Type-2 diabetes currently affects around 2 million people in the UK, with another 750,000 thought to remain undiagnosed,1 and this prevalence is rising dramatically in line with obesity, which is a significant risk factor for development of the condition.2
Improved control of blood glucose can reduce the risk of vascular complications3 and has recently been found to reduce the risk of cardiovascular disease by 56 per cent,4 but it is important that patients themselves are aware of their condition, and the impact their actions may have on their health.
NICE guidelines for the management of blood glucose levels in patients with type-2 diabetes were updated in May 2008 to provide treatment recommendations based on a review of current evidence and to reflect recent developments.5
Patient education is important when initiating insulin therapy
Glycaemic control is the ultimate aim of diabetes treatment, particularly as persistently elevated blood glucose levels can cause blood vessel damage, leading to the development of vascular complications and increased risk of death.
Incentive schemes such as the quality and outcomes framework (QOF) play a role in encouraging HbA1c targets to be met, and are an important way of improving patients' health.
The updated NICE guidelines recommend aiming for a target HbA1c of 6.5 per cent if this can be safely achieved, for those on lifestyle measures alone, for those on metformin monotherapy or for those on metformin plus sulphonylurea.
NICE recommends aiming for a target HBA1c of 7.5 per cent for those on more complex glucose-lowering regimens. It also recommends that targets should be set for each patient according to their individual needs and risk factors.
The guidelines also recommend that patients should be involved in decisions about their individual HbA1c target level, which may be above the general 6.5 per cent target.5
By focusing on reducing HbA1c levels rather than reaching a defined, low target that many patients with diabetes find hard to achieve, more patients may be expected to achieve meaningful improvements in glycaemic control.
In this way, the new guidelines are consistent with findings from the UKPDS study, which found that for every 1 per cent decrease in HbA1c, the risk of microvascular complications reduced by 37 per cent, diabetes-related death reduced by 21 per cent and incidence of MI reduced by 14 per cent.3
Understanding these risks and benefits means that patients are more able to make decisions that affect their long-term health.
Worryingly, according to a recent survey, 90 per cent of patients are currently unaware of the benefits of HbA1c reduction or of this research, and 93 per cent of GPs agree that their patients need to be further educated in order to effectively manage their diabetes.6
The guidelines advise that patient education is an integral part of diabetes care.5
Education for patients with type-2 diabetes is predominantly provided within the primary care setting and is usually offered at the time that a patient is diagnosed with diabetes. However, this education varies in length, time, content and delivery.
These recommendations imply that patients have some level of understanding about their condition and treatment.
Patients with diabetes are intimately involved in their own day-to-day care, therefore providing them with relevant information about their condition helps to ensure that they are able to make informed decisions about their lifestyle and treatment options.
In addition to emphasising patient involvement, the new guidelines recommend that plasma glucose self-monitoring should be offered to a patient newly diagnosed with type-2 diabetes only as an integral part of their self-management.
There should also be ongoing evaluation of complications, including kidney damage and eye screening, HbA1c measurements should be taken every two to six months until stable on unchanging therapy, and BP and blood lipids should be managed with patients receiving adequate antithrombotic therapy.5
All these factors ensure both that the patient is being treated holistically, for the multitude of conditions that affect and can be affected by diabetes, and that maximum QOF points are obtained by the practice.
The purpose of the recommendations within the updated guidelines is to help patients achieve HbA1c targets, and medication is an important part of this.
On diagnosis, diet and lifestyle modifications should be recommended to all patients in combination with a blood glucose lowering oral agent. However, due to the progressive nature of the disease, more than one drug may be required to maintain glycaemic control.
Many patients with diabetes may eventually need to use insulin, as lifestyle changes and oral medications gradually become less effective.7 Earlier use of insulin in combination with oral agents may be beneficial to patients with persistently high HbA1c levels, by providing a more intensive approach to achieving and maintaining glycaemic control.8
Some patients with type-2 diabetes will come to require a more intensive insulin regimen than once-daily basal insulin. In this situation a basal-bolus regimen can be used. This combines a once-daily long-acting insulin with mealtime injections of short-acting insulin analogues to effectively mimic physiologic insulin levels and provide adequate glycaemic control.
However, there is often resistance among patients to the initiation of insulin therapy,9 usually based on outdated perceptions of safety and convenience.
In a recent survey, 85 per cent of GPs agreed that this reluctance reduces their ability to achieve good glycaemic control and to achieve HbA1c targets.6
The guidelines recommend that a structured programme of patient education should be implemented when initiating insulin therapy.
This should encompass frequent self-monitoring, and regular help and advice on dose titration, nutrition and lifestyle issues and how to manage hypoglycaemia, all delivered by an appropriately trained and experienced healthcare professional.5
The NICE guidelines emphasise the need for more patient education and involvement in all aspects of their diabetes management, including decisions about their HbA1c targets.5
The achievement of lower HbA1c levels in more patients is expected to lower the incidence of vascular complications, with subsequent health and cost benefits.10 Intensive treatment regimens may be considered to achieve and maintain glycaemic control, and may include oral or subcutaneous agents and/or insulin therapy.8,9
Further NICE guidance on newer agents in type-2 diabetes is expected in March 2009.
- Dr Gadsby is a GP in Nuneaton, associate clinical professor at Warwick Medical School, University of Warwick and member of guideline development group for NICE guideline on type-2 diabetes
- This and other guideline summaries are available every month in MIMS
1. What is diabetes? www.diabetes.co.uk/what-is-diabetes.html
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3. Stratton IM, Adler AI, Neil AW et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35). BMJ 2000; 321: 405-12.
4. Diabetes UK. Hospital heart admissions high for people with diabetes. 2008.
5. NICE Clincal Guideline 66 (May 2008). Type 2 diabetes: National clinical guideline for management in primary and secondary care (update). www.nice.org.uk
6. Brand Health. Perceptions of Type 2 Diabetes - Patient Reserarch. 2008.
7. Barnett AH, Capaldi B, Davies-Lyons M et al. Expert opinion statement on the use of insulin therapy in patients with type 2 diabetes in primary care. Pract Diab Int 2003; 20(3): 97-102.
8. Eldor R, Stern E, Milicevic Z, Raz I. Early use of insulin in type 2 diabetes. Diabetes Res Clin Pract 2005; 68 Suppl 1: S30-S35.
8. Home PD, Boulton AJM, Jimenez J et al. Issues relating to the early or earlier use of insulin in type 2 diabetes. Pract Diab Int 2003; 20(2): 63-71.
10. Bate KL, Jerums G. 3: Preventing complications of diabetes. Med J Aust 2003; 179 (9): 498-503.