Management of Type 2 Diabetes This PatientPlus article is written for healthcare professionals so the language may be more technical

than the condition leaflets. You may find the abbreviatio ns list helpful. Treatment should be aimed at alleviating symptoms and minimising the risk of lon g-term complications. Optimal control of glucose and other cardiovascular risk f actors (eg, smoking, sedentary lifestyle, hypertension, dyslipidaemia and obesit y) is essential. Management of type 2 diabetes has to be tailored to the individual needs and cir cumstances of each patient - eg, the benefits of tight glucose control must be w eighed against any potential complications such as recurrent hypoglycaemia.[1][2 ] Patient education Structured patient education should be made available to all people with diabete s at the time of initial diagnosis and then as required on an ongoing basis, bas ed on a formal, regular assessment of need.[3] Suitable programmes are the X-PERT Diabetes Programme and the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND). See the separate article Diabetes Education and Self-management Programmes. A study found that a single education and self-management structured programme f or people with newly diagnosed type 2 diabetes mellitus did not show any benefit in biomedical or lifestyle outcomes at three years, although there were sustain ed improvements in some illness beliefs.[4] Discuss diet and give dietary advice, taking into account other factors - eg, ob esity, hypertension, and renal impairment; offer referral to a dietician. Encourage regular physical activity. Give advice and support on smoking cessation where appropriate. If appropriate, advise of the need to contact DVLA to inform them of the diagnos is - see DVLA Medical Standards of Fitness to Drive.[5] Initial assessment and monitoring Check height, weight and calculate BMI; also measure waist circumference. Waist circumference is significantly associated with the risk of cardiovascular diseas e.[6] Check smoking status and offer cessation advice as appropriate. Glucose control: o Offer self-monitoring of plasma glucose to a person newly diagnosed with type 2 diabetes only as an integral part of his or her self-management educatio n. ? Discuss its purpose and agree how it should be interpreted and acted upo n. ? Self-monitoring should be available to those on insulin, oral glucose-lo wering treatment and to assess changes - eg, change of treatment, acute illness, or for safety during activities such as driving.[7] ? Urine glucose monitoring should be offered if blood glucose testing is u nacceptable. See the separate article Self-monitoring in Diabetes Mellitus. o Glycosylated haemoglobin (HbA1c): ? Involve the person in decisions about their individual HbA1c target leve l, which may be above that of 48 mmol/mol (6.5%) set for people with type 2 diab etes in general. ? Encourage the person to maintain their individual target, unless the res ulting side-effects (including hypoglycaemia) or their efforts to achieve this, impair their quality of life. ? Avoid pursuing highly intensive management to levels of less than 48 mmo l/mol (6.5%). ? One study found that low and high mean HbA1c values were associated with increased all-cause mortality and cardiac events. Results showed a general U-sh aped association, with the lowest hazard ratio found to be at an HbA1c of about 7.5%.[8] ? Check HbA1c routinely every six months but as frequently as two-monthly,

