Management of diabetes type 2 nice

In patients diagnosed with diabetes mellitus DM , the therapeutic focus is on preventing complications caused by hyperglycemia. In the United States, Aggressive treatment of dyslipidemia and hypertension focuses on decreasing the cardiovascular complications associated with macrovascular effects. The positive outcomes from adequate glycemic control on microvascular and macrovascular complications have been established in large well-controlled trials. Use of SMBG is an effective method to evaluate short-term glycemic control by providing real-time measure of blood glucose. It helps patients and physicians assess the effects of food, medications, stress, and activity on blood glucose levels and make appropriate adjustments.

We are searching data for your request:

Management of diabetes type 2 nice

Management Skills:
Data from seminars:
Data from registers:
Wait the end of the search in all databases.
Upon completion, a link will appear to access the found materials.
Content:
WATCH RELATED VIDEO: NICE Type 2 Diabetes Guideline - episode 2

Manage Blood Sugar

The journal, published since , is the official publication of the Spanish Society of Cardiology and founder of the REC Publications journal family. Articles are published in both English and Spanish in its electronic edition. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Diabetes mellitus is a chronic disease with one of the highest social and healthcare costs and is associated with a 3-fold to 4-fold increment in cardiovascular morbidity and mortality.

In fact, ischemic heart disease is the main cause of death in diabetic patients. The treatment of diabetes must be based on an understanding of its pathophysiology. Thus, in type 1 diabetes mellitus a severe insulin secretion deficit exists and the only treatment, at present, is the administration of insulin or insulin analog.

However, type 2 diabetes mellitus is a much more complex disease, in which insulin resistance predominates in the early stages. In more advanced stages, insulin resistance persists but the deficit in insulin secretion is more evident.

Therefore, the therapeutic approach will depend on the stage of the disease and characteristics of the patient. The general goals of the treatment of diabetes are to avoid acute decompensation, prevent or delay the appearance of late disease complications, decrease mortality, and maintain a good quality of life.

As for chronic complications of the disease, it is clear that good control of glycemia makes it possible to reduce the incidence of microvascular complications retinopathy, nephropathy, and neuropathy , 3,4 whereas good control of glycemia per se does not seem to be as determinant in the prevention of macrovascular complications ischemic heart disease, cerebrovascular disease, peripheral arteriopathy.

Thus, a treatment designed to obtain optimal glycemic control that neglects other cardiovascular risk factors is not very rational. In fact, it will surely be more beneficial to the diabetic patient to address cardiovascular risk factors overall, even if goals are not strictly reached for any of them. The therapeutic objectives are listed in Table 1. Nevertheless, in older patient or persons with a very limited life expectancy, it is not necessary to reach this therapeutic target since it entails a high risk of causing severe hypoglycemia.

As for the target values for the lipid profile and blood pressure, it should be remembered that ischemic heart disease is the main cause of mortality in diabetic patients 1,2 and that the cardiovascular risk of diabetic patients is similar to that of nondiabetic patients who already have ischemic heart disease. Diet and exercise are fundamental in the treatment of diabetes.

Dietary recommendations must be customized for each individual to achieve the general objectives of treatment. It should be remembered that obesity is common in type 2 diabetics so one of the main objectives should be weight reduction. The calorie content of the diet should be adjusted in each individual in accordance with the body mass index and regular physical activity.

With regard to carbohydrates, emphasis should be placed on total intake rather than on their origin, although rapidly absorbed carbohydrates should be avoided. Physical exercise, aside from constituting a mainstay of the treatment of diabetic patients, helps to prevent the development of diabetes in adult life.

In addition, it gives the patient a sense of well being and better quality of life. The main disadvantage of exercise in diabetic patients is hypoglycemia, which can occur several hours later and should condition adjustments in the therapeutic regimen. In addition, in patients with type 1 diabetes and poor metabolic control, especially after anaerobic exercise, hyperglycemic decompensation or even ketosis can take place.

Aside from disturbing glucose metabolism, physical exercise can entail other risks, which are detailed in Table 2. The diabetological education that the patient receives from qualified healthcare personnel is essential in achieving therapeutic objectives. For example, self-testing of capillary blood glucose informs the patient about the time of day when glycemic control is worse and helps to identify undetected hypoglycemia.

