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

add Metformin  
increase to 2.0 - 2.5gm over 3 months (divided doses)

0-8 weeks, if levels higher than HbA1c 48 mmol/mol / 6.5% .
this is the target for recently diagnosed patients

if low weight

if overweight

Sitagliptin & Linaglyptin (Trajenta) do not cause weight gain, but all the other treatments below increase weight Linaglyptin (Trajenta) if renal function reduced If thin, sulphonylurea and titrate to maximum dose depending on response. Eg gliclazide. start 40-80 mg daily. 160 mg as a single dose, with breakfast; higher doses divided; max. 320 mg daily. Weight will increase. Sulphonylurea do cause hypos. Dapagliflozin (Farxiga) if well or add insulin as below 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.

Once daily Liraglutide or Sitagliptin Dapagliflozin (Farxiga) if well Incretins twice daily Exenatide (BMJ) lowers HbA1c <1.5% /15mmol/l or weekly exenatide (Bydureon) they are injections lower weight avoid if pancreatitis..~2% risk of pancreatitis  Probably no pancreatitis risk Reduced renal function avoid Liraglutide / Exenatide / weekly exenatide if GFR <30 Liraglutide / Exenatide ..care if GFR 30-50 weekly exenatide (Bydureon) avoid at present <GFR 50 Sitagliptin lowers HbA1c 0.7-1.0% /~10 mmol/l, reduce dose if renal fundtion/GFR low (details) Linaglyptin (Trajenta) safe if renal function reduced

 

12 weeks, if levels higher than target (>HbA1c 48 mmol/mol / 6.5% at onset)

Add insulin

• 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