Focus on Type 2 Diabetes – ICGP Guidelines 2016

The ICGP’s ‘Practical Guide to Integrated Type 2 Diabetes Care’, launched in 2016, advocates an integrated care pathway with the joint involvement of all levels of care (primary, secondary and tertiary levels), in order to optimise the outcomes in patients with diabetes. This means that both primary and secondary care centres assume joint responsibility for patients.

According to the ICGP guidelines, patients with uncomplicated type 2 diabetes will be managed by primary care only. If patients develop complications, then they should be referred to secondary care for specialist opinion in diabetes, and will have their care shared between primary and secondary care. Certain patients will have their diabetes managed in secondary care only. (Please refer to full ICGP guidelines for more information).

The guidelines note that organisations such as the American Diabetes Association (ADA), the International Diabetes Federation (IDF) and the UK’s National Institute for Health and Care Excellence (NICE) recommend metformin as an option for first-line or combination therapy. NICE also recommends metformin both for those who are overweight (BMI>25.0kg/m²) and not overweight as the first-line glucose-lowering therapy where blood glucose is inadequately controlled using lifestyle interventions alone. If the HbA_1c target is not achieved quickly with metformin, there are six drug choices including a second oral agent (sulphonylurea, thiazolidinedioine, DPP-4 inhibitor, or SGLT2 inhibitor), a GLP-1 receptor agonist, or basal insulin. The higher the HbA_1c, the more likely insulin will be required.

The ICGP guidelines emphasise that early detection and prompt intervention are essential in the management of complications, and stress the importance of systematic screening for complications as part of integrated care. The guidelines outline a range of measures to prevent or delay the development of micro- and macrovascular complications of diabetes, covering lifestyle interventions, glucose control, hypertension, lipid management and statins, anti-platelet therapy, foot care, eye care, and renal disease.¹

Blood Glucose Lowering Therapy in Type 2 Diabetes Patients Not Achieving Glycaemic Targets¹

Targets and monitoring

• HbA_1c ≤ 53mmol/mol (≤7.0%) is appropriate for the majority of patients and has been shown to reduce diabetes related complications
• Targets should be set in consultation with the patient and taking their individual circumstances into consideration
• More stringent HbA_1c goals such as <48mmol/mol (<6.5%) may be considered for selected individuals if this can be achieved without significant hypoglycemia or other adverse effects
• Less stringent HbA_1c targets such as <58mmol/mol (<8%) may be appropriate for some individuals, with particular consideration for older or frail patients with type 2 diabetes
• Monitor HbA_1c level every four months and adjust treatment as appropriate if target not achieved

Figure 1. Antihyperglycaemic Treatment Recommendations in Patients with Healthy Weight (BMI between 18.5 – 25kg/m²)¹

Insulin initiation is usually carried out in a Diabetes Day Centre; however insulin initiation in General Practice is considered feasible once the practice has established its integrated diabetes service, including education of the Practice Nurses and GPs and the availability of the Community Diabetes Nurse Specialists¹

Figure 2. Antihyperglycaemic Treatment Recommendations in Overweight Patients (BMI between 25 – 30kg/m²)¹

Figure 3. Antihyperglycaemic Treatment Recommendations in Obese Patients (BMI >30kg/m²)¹

Blood Pressure Management in Patients with Type 2 Diabetes¹

Targets and monitoring

• Hypertension should be treated aggressively. Low salt diet, reduced alcohol intake, exercise and weight loss should be instituted where appropriate but should not delay commencement of drug therapy
• Targets should be set in consultation with the patient and taking their individual circumstances into consideration. Target blood pressure (BP) for patients with type 2 diabetes should be systolic ≤140 mm/Hg / diastolic 80 mmHg and stricter (below 130/80 mmHg) if there is kidney, eye or cerebrovascular damage. Higher or lower systolic BP targets may be appropriate depending on patient characteristics and response to therapy
• When type 2 diabetes is diagnosed in an adult already on antihypertensive drug treatment, the BP control and medications used should be reviewed. Changes in therapy should only be made if there is poor control or if current drug treatment is not appropriate due to microvascular complications or metabolic problems
• BP should be measured annually and at every routine practice visit if it is above target level. Repeat BP measurements within one month if BP >150/90 mmHg; within 2 months if BP >140/80 mmHg; or within 2 months if BP >130/80 mmHg (and there is kidney, eye or cerebrovascular damage)

Figure 4. Blood Pressure Treatment Recommendations in Patients with Type 2 Diabetes¹

Reference: 1. Harkins, V. A Practical Guide to Integrated Type 2 Diabetes Care. Irish College of General Practitioners. Published January 2016.

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Table 1. Antihyperglycaemic Therapy in Type 2 Diabetes – List of agents available in Ireland

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