Therefore, self-tests are fundamental for making opportune modifications in therapy. In addition, the patient who knows how to modify treatment based on capillary blood glucose measurements and has received advice on how to handle various situations, such as hypoglycemia or hyperglycemic-ketotic decompensation, will require fewer hospital admissions and have a better quality of life. When acceptable metabolic control is not achieved, either because the patient does not adapt to changes in life style or because, in spite of complying with the diet and exercising regularly, therapeutic objectives are not attained, pharmacological treatment must begin.

Figure 1 shows a diagram of the therapeutic approach to type 2 diabetes mellitus. Scheme of the therapeutic approach proposed for type 2 diabetes mellitus.

Thus, for example, if baseline hyperglycemia predominates and the patient was treated with sulfonylureas SU , metformin MET can be added. However, if the patient follows treatment with MET and poor control is at the expense of postprandial hyperglycemic peaks, a secretagogue or alpha-glycosidase inhibitor should be added. In the mids the first sulfonylureas SU were developed for commercial use carbutamide and tolbutamide. In the mids there were already four SUs on the market tolbutamide, acetohexamide, tolazamide and chlorpropamide , which are currently known as the first-generation SUs.

At the end of the s, second-generation SUs were introduced glibenclamide, glipizide, gliquidone, and gliclazide. In , the results of the University Group Diabetes Program UGDP 16 were published, where it was concluded that tolbutamide was ineffective in the treatment of the diabetes and also increased cardiovascular mortality.

This study had a major impact not only in the U. Nevertheless, since the results of the UGDP were much criticized regarding the methodology of the study, 17 and there was evidence of its clinical effectiveness, in the American Diabetes Society decided to end restrictions of the use of SUs and they have been marketed in the U.

More recently, a new long-acting SU has been introduced: glimepiride. Mechanism of action. The SUs stimulate the second phase of insulin secretion by pancreatic beta cells, that is to say, the release of preformed insulin.

Therefore, the SUs will not be effective in patients who are pancreatectomized or have type 1 diabetes mellitus. The SUs act through high-affinity receptors located in the pancreatic beta cells. As a result, the calcium channels open, increasing intracellular calcium content and calcium binding to calmodulin, which produces microfilament contraction and the exocytosis of insulin granules Figure 2.

Schematic representation of the mechanism of action of the sulfonylureas SU. In the heart and throughout the cardiovascular system there are also SU receptors and ATP-sensitive potassium channels, which have an important cardioprotective effect against ischemia.

Closure of these channels by SUs could contribute to ischemia. Clinical pharmacology. The SU differ in potency, duration of action, metabolism, undesirable effects, and other pharmacological properties.

The second-generation SUs are more potent and have less toxicity than the first-generation SUs. All the SUs are absorbed quickly in the digestive tract, reaching peak plasma level h after ingestion. They bind mainly to albumin, from which they can be displaced by other drugs. The metabolism is fundamentally hepatic and its metabolites are eliminated in urine and, to a lesser extent, in bile. Gliquidone is eliminated mainly in bile, so it can be used in cases of moderate kidney failure creatinine.

Undesirable effects. SUs are generally well tolerated. Hypoglycemia is the most frequent adverse effect and is directly related with the potency and duration of the effect of the drug administered. Hypoglycemia due to SU is less frequent than with insulin, but it is often more prolonged and can require treatment with intravenous glucose infusion for several days.

Kidney and liver failure are risk factors for SU-induced hypoglycemia. The decrease in intake and the use of drugs can potentiate the action of SUs 24 e. All these factors often coincide in diabetics of advanced age.

In addition, in such patients the typical symptoms of hypoglycemia may be absent and manifested only by psychiatric or neurological symptoms. Other undesirable effects are infrequent 25 Table 4. Indications, drug selection, and contraindications. SUs are considered drugs of first choice for the treatment of type 2 diabetes mellitus when the patient is not overweight, as long as the therapeutic objectives are not achieved by means of an individualized program of diet and exercise.

