceHypo Advice

NICE CriteriaNICE

Criteria

IndividualTarget

IndividualTarget

LifestyleLifestyle

IndividualTarget

IndividualTarget

Insulin ButtonInsulin ButtonInsulin

ButtonInsulin Button

Insulin ButtonInsulin Button

Hypo AdviceHypo Advice

Hypo AdviceHypo Advice

Hypo AdviceHypo Advice

Drug Information

Drug Information

Useful resourcesUseful resources

LifestyleLifestyle

LifestyleLifestyleLifestyleLifestyle

IndividualTarget

IndividualTarget

IndividualTarget

IndividualTarget

Management of Low eGFRManagement of Low eGFR

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Diagnosis

Sulphonylurea Pathway

Gliclazide

> HbA1C 52 (7%) or individualised target

Metformin not tolerated or contraindicated then consider Sitagliptin or

Pioglitazone

Gliclazide + Sitagliptin or Pioglitazone

> HbA1C 58 (7.5%) or individualised target

Start Insulin

Intensify Insulin regimen

Hypo AdviceHypo Advice

IndividualTarget

IndividualTarget

Hypo AdviceHypo Advice

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Useful resourcesUseful resources

LifestyleLifestyle

LifestyleLifestyle

Drug Information

Drug Information

IndividualTarget

IndividualTarget

Management of Low eGFRManagement of Low eGFR

Home Home

Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009)

Metformin toleratedReturn to Metformin

pathway (page1)Consider stopping Gliclazide if initial response rapid

Metformin toleratedReturn to Metformin

pathway (page1)Consider stopping Gliclazide if initial response rapid

Poor initial response V low BMI

Exclude underlying pathology

May need insulin, (type1?) refer

Lifestyle interventionsEducation – Type1

Type2

Care Planning with individualised Targets• Example diabetic care plan• Year of Care Link

Diet• Who should see the Dietitian?• Diet sheets• Diet advice – Click here to access the Eat well with DM2 DUK

web page

Weight• Weight loss Help – click here to access the Why Weight page

on the GP website– Why Weight: Tel 0300 123 0892

Exercise• Exercise Referral

Smoking• Stop Smoking advice: Tel 0300 100 1823

Mood Matters – MMG/TTT/Psychology

Self Help signposting – Wellbeing hub Contact numbers

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Hypoglycaemia Advice

• Hypoglycaemia IS DANGEROUSAlways enquire about mild symptoms especially with HbA1C <7 Teach patients to actively pre-empt low blood sugar & know how to manage hypoglycaemia.

• Emergency treatment of hypoglycaemia

• Ongoing management / advice for hypoglycaemia

• Patient leaflet – management advice on hypoglycaemia

• Driving and hypoglycaemia advice

• Medical standards of fitness to drive

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Individualised Target

Aim Hb1C 48-53mmol/mol (6.5-7%)

Younger patient

Newer diagnosis

Low risk of hypoglycaemia

No co-morbidities

Micro-vascular complications

Aim HbA1C 58mmol/mol (7.5% or higher)

Older patient

Long standing diabetes

Multiple hypoglycaemic agents

Cardiovascular risk

Macro-vascular complication

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When setting a target HBA1C):

• Involve the person in decisions about their individual HbA1C target level, see above

• Encourage the person to maintain their individual target unless the resulting side effects (including hypoglycemia) or their efforts to achieve this impair their quality of life

• Offer therapy (lifestyle and medication) to help achieve and maintain the HbA1C target level

• Inform a person with a higher HbA1C that any reduction in HbA1C towards the agreed target is advantageous to future health

• Avoid pursuing highly intensive management to levels of less than 48mmol/l or 6.5 %.

However in early disease tight control (HbA1C 48mmol/mol or 6.5%) holds better long-term outcome

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Insulin

• Insulin should be initiated by qualified practitioners only. Dietitian input should also be sought at the same time

• Aims of treatment with insulin

• Leaflets:

– Sick day rules

– Implication of Ketone levels

– Simple dose adjustment instructions:• QDS / Basal Bolus• BD / pre-mix

– Hypoglycaemia awareness (advice see hypoglycaemia page)

• Link to safe use of insulin on NHS Diabetes website

• Download the Insulin Passport

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Hypo AdviceHypo Advice

NICE CriteriaDPP-4 inhibitors (Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin) • Continue DPP-4 inhibitor therapy only if there is a reduction of ≥ 0.5

percentage points in HbA1c in 6 months. • Discuss the benefits and risks of a DPP-4 inhibitor with the person, bearing in mind

that a DPP-4 inhibitor might be preferable to a Thiazolidinedione if: – further weight gain would cause significant problems, or – a Thiazolidinedione is contraindicated, or the person had a poor response to

or did not tolerate a Thiazolidinedione in the past.

GLP1 agonists (Exenatide/ Liraglutide) These should only be initiated by the team with special interest in

practice• Discuss the benefits of GLP1 agonist to allow the person to make an informed

decision. Consider starting in:• BMI ≥ 35 kg/m2 in people of European descent and there are problems associated

with high weight, or• BMI < 35 kg/m2 and insulin is unacceptable because of occupational implications

or weight loss would benefit other co-morbidities.

6 month review• Continue GLP1 Therapy only if the person has a reduction in HbA1C of ≥ 1.0

percentage point and ≥ 3% of initial body weight in 6 months.

Thiazolidinedione (Pioglitazone) • Continue Thiazolidinedione therapy only if there is a reduction of ≥ 0.5 percentage

points in HbA1c in 6 months. • Discuss the benefits and risks of a Thiazolidinedione with the person, bearing in

mind that a Thiazolidinedione might be preferable to a DPP-4 inhibitor if: – the person has marked insulin insensitivity, or – a DPP-4 inhibitor is contraindicated, or – the person had a poor response to or did not tolerate a DPP-4 inhibitor in the

past. • Do not start or continue a Thiazolidinedione if any suspicion or risk of bladder

cancer/ frank haematuria if the person has heart failure or is at higher risk of fracture.

• When selecting a Thiazolidinedione, take into account the most up-to-date advice from regulatory authorities, cost, safety and prescribing issue

Click here to access the full NICE guidance

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Adapted from NICE Clinical Guideline 87, Type 2 Diabetes (May2009)

Management of Low eGFR

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Prescribers should always check the latest product information in the relevant data sheet by visiting http://www.medicines.org.uk/emc/

Useful ResourcesDiagnostic criteria • WHO.• Quick summary chart

Referral protocols• Dietitian• DSN• Footcare clinic

Information LeafletsFor the patient:• Diet sheets• Driving and the new medical standards for people with diabetes• Footcare instructions• Hypoglycaemia dietary advice

For the Clinician• Mood Management Referral – needs link• Preconception Consultation• Emergency Hypoglycaemia Treatment• Guidelines for Blood Glucose Meter testing use – Type1 Type2Useful Websites• HBA1C conversion chart

• Link to safe use of insulin on NHS Diabetes website

• Click here to access the DVLA Guide to Medical Standards of fitness to drive

• Click here to access the Map of Medicine

• Click here to access the NICE pathway for a Diabetes overview

• Click here to access Diabetes UK

• Click here to access DUK – Understanding Diabetes

• Click here to access Diabetes Bible

Contact Details• Hospital contact details

– Worthing Diabetes Centre 01903 285044 (9am – 4pm, Mon - Fri) – St Richards Diabetes Centre 01243 831614 (9am - 4pm, Mon - Fri) – Email Sc-tr.communitydiabetesservice@nhs.net–

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