Diabetes Type II – Management

 

Type 2 diabetes is a chronic metabolic condition characterised by insulin resistance (that is, the body's inability to effectively use insulin) and insufficient pancreatic insulin production, resulting in high blood glucose levels (hyperglycaemia). Type 2 diabetes is commonly associated with obesity, physical inactivity, raised blood pressure, disturbed blood lipid levels and a tendency to develop thrombosis, and therefore is recognised to have an increased cardiovascular risk

It is estimated that about 90% of adults currently diagnosed with diabetes have type 2 diabetes. Type 2 diabetes is more common in people of African, African-Caribbean and South Asian family origin. It can occur in all age groups and is increasingly being diagnosed in children

Multiple vascular risk factors and wide-ranging complications make diabetes care complex and time-consuming, and many areas of healthcare services must be involved for optimal management.  Necessary lifestyle changes, the complexities and possible side effects of therapy make patient education and self-management important aspects of diabetes care

.

Patient education

Offer structured education to adults with type 2 diabetes and/or their family members or carers (as appropriate) at and around the time of diagnosis, with annual reinforcement and review. Explain to people and their carers that structured education is an integral part of diabetes care

Ensure that any structured education programme for adults with type 2 diabetes includes the following components:

  • It is evidence-based, and suits the needs of the person
  • It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self-manage diabetes
  • It has a structured curriculum that is theory-driven, evidence-based and resource-effective, has supporting materials, and is written down
  • It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme
  • It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency
  • The outcomes are audited regularly

.

Dietary advice

Integrate dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification, such as increasing physical activity and losing weight

.

Blood pressure management

  1. Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80mmHg if there is kidney, eye or cerebrovascular damage)
  2. Monitor blood pressure every 1–2 months, and intensify therapy if the person is already on antihypertensive drug treatment, until the blood pressure is consistently below 140/80 mmHg (below 130/80mmHg if there is kidney, eye or cerebrovascular damage)

.

HbA1C monitoring and targets

In adults with type 2 diabetes, measure HbA1c levels at:

  • 3–6-monthly intervals (tailored to individual needs), until the HbA1c is stable on unchanging therapy
  • 6-monthly intervals once the HbA1c level and blood glucose lowering therapy are stable

.

Involve adults with type 2 diabetes in decisions about their individual HbA1c target. Encourage them to achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life

.

In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:

  • reinforce advice about diet, lifestyle and adherence to drug treatment and
  • support the person to aim for an HbA1c level of 53mmol/mol (7.0%) and
  • intensify drug treatment

.

Blood glucose monitoring

'Blood glucose monitoring and exercise' (EKPG) Dec 2018

Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless:

  • the person is on insulin or
  • there is evidence of hypoglycaemic episodes or
  • the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery or
  • the person is pregnant, or is planning to become pregnant

.

NOTE The FreeStyle Libre flash glucose monitoring system is not routinely funded on the local NHs for any patient group, although this policy is currently under review.  See the RaTC document below:

RaTC April 2019 update - changes to previous version

Click here for the EKPG Recommendation for the choice of blood glucose meters in adults

.

Drug treatment

Click here for the algorithm for blood glucose lowering therapy in adults with type 2 diabetes

Click here for the East Kent prescribing guidelines for the management of type 2 diabetes

.

Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes

.

In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, consider initial drug treatment with:

  • a dipeptidyl peptidase-4 (DPP-4) inhibitor or
  • pioglitazone or
  • a sulfonylurea

.

Managing complications

Gastroparesis

  • Think about a diagnosis of gastroparesis in adults with type 2 diabetes with erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses

.

Autonomic neuropathy

  • Think about the possibility of contributory sympathetic nervous system damage for adults with type 2 diabetes who lose the warning signs of hypoglycaemia
  • Think about the possibility of autonomic neuropathy affecting the gut in adults with type 2 diabetes who have unexplained diarrhoea that happens particularly at night

.

Eye disease

  • On diagnosis, GPs should immediately refer adults with type 2 diabetes to the local eye screening service. Perform screening as soon as possible and no later than 3 months from referral. Arrange repeat structured eye screening annually

.

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

Get in touch