What is the impact of type 2 diabetes?
Individualisation of care
What are the evidence-based priorities?
What is optimal blood glucose control?
Hypoglycaemic drugs ? what are the options?
Type 2 diabetes is a major public health issue.1?3 The prevalence of diabetes in England has increased from 3.3% in 2004/5 to 4.1% in 2008/9.1 The management of these patients is complex, requiring management of blood glucose, blood lipids, blood pressure, and lifestyle issues. The health and resource burden of managing type 2 diabetes is huge, and contributes to the increasing prescribing costs in the management of blood glucose in primary care in England, from ?458.6 million in 2004/5 to ?649.2 million in 2009/10.1
An individualised approach to the care of people with type 2 diabetes is recommended by NICE.4 Blood glucose control is one of the many important aspects of that care, and this Bulletin focusses on how to best manage blood glucose in the overall context of preventing both macrovascular and microvascular diabetic complications. More information on other important aspects of the condition ? patient education, managing lifestyle, smoking cessation, controlling blood pressure and blood lipids, are available in NPC e-learning materials on type 2 diabetes, and there are ongoing additions to our portfolio of MeReC Rapid Reviews on type 2 diabetes. This Bulletin is aimed at GPs, nurses, pharmacists, prescribing managers and other professionals involved in the care of people with type 2 diabetes.
Summary
?The management of type 2 diabetes is complex. There are many issues to consider when prioritising the needs of an individual patient. Clinicians need to take account of clinical, physical, psychological and social needs, and the individual?s own preferences for care.
?Controlling blood glucose requires a careful balance. There are no arguments in favour of poor blood glucose control. However, achieving good blood glucose control, while addressing lifestyle, blood pressure, and blood lipids seems likely to prevent more complications, than a narrower approach focused on intensive blood glucose control.
?If appropriate and achievable in an individual, reducing blood glucose to HbA1c levels of around 7.5% (59mmol/mol) would seem optimal based on current evidence. Lower levels may be appropriate for individuals with early disease.
?The preferred hypoglycaemic drugs recommended by NICE are metformin, a sulfonylurea and human NPH insulin ? these interventions have been shown in randomised controlled trials to help patients live longer or better lives.
?Newer hypoglycaemic drugs may have a role in some individuals, but their long term safety is not known and robust evidence that they help patients live longer or better lives is not yet available.
?Progression to triple blood glucose lowering therapy should not be automatic ? clinicians should discuss adherence and the risks and benefits of this approach with individual patients.
?In type 2 diabetes, long-acting insulin analogues have few advantages over human NPH insulin, and are expensive. Therefore, they should be targeted for use in specific individual patients. Their widespread use for type 2 diabetes may not represent the best use of resources.
?The NPC QIPP document includes oral hypoglycaemic drugs, long-acting insulin analogues and blood glucose testing strips as key current priorities for medicines management.
