Type II Diabetes: Free

Diabetes Management

This is an interesting case, as they aren’t testing your knowledge of the fourth step in diabetes management, but rather your holistic approach to managing chronic conditions.

As you may be aware, the management of Diabetes has recently been updated with a new NICE Guidance on the matter: https://www.nice.org.uk/guidance/ng28

The first thing we need to establish is where their Hba1c Target should sit. The current recommendations from NICE are below:

Educate the person about their individual recommended HbA1c target, and encourage measures to achieve and maintain it, where possible.

1. Lifestyle including diet management — 48 mmol/mol (6.5%).

2. Lifestyle including diet combined with a single drug not associated with hypoglycaemia (such as metformin) — 48 mmol/mol (6.5%).

3. Drug treatment associated with hypoglycaemia (such as sulfonylurea): 53 mmol/mol (7.0%).

Once you have an established target, the next thing to discuss is lifestyle measures, in all diabetic reviews. Ask the patient what their current lifestyle and diet is, what they would like it to be, what is a realistic aim for them, and what barriers, if any, exist to stop them from achieving their goals.

In this case, the barrier is his work, and in some ways, the three times daily dosing of metformin.

So what could we do in this case to help his control: Well, it wouldn’t be a good idea to add in any more medication at this time. Any further medication added could potentially increase the risk of hypoglycaemic attacks. This is something he would want to avoid given his line of work. Therefore we could look at amending the medication to make it easier for him to take.

As he is already on Metformin 500mg TDS, we could swap this to 1g M/R BD. This would likely double the effective dose he is getting (as he states he wasn’t really taking the lunchtime dose), and it would be easier for him to take as it’s only twice daily. To help remind him, you could suggest setting up alarms within his phone, or there are special apps you can download to your smartphone to help remind you.

What if his compliance was perfect:

If his compliance was perfect, and there were no glaring obvious changes he could make to his lifestyle, then we would need to look at increasing his diabetic medication to bring his blood sugars down. NICE guidance currently suggests the following:

1st Line, is still Metformin, standard release. Slowly up titrated. Once Metformin has been established then assess the person's cardiovascular status and risk to determine whether they; have chronic heart failure, have established atherosclerotic cardiovascular disease, or are at high risk of developing cardiovascular disease. Based on this cardiovascular risk assessment for the person with type 2 diabetes:

1. If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin.

2. If they are at high risk of developing cardiovascular disease, consider an SGLT-2 inhibitor with proven cardiovascular benefit in addition to metformin.

3. If They have none of the above, and their Qrisk is under 10%, then just Start with Metformin Alone

Second-line: If first-line treatment is ineffective, consider one of the following second-line treatment options:

For people who can take metformin, consider dual therapy with:

1. Metformin plus a DPP-4 inhibitor, or

2. Metformin plus pioglitazone, or

3. Metformin plus a sulfonylurea.

4. Metformin plus an SGLT-2 inhibitor may be considered if a sulfonylurea is contraindicated or not tolerated, or the person is at significant risk of hypoglycaemia or its consequences.

For people in whom metformin is contraindicated or not tolerated, consider the following:

1. Offer an SGLT-2 inhibitor to people with chronic heart failure or established atherosclerotic cardiovascular disease, and consider offering an SGLT-2 inhibitor to people at high risk of developing cardiovascular disease.

2. For other people, consider one of the  following as first-line treatment:

   • A dipeptidyl peptidase-4 inhibitor (DPP-4 inhibitor).

   • Pioglitazone. 

   • A sulfonylurea.

   • A sodium-glucose cotransporter-2 inhibitor (SGLT-2 inhibitor) — this may be considered instead of a DPP-4 inhibitor if a sulfonylurea or pioglitazone is not appropriate.

Third-line: If second-line treatment is ineffective, consider one of the following treatment options:

For people who can take metformin:

1. Triple therapy by adding a DPP-4 inhibitor, pioglitazone, a sulfonylurea, or an SGLT-2 inhibitor (canagliflozin or empagliflozin). Note: dapagliflozin is recommended only in combination with metformin and a sulfonylurea, not pioglitazone, and ertugliflozin only in combination with metformin and a DPP-4 inhibitor, if a sulfonylurea or pioglitazone is not appropriate.

What would be of relevance in this case (If his compliance was excellent), is the section about second-line treatment not being effective, and what to add in third-line. Given that he is already on Metformin and a DPP-4, then the next step could either be an SGLT-2 or a Sulfonylurea, depending on his Qrisk and preferences. Undoubtedly the sulfonylurea would be better at bringing the blood sugars down, but would increase his risk of Hypos and may cause problems with his driving. Therefore in this instance, adding in an SGLT-2 would be the better option, especially as it’s likely his Qrisk is greater than 10%.