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Introduction

Increasingly, day-to-day management of people with type 2 diabetes falls to general practice nurses (GPNs).¹ It is therefore important that they are familiar with the latest guidelines, and understand how to apply the recommendations to their individual patients. This includes recognising how to determine appropriate targets (for example, for blood glucose control) in each individual case.

This module will help improve awareness of the role of adequate blood glucose control in the prevention of the complications of diabetes.

Reference

Royal College of Nursing. Education, prevention and the role of the nurse, 2020. https://www.rcn.org.uk/clinical-topics/diabetes/education-prevention-and-the-role-of-the-nurse. [Accessed March 2022]

Learning Objectives

On completion of this module, you will be aware of:

Current targets as recommended in the national and international guidelines
The importance of agreeing targets with individual patients
When to intensify drug treatment to achieve targets
When to consider relaxing the target (on a case-by-case basis)
The importance of good blood glucose control for the prevention of complications

This module is one of a series of five

Others in the series are:

Tailoring therapy to the individual patient
Short-term complications of diabetes
Renal considerations in patients with type 2 diabetes
Cardiovascular considerations in patients with type 2 diabetes

Read the article and answer the self-assessment questions, and reflect on what you have learned.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Boehringer Ingelheim Drug Safety on 0800 328 1627 (freephone) or by email pv_local_uk_ireland@boehringer-ingelheim.com.

Adverse events should be reported. Reporting forms and information can be found at https://www.hpra.ie/homepage/about-us/report-an-issue. Adverse events should also be reported to Boehringer Ingelheim Drug Safety on 01 2913960, Fax: +44 1344 742661 or by email pv_local_uk_ireland@boehringer-ingelheim.com.

Setting targets

The focus on strict numerical targets for hypoglycaemic control has changed in recent years, allowing greater flexibility in recognition of the needs of individuals.¹

Reducing HbA1c levels is associated with a reduction in microvascular and macrovascular complications in patients with type 2 diabetes.² Although several studies have demonstrated benefits of intensive glycaemic control in terms of cardiovascular risk and other outcomes, there is also some evidence that very low targets (46mmol/mol, 6.4%) may be associated with increased mortality.²

There is consensus between national (National Institute for Health and Care Excellence [NICE] and the Scottish Intercollegiate Guidelines Network [SIGN]) and international guidelines (American Diabetes Association/European Association for the Study of Diabetes [ADA/EASD]) that a ‘reasonable’ HbA1c target for most adult patients with type 2 diabetes would be 53mmol/mol (7.0%).^1-3

NICE defines good glycaemic control as an HbA1c of 53mmol/mol (7.0%), but stresses the importance of tailoring targets to the individual, to somewhere between 48mmol/mol (6.5%) and 53mmol/mol (7.0%).³

SIGN also recommends a target of 53mmol/mol as reasonable to reduce the risk of complications, but suggests that a more stringent target (48mmol/mol [6.5%]) may be appropriate at diagnosis.²

It is important to balance benefits with potential harms, including the risk of hypoglycaemia and weight gain,² and to involve patients in decisions about targets.³

The ADA/EASD consensus statement also recommends setting individualised glycaemic targets based on patient preferences and goals, the risk of adverse events (hypoglycaemia and weight gain), and patient characteristics, including frailty and comorbid conditions.¹

NICE³ recommends that clinicians should consider relaxing the target HbA1c level, on a case-by-case basis for people with type 2 diabetes who are older or frailer if they are:

Unlikely to achieve longer-term risk-reduction benefits, for example people with a reduced life expectancy
At increased risk of the consequences of hypoglycaemia as a result of tight blood glucose control, e.g.
- People who are at risk of falling
- People who have impaired awareness of hypoglycaemia, and
- People who drive or operate machinery as part of their job
Suffering from significant comorbidities, for example, for whom intensive management would be inappropriate.

In the self-assessment that follows, hypothetical case scenarios based on fictitious patients are presented. Please refer to the relevant Summary of Product Characteristics before prescribing any of the medications mentioned.

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

Davies MJ, D’Alessio DA, Fradkin F, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018;41:2669-2701
SIGN SIGN154. Pharmacological management of type 2 diabetes, 2017. https://www.sign.ac.uk/media/1090/sign154.pdf [Accessed March 2022]
NICE NG28. Type 2 diabetes in adults: management, 2015 (2022 update). https://www.nice.org.uk/guidance/ng28 [Accessed March 2022]

Achieving and maintaining control

Patients should be encouraged to achieve and maintain agreed targets unless any adverse effects, including hypoglycaemia, or their efforts to achieve their target, impair their quality of life.¹

NICE suggests that the target for HbA1c for individuals whose type 2 diabetes is managed by lifestyle and diet, or by lifestyle and diet combined with one drug that does not have an associated risk of hypoglycaemia is 48mmol/mol. For those who are treated with a drug associated with hypoglycaemia, the higher target (53mmol/mol [7.0%]) is recommended.¹ If HbA1c levels are not adequately controlled by a single drug, and rise to 58mmol/mol (7.5%) or higher, the addition of a second glucose lowering drug is recommended, alongside reinforcing advice on diet, lifestyle and adherence to drug treatment. These patients should be supported to aim for an HbA1c level of 53mmol/mol (7.0%).¹

