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Diabetes mellitus
A stepped approach to diabetes management
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(Read with protocol 'Changing Type 2 patients to insulin for more details)
Theory of management, targets and importance of good diabetes control
- Type 2 diabetes is a progressive disorder
- Healthy diet, regular exercise and maintenance of ideal body weight are
the foundation
- Good glycaemic control (HIBA1c <7.5, FPG <8, 2 hour postprandial
<10) can slow progression and prevent complications.
Drug sequence (OHAs) to maintain targets
- First line
Metformin (increase gradually to avoid side effects - in about 25%), Max.
dose 1 gm tds If Metformin not tolerated/contraindicated - commence
sulphonylurea Tolbutamide maximum dose 1gm bd Or Glibenclamide maximum dose
15mg i.e. 10+ 5mg Or Gliclazide 160mg bd
- Second line
If HbA1c >7.5% add 2nd line agent - Sulphonylurea. · Non tolerance of
Metformin or contraindicated: Maximum sulphonylurea and Rosiglitazone 4mg
daily.
Contraindications for Rosiglitazone raised LFTs (ALT>2.5x upper limit
normal, heart failure, Cr >500.
- Third line
- At present all three drugs cannot be used together.
- If HbAlc >7.5 on maximum tolerated sulphonylurea + Metformin: try
maximum tolerated Metformin + Rosiglitazone 4mg daily (i.e. reduce and
stop sulphonylurea over 4f52. After 4 weeks Rosiglitazone can be
increased to 8mg in combination with Metformin (4mg bd or 8mg od) (This
is the preferred third line combination especially in obese subjects)
- If Metformin is only tolerated in a small dose in combination with
max. sulphonylurea - can try substituting Metformin for Rosiglitazone
i.e. max. Sulphonylurea + Rosiglitazone 4mg daily.
- Consider insulin as alternative early.
- Acarbose may be added for a few individual clinical reasons (with
sulphonylurea +/or Metformin, but not in combination with
Rosiglitazone). Very poorly tolerated - gradual introduction may help
(see patient information leaflet) 25mgs od 25mgs bd 25mgs tds 50mgs bd
50mgs tds max dose100mgs tds
Adding insulin - 30% will need this to maintain targets
Insulin therapy will be a significant 'life event' for many patients,
providing an opportunity to re-evaluate lifestyle, have a rethink on energy
intake and physical activity. All patients should have an opportunity to discuss
this with a 'lifestyle advisor' before the 'technical' change is made.
- Those poorly controlled for a long time on maximal oral agents and now
symptomatic (osmotic and weight loss)
- Stop Metformin / Stop I tail off snlphonylureas / stop Rosiglitazone
- Commence bd Insulatard / Mixtard
- Consider reintroducing Metformin when stable
- Overweight (BMI >30)
- Continue with metformin
- Stop / Tail off sulphonyhirea / Rosiglitazone
- Commence bd insulatard / mixtard
- 'Catching them early'- i.e HbA1c beginning to rise, despite maximal OHAs,
relatively asymptomatic
- Continue Metformin ± sulphonylurea/ stop Rosiglitazone.
- Add od insulatard at breakfast or teatime (depending on BM profile
over 24 hours)
- If good BM control not achieved change to bd insulin
- If bd insulin >40 units stop sulphonylurea
Source: Northumbria NHS Health Care Trust diabetes protocol