The second-generation SUs are the most frequently used and there is none that clearly surpasses the others, which is why it is more important that the physician prescribe the preparation she is most experienced with. Tolbutamide and glimepiride have been recommended for older persons due to the lower risk of serious hypoglycemia.

Treatment should begin with small doses generally half a tablet to avoid hypoglycemia and to increase the dose at weekly intervals until good metabolic control has been achieved or the recommended maximum dose has been reached.

When an adequate response is obtained, the possibility of reducing the doses should be reviewed. If a lower dose can be given, it likely that good control will be obtained with diet alone. If good glycemic control is not achieved with the maximum dose of SU used, combined treatment with metformin can be tried or the patient can be switched to insulin. SUs are contraindicated in patients allergic to sulfonamides and, of course, in type 1 diabetics and in pancreas-deficient diabetes e.

They cannot be prescribed during pregnancy and breastfeeding because they can cross the placental barrier and be secreted in maternal milk.

Its use in situations that cause important stress is not recommended since, in these cases, the SUs will not be capable of meeting insulin needs. Thus, in situations such as acute myocardial infarction AMI , severe trauma, or infectious processes of certain importance, it is preferable to switch to insulin treatment and then reassess SU treatment after overcoming the period of stress.

They should not be used in the case of major surgical interventions, which, aside from constituting a stressful situation, also entails the need for fasting. Therefore, patients should be switched to insulin treatment and intravenous glucose infusion. The presence of liver disease is a relative contraindication. Most SUs are metabolized by the liver into compounds with little or no activity. Therefore, when impaired liver function exists, deactivation of the SUs decreases, the half-life becomes longer, and the hypoglycemic action increases.

Hypoalbuminemia is an aggravating factor since a larger amount of SU will be present. If the patient also consumes alcohol, the risk of hypoglycemia will increase. Kidney failure results in a decrease in the elimination of SUs and their metabolites, prolonging their action and increasing the risk of hypoglycemia. Therefore, their use in patients with kidney disease is not recommended. As has been mentioned, gliquidone, which is eliminated preponderantly in bile, could be an alternative in the case of moderate kidney failure whenever therapeutic objectives are strictly met; if not, patients should be passed immediately to insulin treatment.

Other secretagogue drugs: repaglinideand nateglinide. Repaglinide and nateglinide are new secretagogues characterized by a selective action on the first phase of insulin secretion. From the clinical vantage point, they have a shorter but more intense action than the SUs, which produces into a smaller postprandial glucose elevation and less intense later hypoglycemic action, meaning that beta-cell stimulation is avoided during periods of fasting.

These fast-acting secretagogues, like the SUs, are indicated in type 2 diabetes mellitus when therapeutic objectives are not reached with diet and exercise. It has a mechanism of action very similar to that of the SUs, but differs in the specific binding site to the SU receptor 29 Figure 2.

Its insulin-releasing action begins within the first 30 min of administration and the eff ect disappears in approximately 4 h. Therefore, it should be taken about min before eating; it is fundamental to coordinate its administration with the meal schedule.


Personalising treatment for type 2 diabetes: why is NICE so behind?

The journal, published since , is the official publication of the Spanish Society of Cardiology and founder of the REC Publications journal family. Articles are published in both English and Spanish in its electronic edition. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years. SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact. SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Diabetes mellitus is a chronic disease with one of the highest social and healthcare costs and is associated with a 3-fold to 4-fold increment in cardiovascular morbidity and mortality.

It is commonly recommended that patients with type 2 DM self-monitor their blood glucose levels, but the evidence to support the effectiveness of this practice.

U.S. Food and Drug Administration

These new guidelines represent a shift towards a better understanding of technology as an integral part of diabetes management, rather than an added luxury. We are also pleased to see the new guidelines recommending that the health system addresses the inequalities in Flash and CGM access that already exist — something we called for them to do in our response to the consultation on these guidelines. See detail on what these tech recommendations and other guidelines are from across the UK. We know that many of you will understandably be keen to get access to Flash or CGM as soon as possible considering these new guidelines and we suggest that you speak to your diabetes team about this at your next appointment. We will of course be working to ensure this happens. Not least by continuing to press the Government to prioritise diabetes care as the NHS tries to recover from the enormous impact of the coronavirus pandemic. Please fill in this form to tell us about your experience trying to access Flash or CGM after your next diabetes appointment. There is still work to do, but today here at Diabetes UK, we are celebrating a clear step towards many more people living with all types of diabetes having access to the technologies that can help them lives happier and healthier lives with the condition.