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

NICE NG28. Type 2 diabetes in adults: management, 2015 (2022 update). https://www.nice.org.uk/guidance/ng28 [Accessed March 2022]

Initial drug therapy

Metformin remains the first line oral treatment choice in national and international guidelines for management of type 2 diabetes in adults, together with comprehensive lifestyle measures including weight management and physical activity.^1-3

NICE recommends that metformin should be the first line oral hypoglycaemic agent unless contraindicated or not tolerated. The guideline reminds clinicians that gradual titration of metformin is likely to improve tolerability, and that if standard release metformin is not tolerated, even when introduced at a low dose, modified release metformin may be more readily tolerated.²

The 2022 update to the NICE guidelines provide additional recommendations for initial drug therapy. Patients should be assessed to determine if they have chronic heart failure (CHF) or established atherosclerotic cardiovascular disease (ASCVD) or are at high risk of developing cardiovascular disease.²

In patients with CHF or established ASCVD, a sodium-glucose co-transporter-2 (SGLT2) inhibitor with proven cardiovascular beneﬁts should be oﬀered in addition to metformin. In patients at high risk of developing CVD, an SGLT2 inhibitor with proven cardiovascular beneﬁts should be considered in addition to metformin.²

Alternatives to metformin (if metformin is contraindicated or not tolerated) would include a dipeptidyl-peptidase-4 (DPP-4) inhibitor, pioglitazone a sulphonylurea, or an SGLT2 inhibitor.²

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

SIGN SIGN154. Pharmacological management of type 2 diabetes, 2017. https://www.sign.ac.uk/media/1090/sign154.pdf [Accessed March 2022]
NICE NG28. Type 2 diabetes in adults: management, 2015 (2022 update). https://www.nice.org.uk/guidance/ng28 [Accessed March 2022]
Davies MJ, D’Alessio DA, Fradkin F, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018;41:2669-2701

First and second intensification

When considering intensification of treatment it is important to discuss options for treatment intensification first. These discussions should cover potential adverse events, adherence to existing medicines, the need to look at diet and exercise advice and the doses and formulations of current treatments.¹

If the patient still requires further interventions, consideration should be given to:¹

a DPP-4 inhibitor
pioglitazone
a sulphonylurea
an SGLT2 inhibitor

If dual therapy is unable to keep the patient under their agreed threshold, the addition of a DPP-4 inhibitor, pioglitazone, a sulphonylurea or an SGLT2 inhibitor should be considered or alternatively, insulin-based treatment should be started.¹

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

NICE NG28. Type 2 diabetes in adults: management, 2015 (2022 update). https://www.nice.org.uk/guidance/ng28 [Accessed March 2022]

Frail and/or elderly patients

There is growing recognition that intensive glucose-lowering treatment in type 2 diabetes has limited benefits and may even be dangerous in older people.¹ This should prompt clinicians to modify HbA1c targets in patients who are very frail or have limited life expectancy. Guidance developed by the University of Exeter Medical School in collaboration with NHS England recommends a target of 64mmol/mol (8.0%) for adults with moderate frailty, and 70mmol/mol (8.5%) for the very frail, elderly patient. The guidance warns that metformin may be contraindicated in up to 50% of frail or very frail elderly patients who are likely to have a degree of renal impairment.¹ Other agents, including sulfonylureas, pioglitazone, GLP-1 RAs and SGLT2 inhibitors may all have disadvantages in frail, elderly patients. DPP-4 inhibitors have been used in frail and elderly patients, and have similar efficacy in older patients to that in younger populations.¹

Frailty is fast becoming a critical complication for healthcare professionals to consider, when managing older people and their type 2 diabetes, providing that it has actually been identified for an individual patient. Now more than ever there needs to be clear guidance and support for healthcare professionals in managing this group, especially as the numbers will continue to grow as the population ages.

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

Strain WD, Hope SV, Green A, et al. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabetic Med 2018;35(7):838-245
Abdelhafiz A, Koay L, Sinclair A. Frailty and hypoglycaemia in older people with type 2 diabetes: therapeutic implications. J Diabetes Nurs 2016;20:330–331
NICE NG28. Type 2 diabetes in adults: management, 2015 (2022 update). https://www.nice.org.uk/guidance/ng28 [Accessed March 2022]
SIGN SIGN154. Pharmacological management of glycaemic control in people with Type 2 Diabetes, 2017. Available at https://www.sign.ac.uk/assets/qrg116.pdf [Accessed March 2022]
Davies MJ, D’Alessio DA, Fradkin F, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018;61:2461–2498
ADA. Older Adults: Standards of Medical Care in Diabetes-2021. Diabetes Care 2021;44:S168–S179

Introduction

Reference

Learning Objectives

This module is one of a series of five

Setting targets

Boehringer Ingelheim has no control of the content of the external websites listed in References below. References

Achieving and maintaining control

Boehringer Ingelheim has no control of the content of the external websites listed in References below. References

Initial drug therapy

Boehringer Ingelheim has no control of the content of the external websites listed in References below. References

First and second intensification

Boehringer Ingelheim has no control of the content of the external websites listed in References below. References

Frail and/or elderly patients

Boehringer Ingelheim has no control of the content of the external websites listed in References below. References

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References

Boehringer Ingelheim has no control of the content of the external websites listed in References below.

References