Type 2 diabetes: a treatment plan (separate page)
Proceed down until target reached:
address diet exercise losing weight learn to test glucose
0-8 weeks, if levels higher than HbA1c 48 mmol/mol / 6.5% at onset of diabetes if well
increase to 2.0 - 2.5gm over 3 months (divided doses)
weeks, if levels higher than HbA1c 48 mmol/mol / 6.5% .
this is the target for recently diagnosed patients
|if low weight||if overweight|
These drugs (and only one of this list would normally be added) will only lower the HbA1c 0.5-1.0%.
Therefore if the HbA1c is >8.5% 69mmol/l, a 7.5% /58mmol/ltarget will not be reached, so insulin may be best. However, a gradual HbA1c drop may be best in retinopathy patients.
12 weeks, if levels higher than target (>HbA1c 48 mmol/mol / 6.5% at onset)
- Add bedtime basal insulin (Lantus/glargine & Levemir/detemir)
- adjust dose to achieve fasting blood glucose 4-7mmol/l slowly over several weeks
- Continue treatment with metformin, continue exentatide (licensed 2012), stop other glucose lowering drugs
- this is reviewed here (NEJM)
- Insulin will cause weight gain..consider bariatric surgery if very overweight
12 weeks, if levels higher than target
- Add rapid acting insulin prior to meals (basal bolus).
- Continue metformin
- infirm/very elderly/poor compliance convert to twice daily insulin mixture +/- metformin, consider degludec
- twice daily Levemir/detemir is easier to adjust than Lantus/glargine, and would be my reommendation for well motivated patients, especially those taking regular exercise such as a round of golf (less insulin will be needed on golfing days).
- aim for lower HbA1c is well motivated patients, perhaps 6.5%, if insulin not needed
- aim for HbA1c <58 mmol/mol / 7.5% if using insulin
- lipids....usually a statin is helpful to lower cholesterol in most patients;
- a fibrate is preferable if triglycerides high (? fibrate in all type 2 patients)
- exercise 60 minutes a day, 120 minutes if overweight...any exercise, such as walking, swimming, cycling, gardening
- losing weight if overweight is critical..overweight patients should be advised about a diet and lose a pound a week..prognosis is significantly improved
- low blood pressure needed
- patients should be taught to monitor their own blood sugar and should attend a diabetes education program
- for insulin patients taking lots of exercise on some days, or who are well but have lots of hypos, a pump might be helpful.
- why do insulin users gain weight..Joslin