Further info regarding notes see: Figure 4, page14, NZGG Type 2 Diabetes Management
Further info regarding notes see: Figure 3, page 10, NZGG Type 2 Diabetes Management
All patients with type 2 diabetes should be prescribed lipid lowering medication regardless of their lipid profile
Further info regarding notes see: Table 27 and other information on Page 33-34, CVD Handbook
Predominant hypertriglyceridaemia and low HDL-CBefore using medications, it is important to identify lifestyle relating factors (eg, diet, alcohol, obesity) or any primary cause (eg, diabetes) which may be exacerbating lipid abnormalities. Correcting these factors may make drug treatment unnecessary. Nicotinic acid, acipimox or fibrates are the most appropriate options to consider. Statins are not usually effective if triglycerides are markedly elevated (>5 mmol/L).
Combined dyslipidaemiaLifestyle factors may be significant. Consider treatment with a statin and nicotinic acid or a fibrate in people with moderate to marked elevation of LDL-C and triglycerides. Because of the increased risk of myopathy with combinations (particularly with gemfibrozil), special care should be taken to inform and monitor people on combination treatment.
For further information see - Table 27 and other information on Page 33-34, CVD Handbook
Consider if CVD risk greater than 15%
The following recommendations are intended for use by primary care practitioners as a guide. Practitioners should seek specialist advice to support patient management as needed. It is important that the individual is helped to understand their insulin regimen and encouraged to take an active role in management during the initiation of insulin.
Insulin Initiation in Primary Care
When to consider insulin
Consider insulin therapy if the individual with type 2 diabetes has unsatisfactory glycaemic control (measured HbA1c does not meet or closely approach agreed target) or there are signs and symptoms of hyperglycaemia despite:
People who have an HbA1c above 65 mmol/mol should be seriously considered for insulin therapy.
Note: Target HbA1c is 50-55 mmol/molor as individually agreed.
It is important to assess the individual's readiness for commencing insulin therapy and address any patient concerns - Appendix E, page 32, NZGG Type 2 Diabetes Management
A patient education checklist for practitioners relating to initiation of insulin therapy is available - Appendix F, page 34, NZGG Type 2 Diabetes Management
Assess blood glucose profile
Prior to initiating insulin therapy, it is essential that the patient is regularly self-monitoring their blood glucose levels to assist decision-making about an appropriate insulin regimen.
Blood glucose profile: practice points
When initiating insulin therapy for a given patient, ensure that the patient understands that the initial insulin dose is a starting point for dose titration.
Discuss and agree on the frequency of follow-up.
A summary algorithm outlining appropriate initiation of insulin in primary care for people with type 2 diabetes. - Figure 5, page 18, NZGG Type 2 Diabetes Management
Maintenance self-monitoring blood glucose
Once the patient is established on insulin and blood glucose levels are stable, frequency of blood glucose testing can be reduced but should still be such as to show the blood glucose profile over the course of the day.
Maintenance SMBG can be combined with checking HbA1c levels (3-6 monthly) to assess glycaemic control and the need for medication changes.
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