The updated guidance, which replaces that issued in 2009, places increased importance on individualising care for patients with type II diabetes and includes new recommendations on the sequence of drug treatments that can be offered.
The new MIMS summary of the guidance is available online and will appear in the March print issue of MIMS.
Managing HbA1c levels
HbA1c levels should be monitored at three- to six-monthly intervals until levels are stable on unchanging therapy, and at six-monthly intervals thereafter. If HbA1c levels are not controlled with a single drug and rise to 58mmol/mol (7.5%) or more, healthcare professionals should reinforce advice about diet, lifestyle and drug adherence and intensify drug treatment with the aim of reducing HbA1c to 53mmol/mol (7%).
Drug treatmentThe revised guidance states that all patients with type II diabetes should be offered standard-release metformin as initial treatment, with a gradual increase in dose over several weeks to minimise the risk of gastrointestinal side-effects. If gastrointestinal intolerance occurs, prescribers should consider a trial of modified-release metformin as an alternative.
If metformin is contraindicated or not tolerated, patients may begin drug treatment with a dipeptidyl peptidase-4 (DPP4) inhibitor, pioglitazone or a sulfonylurea.
Treatment intensificationBoth treatment pathways, whether beginning with standard-release metformin or with an alternative treatment, have two intensification steps. The metformin pathway features dual therapy (metformin plus one of four options) as the first intensification, followed by triple therapy (all metformin-based options) or insulin-based treatment as the second intensification. In the non-metformin pathway the first intensification comprises dual therapy (three suggested options) with insulin-based treatment as the second intensification.
The revised guidance includes advice on starting insulin-based treatments using a structured programme involving active insulin dose titration encompassing a number of points, from injection technique to management of hypoglycaemia. The guidance also includes recommendations on switching between the various types of insulin preparations available dependent on response, adverse effects and individual patient preference.