Diabetes  |  Type 2 Pathway - Medications




Diabetes

Type 2 Pathway - Medications

Management of Glycaemic Control

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Further info regarding notes see: Figure 4, page14, NZGG Type 2 Diabetes Management

Management of raised blood pressure and microalbuminuria in Type 2 Diabetes

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Further info regarding notes see: Figure 3, page 10, NZGG Type 2 Diabetes Management

Lipid management - Optimal lipid levels for people with Diabetes

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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

Specific lipid profiles and treatments

Predominant hypercholesterolaemia

Statins are first line treatment and can be used in combination with ezetimibe, nicotinic acid or resins to lower TC and LDL-C. Nicotinic acid or possibly fibrates may be considered if low HDL-C (<1.0 mmol/L) persists on statin treatment. People with a very low HDL-C (<0.7 mmol/L) may need specialist review.

Predominant hypertriglyceridaemia and low HDL-C

Before 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 dyslipidaemia

Lifestyle 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

Aspirin

Consider if CVD risk greater than 15%

Insulin

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:

  • management including appropriate food/diet, physical exercise and behavioural strategies
  • review of medication adherence and dose optimisation of oral hypoglycaemic agents

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

  • Educate the patient on how to measure blood glucose levels using a meter and how to record results using a log book to determine their current blood glucose profi le.
  • Review recorded blood glucose results with the patient to identify their current blood glucose profile and 'problem' times of the day
  • Use their blood glucose profile to help you and the patient decide on an appropriate insulin regimen

 

Insulin therapy

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.

Isophane insulin

  • Once daily isophane (NPH*) insulin at night (or pre breakfast if the patient has daytime hyperglycaemia) should be used when adding insulin to metformin and/or sulphonylurea therapy. * Neutral protamine Hagedorm
  • Twice daily isophane (NPH) insulin may be considered if the person has high blood glucose levels during both the day and night. The NZGG Diabetes Advisory Group also recommends considering twice daily insulin if the person is markedly hyperglycaemic. When prescribing twice daily insulin therapy sulphonylurea therapy should be stopped.

Other regimens

  • Basal insulin analogues should be considered if there are concerns regarding hypoglycaemia.
  • Premixed insulin can be considered if post prandial levels are elevated and the HbA1c target has not been met.
  • Seek specialist advice if instigating a premixed insulin regimen.
  • The option of adding short-acting insulin relates to the intensification of insulin therapy and is not included in this guidance.

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.

  • If the patient chooses to test less frequently, ask them to vary testing across different times of the day.
  • Patients may choose to test in other patterns eg, 4 times a day on one or two days of the week.

Maintenance SMBG can be combined with checking HbA1c levels (3-6 monthly) to assess glycaemic control and the need for medication changes.

Guide to dose adjustments for initial titration



Last updated : Wednesday, July 26, 2017
Next review date : Thursday, July 26,2018


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