B-QuiCK: Type 2 diabetes

Type 2 diabetes

Screening and diagnosis

• Test HbA_1c in people at high risk of type 2 diabetes of any age; the threshold for diagnosis is:
  • HbA_1c ≥ 50 mmol/mol
  • HbA_1c 41 – 49 mmol/mol classified as “pre-diabetes”

Management

• Select an appropriate glycaemic target based on patient age, co-morbidities, duration of diabetes, history of hypoglycaemia and overall health status:
  • HbA_1c < 48 mmol/mol, appropriate for younger people, e.g. aged < 40 years
  • HbA_1c < 53 mmol/mol, appropriate for most people
  • HbA_1c 54 – 70 mmol/mol, appropriate if hypoglycaemic risk outweighs benefits of lower target
• Follow a stepwise treatment progression:
  • Step 1: Lifestyle interventions + metformin (initiate at diagnosis)
  • Step 2: Add a second non-insulin glucose-lowering medicine, i.e. empagliflozin, dulaglutide, vildagliptin, a sulfonylurea or pioglitazone; a third medicine can be added instead of stepping up to insulin
  • Step 3: Add insulin (isophane insulin appropriate for most patients)
  • If HbA_1c > 64 mmol/mol at diagnosis, initiate two glucose-lowering medicines; if HbA_1c very high, e.g. 80 – 90 mmol/mol, initiate insulin
• Check adherence to the existing medicine regimen and diet and physical activity approaches before stepping up pharmacological treatment
• Encourage weight loss at any step to induce remission, slow progression, step down treatment intensity or delay treatment escalation
• Encourage consumption of low calorie and low GI foods, increase vegetable intake and minimise dietary fat, sugar and alcohol
• Connect patients to services that can assist with lifestyle changes and provide support
• Consider referral for bariatric surgery if BMI between 35 – 55 kg/m^{2 *} to assist with weight loss
• If patients are transitioning from a paediatric service, establish who is responsible for the patient’s diabetes care and ensure they are followed up regularly

^{* Referral criteria may differ; check with your local DHB}

Choosing a Step 2 medicine

• Consider contraindications, co-morbidities, risk of hypoglycaemia, effects on weight, medicines interactions, adverse effects and eligibility for funding
• Empagliflozin or dulaglutide are preferred for people with established CVD or at high risk (including Māori and Pacific peoples), or with heart failure or diabetic kidney disease
• Vildagliptin is preferred for patients who are not eligible for funded empagliflozin or dulaglutide treatment (and are not self-funding treatment)
• Consider other prescribed medicines and how additional diabetes medicines might affect adherence

Initiating insulin

• Initiate once-daily basal insulin, injected at night; isophane insulin is appropriate for most patients
• Determine initial basal insulin dose using body weight:
  • 0.1 units/kg daily if at least one of: HbA_1c < 64 mmol/mol, BMI < 18 kg/m², older age (e.g. aged > 65 years) or frailty, renal or liver failure
  • 0.2 units/kg daily if HbA_1c > 64 mmol/mol and BMI > 18 kg/m²
• Advise patients to begin self-monitoring blood glucose levels once daily before breakfast; goal is blood glucose levels 6 – 8 mmol/L
• Ensure patients understand how to up-titrate the insulin dose based on fasting blood glucose levels + how to manage hypoglycaemia
• If treatment intensification required, add bolus insulin to a basal regimen OR initiate a biphasic (premixed) insulin:
  • If starting basal-bolus regimen, add a rapid-acting insulin before largest meal (start with 4 units); increase by 2 units if blood glucose level increase with the meal is > 3 mmol/L on three occasions

Annual review

• Measure weight, waist circumference (optional), blood pressure
• Examine feet (including skin, nails, deformity), teeth and gums
• Request HbA_1c, urinary ACR, serum creatinine, LFTs, non-fasting lipid studies
• Review:
  • Retinal photoscreening up to date
  • CVD risk
  • Smoking status, alcohol intake and recreational drug use
  • Mental health
  • Contraception
  • Cervical, breast and bowel cancer screening up to date
  • Any other associated complications, e.g. sexual dysfunction, recurrent skin or genitourinary infection

Optimising the management of HbA_1c levels with glucose-lowering medicines in patients with type 2 diabetes

	Metformin Initiate metformin at or soon after diagnosis for all patients with type 2 diabetes (HbA1c ≥ 50 mmol/mol) If patients have contraindications to using metformin, initiate an alternative glucose-lowering medicine If patients have high HbA1c levels at diagnosis, e.g. > 64 mmol/mol, consider initiating metformin + another non-insulin medicine; if levels are very high > 80 – 90 mmol/mol, insulin initiation is recommended Consider initiating metformin in combination with lifestyle advice for patients with "pre-diabetes" (HbA1c 41 – 49 mmol/mol)	Review management at each step Measure HbA1c levels at three to six month intervals Discuss diet and physical activity approaches Discuss medicine use and adverse effects Ask about hypoglycaemia Review management of cardiovascular and renal risk factors
	Add a second non-insulin glucose-lowering medicine See Figure 1 in “New diabetes medicines funded: empagliflozin and dulaglutide”, for further guidance on selecting an option. Initiate any one of the following medicines in combination with metformin: Empagliflozin*† Dulaglutide† Vildagliptin* Pioglitazone A sulfonylurea: either gliclazide or glipazide Acarbose** Add a third non-insulin glucose-lowering medicine An alternative to initiating insulin; the options are: Three oral glucose-lowering medicines Two oral glucose-lowering medicines + an injectable GLP-1 receptor agonist (i.e. dulaglutide‡)	Determine whether changes in treatment are necessary and an appropriate interval for the next review. Options could include: Continuing with the same plan for treatment Increasing dietary or physical activity approaches Increasing doses of, or adding, glucose-lowering medicines Switching medicines due to adverse effects De-escalating treatment
	Add insulin An alternative to initiating insulin; the options are: Once daily long-acting insulin is typically used when first initiating insulin; isophane insulin is appropriate for most patients
* Combination formulations with metformin available † Special Authority criteria apply ** May be useful for some patients, however, when added to metformin treatment it is less effective at lowering HbA1c levels than other oral medicines ‡ Dual treatment with dulaglutide and empagliflozin is not currently funded