Diabetes mellitus: Management of type 2..

A 64-year-old man is reviewed in clinic. He has a history of ischemic heart disease and was diagnosed with type 2 diabetes mellitus around 12 months ago. At this time of diagnosis his HbA1c was 7.6% (60 mmol/mol) and he was started on metformin which was titrated up to a dose of 1g bd. The most recent bloods show a HbA1c of 6.8% (51 mmol/mol). He has just retired from working in the IT industry and his body mass index (BMI) today is 28 kg/m2.
His other medication is as follows: Atorvastatin 80mg od, Aspirin 75mg od, Bisoprolol 2.5 mg od, Ramipril 5mg od .

What is the most appropriate next step?
A. Add sitagliptin
B. Make no changes to his medication
C. Add glimepiride
D. Add pioglitazone
E. Add exenatide

Answer:
C. Add glimepiride

Discussion: NICE recommend we add another drug if the HbA1c is >= 6.5% at this stage. This is no reason in the history not to add a sulfonylurea.

Diabetes mellitus: management of type 2
NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2009. Key points are listed below:

Dietary advice
 encourage high fibre, low glycaemic index sources of carbohydrates
 include low-fat dairy products and oily fish
 control the intake of foods containing saturated fats and trans fatty acids
 limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake
 discourage use of foods marketed specifically at people with diabetes
 initial target weight loss in an overweight person is 5-10%

HbA1c
 the general target for patients is 48 mmol/mol (DCCT = 6.5%). HbA1c levels below 48 mmol/mol (DCCT = 6.5%) should not be pursued
 however, individual targets should be agreed with patients to encourage motivation
 HbA1c should be checked every 2-6 months until stable, then 6 monthly

Blood pressure 
 target is < 140/80 mmHg (or < 130/80 mmHg if end-organ damage is present)
 ACE inhibitors are first-line T

The NICE treatment algorithm has become much more complicated following the introduction of new therapies for type 2 diabetes.
 NICE still suggest a trial of lifestyle interventions first
 usually metformin is first-line, followed by a sulfonylurea if the HbA1c remains > 48 mmol/mol (DCCT = 6.5%)
 if the patient is at risk from hypoglycaemia (or the consequences of) then a DPP-4 inhibitor or thiazolidinedione should be considered rather than a sulfonylurea
 meglitinides (insulin secretagogues) should be considered for patients with an erratic lifestyle
 if HbA1c > 58 mmol/mol (DCCT = 7.5%) then consider human insulin
 metformin treatment should be continued after starting insulin
 exenatide should be used only when insulin would otherwise be started, obesity is a problem (BMI > 35 kg/m^2) and the need for high dose insulin is likely. Continue only if beneficial response occurs and is maintained (> 1.0 percentage point HbA1c reduction and weight loss > 3% at 6 months)

Starting insulin 
 usually commenced if HbA1c > HbA1c > 58 mmol/mol (DCCT = 7.5%)
 NICE recommend starting with human NPH insulin (isophane, intermediate acting) taken at bed-time or twice daily according to need

Other risk factor modification
 current NICE guidelines suggest giving aspirin to all patients > 50 years and to younger patients with other significant risk factors. However, recent evidence does not support this approach. The 2010 SIGN guidelines do not advocate the use of aspirin for primary prevention in diabetics
 following the 2014 NICE lipid modification guidelines only patients with a 10-year cardiovascular risk > 10% (using QRISK2) should be offered a statin. The first-line statin of choice is atorvastatin 20mg od