Diabetes – NICE guidelines
By Aradhana, Muninder, Amandeep,
Vikash
Diagnosis
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Symptomatic – One off reading
-FBG >7.0 or RBG >11.1
-HBA1C 48mmol/l
Asymptomatic – at least 2 readings
-HBA1C and FBG together
- 2 FBG or 2 RBG
Sensible to rpt in 4-6 weeks (no evidence)
Mgmt
• Step 1: Lifestyle and rpt HBA1C in 3/12
– Low GI, high fibre
– Aim for 5-10% wt loss
• Step 2: Metformin
od for first week, bd for 2nd week, tds for 3rd week
starting does is always 500mg
Common s.e’s: transient FOR 2-3 WEEKS
Increase to max (1g TDS) before adding on rx
• Step 3: Add-in sulphonylurea
– Ensure counselling for hypos (elderly/drivers)
– Alternatives Glitazones/gliptins
– Glitazones: CIs inc – CCF, LF, Ca Bladder, fractures,
wt gain
– Gliptins: CIs inc – CKD
REMEMBER TARGET IS HBA1C 6.5% until step 4
• Step 4:
Exenatide
- pros: occupational and BMI >35
- cons: Have to loose 3% wt and 1% drop in
HBA1C in 6 months
Insulin
- Pros: better ctrl
- Cons: hypos, wt gain, lipdystrophy
Both are given subcut. ?pt compliance
NEW HBA1C target 7.5% in Step 4
Risks
• Lipids – TC 4mmol/l and LDL-C <2mmol/l
• BP – <140/80, if 130/80 with end organ
damage
• Footcare – annual neurovascular check
• Eyes – annual retinopathy screening
• Nerves - ?1st line rx in dm
• Renal function – ACR with 6 mthly u+e’s
AKT questions
• 1. 55 years old male presents with h/o htn. He
has a FH of DM and requests a health check.
HBA1C result comes back at 48mmol/l.
– What do you do?
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A. Start metformin
B. Rpt test
C. Advice only
D Start metformin and gliclazide
• 2. At what level of creatinine would you
consider reducing metformin?
– A. 108
– B. 136
– C. 150
– D. 80
• 3. 57 years old lorry driver with dm. He is
obese and claims to have good bm ctrl. Which
is the least suitable?
– A. Pioglitazone
– B. Gliclazide
– C. Exenatide
– D. Saxagliptin
• 4. 55 years old DM pt on max dose of
Metformin and Sitagliptin. He is a lorry driver
and his HBA1C is 7%. What is the next best
mgmt?
– A. Insulin
– B. Pioglitazone
– C. Linogliptin
– D. Rosiglitazone
– E. Exenatide