Type 2 Diabetes Management
In the initial stages of diagnosis, people with type 2 diabetes should routinely be offered a trial of lifestyle modification including diet, exercise and weight reducing strategies.
However, pharmacotherapy may also be required in people presenting with significant hyperglycaemia.
Physical activity is one of the key modifiable risk factors for glycaemic control. Exercise in combination with diet, oral antidiabetic medications, or insulin, is a key component of therapy for type 2 diabetes.
HbA1c targets
The general HbA1c target in people with type 2 diabetes is ≤ 7%.1 If HbA1c results are >7% it is important to consider intensifying treatment, so long as hypoglycaemia is not a concern.1 Achievement of HbA1c targets must be balanced against risk of severe hypoglycaemia, especially among older people.
For patients with stable blood glucose, the NHMRC National Evidence Based Guideline recommends a minimum of two HbA1c measurements a year for routine assessment of diabetes control.
If diabetes control is not at target and is not improving or is worsening after 3-6 months of a specific treatment strategy, treatment should be intensified. This time interval should be shortened in the presence of significant hyperglycaemia. Where blood glucose control is not optimal or when therapeutic changes are made, HbA1c should be measured after 3 months to assess the response.
Pharmacotherapy
After lifestyle modifications (diet modification, weight control, physical activity) the NHMRC Evidence Based Guideline recommends commencing treatment with metformin followed by sulphonylureas. It is preferable to add a second oral anti-diabetic medication rather than using a maximum dose of one medication alone.
If additional anti-hyperglycaemic agents are required the Guideline recommends any of the following agents as suitable third line options
• Acarbose
• Dipeptidyl peptidase-IV (DPP-IV) inhibitors
• Thiazolidinediones (TZDs) or glitazones*
• Insulin.
Insulin is frequently required for glycaemic control in people with type 2 diabetes and can be initiated as basal therapy or as premixed insulins, usually in combination with oral anti-diabetic medications. Once pharmacotherapy has been commenced, it is important to take regular HbA1c levels to assess response and titrate dosing as required.
Useful URLs
Diabetes Australia www.diabetesaustralia.com.au
National Health and Medical Research Council www.nhmrc.gov.au