New NICE guidelines for type 2 diabetes out for consultation

management of diabetes type 2 nice

Below you'll find a list of the various types of guidance produced by NICE relating to diabetes technology. Our type 1 technology guides under e-downloads provide a summary of all the guidance along with their criteria. This ensures that all NHS patients have equitable access to the most clinically and cost-effective treatments that are available. Regulations require clinical commissioning groups, NHS England and local authorities to comply with recommendations in a technology appraisal within 3 months of its date of publication.

There are two types of diabetes, a disease where your blood sugar, or blood glucose, levels are too high. Both types have to do with how your body creates and regulates Insulin, a hormone that helps the glucose sugars broken down from the food you eat get into your cells, to give them energy.

Type 2 diabetes in adults: management - NICE guideline

Clinical guidelines help healthcare professionals and patients make appropriate healthcare decisions [1]. With the proliferation of guidelines and position statements for type 2 diabetes mellitus T2DM , generalist front-line clinicians need more prescriptive advice on the most appropriate therapeutic options for individual patients. When guidelines are used uniformly across the population, evidence-based medicine is translated into clinical practice: care is cost-effectively standardised across the healthcare system to facilitate consistent and effective practice, which improves health outcomes for patients. But quantitative and qualitative studies have shown wide variation in adherence to T2DM guidelines [2] — so how clinically applicable are these guidelines in practice? However, the central theme of NG28 lies in the attainment of glycaemic targets for people with T2DM, with a preference for antidiabetic drugs with the lowest acquisition cost.

NICE type 2 diabetes management guidance: What’s new?

Vol No The most significant change in this update is to the recommendations regarding glycaemic control. Optimal glycaemic management is an acknowledged element of good diabetes care. However, many individuals fail to achieve and maintain their glycaemic targets Khunti, ; Blonde, ; Bain, It is recommended that the target HbA 1c level be individualised to account for multiple factors. These factors include:. The determination of high cardiovascular risk is defined as:. This identification process should take place at diagnosis and at every diabetes review thereafter.

These guidelines are based on recommendations in NICE guidelines. Tools and resources to support implementation of the guideline are signposted in Appendix A.

Ketogenic Diet: Is It Good for Diabetes and Weight Loss?

You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. JavaScript Required JavaScript is required to use content on this page. Please enable JavaScript in your browser.

Type 2 diabetes management toolbox: from lifestyle to insulin

The NICE algorithm for blood glucose lowering therapy in adults with type 2 diabetes can be viewed here. Please note: when diagnosing type 2 diabetes if the patient is aged less than 45 years OR BMI is less than 25, consider referral to secondary care for investigation of other aetiology. Involve adults with type 2 diabetes in decisions about their individual HbA1c target. Agree an individualised HbA1c target based on the person's needs and circumstances.

The management of type 2 diabetes is multi-faceted, including patient education on management of their condition, lifestyle interventions and pharmacological treatments.

Type 2 diabetes: guideline consultation Effectiveness of a diabetes education and self-management programme DESMOND for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. BMJ ;e Diabet Med 23; Impact of self-monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ ; A diabetes outcome progression trial ADOPT : an international multicentre study of the comparative efficacy of rosiglitazone, glyburide, and metformin in recently diagnosed type 2 diabetes.

This site complies with the HONcode standard for trustworthy health information: verify here. Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar glucose levels to be abnormally high. Diabetes damages blood vessels and increases the risk of heart attack, stroke, chronic kidney disease, and vision loss.

Comments: 1
Thanks! Your comment will appear after verification.
Add a comment

  1. Ulysses

    Of course. I agree with all of the above. We can communicate on this theme. Here or at PM.