Chris Smith RAH Chair of Type 2 DM MCN subgroup Outline Type 2 Diabetes Guideline LifestyleGWMS Earlier Intensification Structured Education GWMSTriage Community Weight Management Service currently Weight Watchers ID: 934367
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Slide1
Type 2 Diabetes Subgroup
Chris Smith, RAH
Chair of Type 2 DM MCN sub-group
Slide2Outline
Type 2 Diabetes Guideline
Lifestyle/GWMS
Earlier Intensification
Structured Education
Slide3GWMS/Triage
Community Weight Management Service (currently Weight Watchers)
Specialist Weight Management Service
T2DM
BMI ≥25 (22.5*)
T2DMBMI≥45T1DMBMI ≥30 (27.5*)T1DMBMI≥45Impaired fasting glucose/ impaired glucose tolerance/ BMI ≥25 (22.5*)Potential bariatric surgery patient (as per criteria)BMI≥35
http://www.nhsggc.org.uk/your-health/health-services/glasgow-and-clyde-weight-management-service/health-professionals-guide-to-gcwms/
Slide4Stratification
Target HbA1c achieved (eg <53 mmol/mol)
Arrange 6-12 monthly HbA1c
If HbA1c above target, back into Rx algorithm
Treatment failure ie HbA1c drop <5.5mmol/mol, therefore stop RX and consider alternative from Rx line
1st line agentArrange 3/12 HbA1c
2
nd
line agent
HbA1c 3/12
3
rd
line agent
HbA1c 3/12
4
th
line agent (typically need specialist support)
GLP1 or basal insulin start (with cDSN support)
HbA1c 3/12
B
- INTENSIFICATION
A+C -
MONITORING
Emphasise the benefits of achieving and maintaining healthy BMI
A – Target achieved (national or individualised):
Monitoring
B – Target not achieved: Active
Intensification
C – Target not achieved:
Monitoring
Intensification complete, drug intolerance/adherence, patient decision
D – Disengaged from healthcare
Slide54
th
line agent (typically need specialist support)
GLP1 or basal insulin start (with cDSN support)
HbA1c 3/12
Insulin intensification beyond basal insulin ie introduction of prandial or premix regimes (case reviewed by specialist)
Slide6FIRST LINE
METFORMIN
*SU
*SGLT2i (if BMI>30
or
CV disease)AdvantagesWeightCV Low hypo riskEfficacyWeight lossCV (and BP)Low hypo riskCautions/ side effectsGIHyposWeight gainFrailtyBGMDiureticsThrushKetosisContraindicationsCKD 4
CKD 3a (initiation)
Frailty
Slide7SECOND LINE
SGLT2i
SU
DPP4i
Pioglitazone
AdvantagesWeight lossCV (and BP)Low hypo riskEfficacyWeightLow hypo risktoleratedEfficacyLow hypo riskCautions/ side effectsDiureticsThrushKetosisHyposWeight gainFrailtyBGMEfficacyCKD (adjustment)Oedema
Central adiposity
osteoporosis
Contraindications
CKD 3a (initiation)
Frailty
Pancreatic history
CCF
Bladder cancer (
haematuria
)
Slide8THIRD LINE
3
rd
agent from 2
nd
line GLP1 RAO.D. insulinAdvantagesAs aboveEfficacyWeight lossCVLow hypo riskEfficacyCautions/ side effectsAs aboveGI InjectionsHyposWeight gainBGMInjectionsContraindicationsAs abovePancreatic history
CKD 4 (egfr <15 for some)
FOURTH LINE
Specialist input (cDSN and/or consultant)
If >1 insulin injection required should be offered clinic review until stable
Slide9Subgroups: Obesity and/or CV disease
FIRST LINE
METFORMIN
*SU
*SGLT2i (if BMI>30
or CV disease)SECOND LINESGLT2iSUDPP4iPioglitazoneTHIRD LINEGLP1 RA3rd agent from 2nd line O.D. insulin
If known CV disease, choose SGLT2i or GLP1 RA with proven CV benefit.
Slide10Frail/Elderly
FIRST LINE
METFORMIN
*SU
*SGLT2i (if BMI>30
or CV disease)SECOND LINEDPP4iSGLT2iSUPioglitazoneRelaxing glycaemic target may be appropriate eg HbA1c 65-75 mmol/mol, and concentrating on treating symptoms whilst minimising risks of potential side effects like hypoglycaemia.