Glucose control
For patients with early type 2 diabetes, intensive glucose control to HbA1c levels of around 6.5% is probably useful. ut after 5-10 years, control might be relaxed to around 7%. That was the recommendation given by Dr Neil Munro GP, Surrey, and Chelsea and Westminster Hospital, London, UK). He explained that when UKPDS was published in
1998 there was no apparent macrovascular benefit from intensive glucose control. But follow-up data, after patients ad been on routine treatment for 10 years, showed a significant reduction of MI.
“So there seems to be a legacy effect, if you treat people aggressively to target early.”
Three more recent studies had found no macrovascular benefit, but they had only lasted 3-5 years.
“The likelihood is that there is (macrovascular) benefit, but this is not obvious early on.”
Good glycaemia control is also important for reducing disabling microvascular complications. The recent ACCORD rial, involving patients with advanced diabetes and cardiovascular disease, tried to reduce HbA1c very quickly but howed increased cardiovascular mortality in intensively treated patients.
”Whatever the cause, going down to 6% rapidly was not a good idea. We should be mindful of pushing it very low in advanced disease.”
Dr Munro said that metformin is definitely the first line drug. If weight is an issue, he would avoid sulphonylureas. He thought that the newer DPP4 inhibitors and GLP1 agonists – both of which modulate the incretin system – would find increasing use, although there will be cost implications. It is important to tailor treatment to the individual, and this includes asking patients what side effect they can tolerate. Current GLP1 agonists have to be injected but inhaled, nasal and transdermal formulations are being investigated.
Insulin
GPs do not need to refer patients with type 2 diabetes to secondary care for introduction of insulin, said Dr Xavier Cos (Barcelona, Spain).
”There is no reason to refer (for insulin) if you feel comfortable with it.”
There could be both patient and health care professional barriers to starting insulin. He emphasized that hypoglycaemia is not as much of an issue as with type 1 diabetes, and slow dose titration can minimize the risk. It is important to titrate insulin doses according to fasting blood glucose:
”European audits show that we are not using insulin in the doses our patients need.”
Weight gain discourages many patients. A 4-6kg increase in weight can be expected in the first year of starting insulin and so it is helpful to give diet/exercise advice to try to avoid this. The patient might also have feelings of failure:
“Sometimes the patient feels that they have done something wrong to need insulin. The health care professional needs to explain the progressive nature of type 2 diabetes and to dispel negative beliefs about insulin therapy.”