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 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 2 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 diabetes, dapagliflozin in combination therapy
|
for treating type 2 diabetes, dapagliflozin in triple therapy for treating type 2 diabetes and empagliflozin in combination therapy
|
| for treating type 2 diabetes. |
| |
| |
| |
| |
