ELMMB logo
Facebook logo Twitter logo
Menu
6.1 Drugs used in diabetes

6.1 Drugs used in diabetes

Diabetes care should be tailored to the needs and circumstances of individuals with diabetes, taking into account their personal
preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long‑term interventions because of reduced
life expectancy. Such an approach is especially important in the context of multimorbidity. Reassess the person's needs and
circumstances at each review and think about whether to stop any medicines that are not effective.
 
Structured education should be offered to all adults with type 2 diabetes and/or their family members or carers at and around the
time of diagnosis, with annual reinforcement and review. It should be explained to people that structured education is an integral
part of diabetes care. 
 
The process for referrals to EMPOWER for structured diabetes education can be accessed here  
It should be remembered that control of modifiable cardiovascular risk factors such as smoking cessation, lipids and blood
pressure are the most important interventions to be made in patients with type II diabetes. 
 
Blood glucose management  
In adults with type 2 diabetes, HbA1c levels should be measured at:  
 
         >     3 - 6 monthly  intervals (tailored to individual needs), until the HbA1c is stable on unchanging therapy
         >     6 monthly intervals once the HbA1c level and blood glucose lowering therapy are stable 
 
For adults with type 2 diabetes they should be involved in decisions about their individual HbA1c target. Encourage them to 
achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their 
target, impair their quality of life.
 
For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not
associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%).
 
For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%), 
in adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise  to 58 mmol/mol (7.5%) or 
higher:  
 
         >     reinforce advice about diet, lifestyle and adherence to drug treatment and 

         >     support the person to aim for an HbA1c level of 53 mmol/mol (7.00%) and intensify drug treatment.

Consider relaxing the target HbA1c on a case‑by‑case basis, with particular consideration for people who are older or frail, for 
adults with type 2 diabetes:  
 
         >     who are unlikely to achieve longer‑term risk‑reduction benefits, for example, people with a reduced life expectancy
         >     for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who
                   are at risk of falling, people who have impaired  awareness of hypoglycaemia, and people who drive or operate
                   machinery as part of their job
          >     for whom intensive management would not be appropriate, for example, people with significant comorbidities. 
 
 If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, 
encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example, 
deteriorating renal function or sudden weight loss. 
For guidance on HbA1c targets for women with type 2 diabetes who are pregnant or planning to become pregnant, see the NICE 
guideline on diabetes in pregnancy
 
Initial Drug treatment 
Standard-release metformin is the initial drug treatment for adults with type 2 diabetes. The dose of standard‑release metformin 
should be gradually increased over several weeks to minimise the risk of gastrointestinal side effects. If an adult with type 2 
diabetes experiences gastrointestinal side effects with standard‑release metformin then consider a trial of modified‑release 
metformin. 
In adults with type 2 diabetes, review the dose of metformin if the estimated glomerular filtration rate (eGFR) is below 
45 ml/minute/1.73m   2  :
 
          >     stop metformin if the eGFR is below 30 ml/minute/1.73m 2 . 
          >     prescribe metformin with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR 
                 falling below 45 ml/minute/1.73m 2
          >     If metformin is contraindicated or not tolerated, consider initial drug treatment with: 
                         > a sulfonylurea or a dipeptidyl peptidase‑4 (DPP‑4) inhibitor or pioglitazone.
 
 
First intensification of drug treatment 
In adults with type 2 diabetes, if initial drug treatment with metformin has not continued to control HbA1c to below the person's 
individually agreed threshold for intensification, consider dual therapy with:  
 
            >     metformin and a DPP-4 inhibitor or
            >     metformin and pioglitazone  [ 4 ] or 
            >     metformin and a sulfonylurea.
 
In adults with type 2 diabetes, if metformin is contraindicated or not tolerated and initial drug treatment has not continued to 
control HbA1c to below the person's individually agreed threshold for intensification, consider dual therapy with:  
 
            >     a DPP-4 inhibitor and pioglitazone or
            >     a DPP-4 inhibitor and a sulfonylurea or
            >     pioglitazone and a sulfonylurea 
 
Treatment with combinations of medicines including sodium–glucose cotransporter 2 (SGLT‑2) inhibitors may be appropriate for
some people with type 2 diabetes; see the NICE guidance on canagliflozin in combination therapy for treating type 2 type 2 
diabetes, dapagliflozin in combination therapy for treating type 2 diabetes and empagliflozin in combination therapy for treating 
diabetes. 
 
Second intensification of drug treatment  
In adults with type 2 diabetes, if dual therapy with metformin and another oral drug has not continued to control HbA1c to below 
the person's individually agreed threshold for intensification, consider either:   
 
     >     triple therapy with:
                 >     metformin, a DPP‑4 inhibitor and a sulfonylurea or
                 >     metformin, pioglitazone [ 4 ] and a sulfonylurea or
                 >     starting insulin-based treatment
                 >     glucagon‑like peptide‑1 (GLP‑1) mimetic for adults with type 2 diabetes who:
                            >     have a BMI of 35 kg/m  or higher (adjust accordingly for people from black, Asian and other minority
                                   ethnic groups) and specific psychological or other medical problems associated with obesity or 
                            >     have a BMI lower than 35 kg/m 2 and: 
                                           >     for whom insulin therapy would have significant occupational implications or 
                                           >     weight loss would benefit other significant obesity‑related comorbidities.
 
Only continue GLP‑1 mimetic therapy if the person with type 2 diabetes has had a beneficial metabolic response (a reduction of at 
least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months). 
In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, and if dual therapy with 2 oral drugs has not
continued to control HbA1c to below the person's individually agreed threshold for intensification, consider insulin‑based
treatment .
 
In adults with type 2 diabetes, only offer a GLP‑1 mimetic in combination with insulin with specialist care advice and ongoing 
support from a consultant‑led multidisciplinary team. 
 
Treatment with combinations of medicines including SGLT‑2 inhibitors may be appropriate for some people with type 2 diabetes; 
see the NICE guidance on canagliflozin in combination therapy for treating type 2 diabetesdapagliflozin in combination therapy 
for treating type 2 diabetesdapagliflozin in triple therapy for treating type 2 diabetes and empagliflozin in combination therapy 
for treating type 2 diabetes.
 
 
 
 
 
 
 

All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the  
public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service. 
  Email: info.elmmb@nhs.net
 Copyright© 2016 East Lancashire Medicines Management Board. 
 All rights reserved.  Disclaimer/Terms and conditions