Rapid E clinical guidance in the management of Type 2 diabetes

New Zealand Guidelines Group

Introduction to guidance

• Developed for use in primary care

• Addresses 3 identified priority areas:

I. Early identification of patients at high risk of diabetes-related complications

II. Better management of raised blood pressure and microalbuminuria

III. Improved glycaemic control (including insulin initiation)

Draws on SIGN guideline 116 Management of Diabetes 2010 www.sign.ac.uk

1. Early identification of risk

• Risk of diabetes-related complications varies from patient to patient

• Aim is to prevent complications, especially targeting those at high risk

• Patients with existing complications (eye, foot, kidney or cardiovascular disease) are high risk and should be managed intensively

2.Management: BP & microalbuminuria

• BP is measured frequently but BP targets set in clinical guidelines are not being consistently met

• Recent NZ reports indicate 53 ̶ 78% of people with type 2 diabetes have a BP above 130/80 mm Hg

• Key reasons are medication adherence by patients and clinical inertia ie, failure of health practitioners to initiate or intensify treatment when indicated

• The guidance assists stepwise intensification of treatment as appropriate to individual patients

Blood pressure management

• Target BP <130/80 mm Hg

• Evidence suggests BP target <120 mm Hg may be harmful (Accord 2010)

Management: microalbuminuria

• People with confirmed microalbuminuria should be treated with an ACE inhibitor or ARB whether or not hypertension present

More on renal disease

•Māori, Pacific Island and South Asian peoples are at higher risk of renal complications

•More frequent monitoring of renal status is indicated

• Any evidence of renal disease based on decreasing eGFR should be treated with urgency

3. Glycaemic control.

• Good glycaemic control is difficult to maintain over time as the condition progresses

• More intensive treatment is required over time to meet the treatment target

• Good glycaemic control has a clear benefit on microvascular outcomes and if started early enough, on long-term macrovascular outcomes

Management of glycaemic control

• Target HbA1c 50 ̶ 55 mmol/mol (7%) or as individually agreed

• Any reduction in HbA1c is beneficial

When to consider insulin therapy

Consider if:

•unsatisfactory glycaemic control (measured HbA1c does not meet or closely approach agreed target) or

•signs & symptoms of hyperglycaemia

AND

Management has included:•diet, physical exercise and behavioural strategies•review of medication adherence & dose optimisation.

When to consider insulin therapy cont.

• Also seriously consider insulin therapy if the person has an HbA1c >65 mmol/L

Key Points For General Practice

1. General Practice and Primary Care need to take the lead

2. Identify risk of complications early for intensive intervention

Key Points (2)

3. Aim for HbA1c 50–55 mmol/mol (~7%)

I. Don’t be too aggressive. 7%(50-55)

II. Accord (2010) – Some evidence increase fatal events with tighter control (6%)

III. Metformin till eGFR < 30

IV. Insulin early rather than late

Key Points (3)4. BP aim <130/80.

I. Avoid Clinical Inertia

II. Often multiple medication required

III. <120 maybe harmful(Accord)

5. ACEI/ARB with microalbuminuria, whether or not hypertensive

6. Lipid control –

I. Consider satins early: Aim TC<4, TG<1.7

II. CV Guidelines

Key Points (4)7. Diet/Exercise/Smoking Cessation essential in

management:

I. Diet/Exercise: Additional Benefit compared with most expensive new drugs if intensify diet/exercise.

8. Practice recalls for retinal screening/podiatry review/bloods/medical review

9. Specialist advice as required:

I. Case Conferencing, Phone, E-mail, combined Consults, Outpatients

Guidelines

1.Available on line2.Published Nov 2011 with new CV Handbook