especially where there is changing treatment, poor control or intercurrent illn ess.[7] ? HbA1c measurement is invalid in the presence of haemoglobinopathy or abn ormal erythrocyte turnover. If blood pressure is <130/80 mm Hg (with end-organ damage), monitor 4- to 6-mont hly. Otherwise, target BP is 140/80 mm Hg which can be monitored annually. Renal monitoring: annual urine for albumin creatinine ratio (ACR); ideally a sam ple from the first passed urine of the day; creatinine and estimated glomerular filtration rate (eGFR). If abnormal, see 'Monitoring for kidney damage', below. Serum lipids (see below); serum total and high-density lipoprotein cholesterol, fasting serum triglycerides.[9] TFTs (at diagnosis and annually). Eye: annual eye screening (including, for example, visual acuity, cataracts, dia betic retinopathy) and retinal photography. Neuropathic pain: ask at least once annually about symptoms of neuropathic pain. Feet: annual examination, including sensation (10 g monofilament or vibration), foot pulses, ulcers, foot deformity and footwear. Dietary advice See the separate article Diabetes Diet And Exercise. Provide individualised and ongoing nutritional advice from a healthcare professi onal with specific expertise and competencies in nutrition. Referral The precise arrangements for referrals will depend on local service provisions a nd guidelines. Refer to a dietician as available and when indicated. Refer to local retinal screening service.[9] Refer people who have poor control of glucose or other cardiovascular risk facto rs despite optimal management in primary care. Refer people who present with complications of diabetes (eg, nephropathy, retino pathy, cataracts, retinopathy).[9] Increased risk of foot ulcers (neuropathy or absent pulses or other risk factor) - arrange regular review, 3- to 6-monthly, by a foot protection team.[10] High risk of foot ulcers (neuropathy or absent pulses plus deformity or skin cha nges or previous ulcer) - arrange frequent review (1- to 3-monthly) by a foot pr otection team.[10] Foot care emergency (new ulceration, swelling, discolouration) - refer to a mult idisciplinary footcare team within 24 hours.[10] Refer pregnant women with diabetes, or those planning a pregnancy, for specialis t care. Management of glucose control[7] Decision Aids Doctors and patients can use Decision Aids together to help choose the best cour se of action to take. Compare the options for Management of Type 2 Diabetes. See the separate articles Antihyperglycaemic Agents used for Type 2 Diabetes and Insulin Regimens. The recommended steps for glucose control in the National Institute for Health a nd Care Excellence (NICE) guidance are:[7] o Metformin. o Metformin and a sulfonylurea (consider substituting a DPP-4 inhibitor or a thiazolidinedione for the sulfonylurea if there is a significant risk of hypo glycaemia or a sulfonylurea is contra-indicated or not tolerated). o Add thiazolidinedione or insulin (exenatide may be considered at this st age if NICE criteria are met - see the separate article above, and the NICE guid eline). o Insulin and metformin and a sulfonylurea. o Increase the insulin dose and intensify the regimen over time. All decisions concerning treatment should be made with the patient in partnershi p, as patients who make informed shared decisions concerning their management ar e more likely to adhere to any given regime.

Follow-up Blood pressure management[7] See the separate article Diabetes with Hypertension. If there is kidney, eye or cerebrovascular damage, set a blood pressure target < 130/80 mm Hg; for others set a target <140/80 mm Hg. The stages of treatment for raised blood pressure in people with type 2 diabetes are: o Advise on lifestyle measures. o Offer an angiotensin-converting enzyme (ACE) inhibitor (titrate dose); f or people of African-Caribbean descent, offer an ACE inhibitor plus a diuretic o r calcium-channel blocker (CCB). ? If there is a possibility of the person becoming pregnant, start with a CCB. ? If there is continuing intolerance to an ACE inhibitor (other than renal deterioration or hyperkalaemia), change to an angiotensin-II receptor antagonis t. o Add a CCB or diuretic (usually bendroflumethiazide, 2.5 mg daily). o Add the other drug (diuretic or CCB). o Add an alpha-blocker, beta-blocker or a potassium-sparing diuretic. PatientPlus Insulin Regimens Diabetes Education and Self-management Programmes Antihyperglycaemic Agents used for Type 2 Diabetes Assessment of the Patient with Established Diabetes Management of blood lipids[7] See the separate article Hyperlipidaemia. Review cardiovascular (CV) risk status annually, including risk factors such as features of metabolic syndrome and waist circumference, and full lipid profile ( including HDL-C and TG). Consider to be at high CV risk unless all of the follow ing apply: o Not overweight (tailor with a body weight-associated risk assessment acc ording to ethnic group) o Normotensive (<140/80 mm Hg in the absence of antihypertensive therapy) o No microalbuminuria o Non-smoker o No high-risk lipid profile o No history of CV disease o No family history of CV disease. Estimate CV risk from the UK Prospective Diabetes Study (UKPDS) risk engine annu ally if assessed as not at high CV risk.[11] Consider generic simvastatin (to 40 mg) or a statin of similar efficacy and cost if: o Aged under 40 years and with a poor CV risk factor profile. o Aged 40+ years and with a CV risk >20% over 10 years. Assess lipid profile and modifiable risk factors 1-3 months after starting thera py. Continue to monitor annually: o If there is a high CV risk and TG = 2.3-4.5 mmol/L despite a statin, con sider adding fibrate. o Treat to achieve total cholesterol <4.0 mmol/L (HDL-C 1.4 mmol/L or belo w) or LDL-C <2.0 mmol/L. If target is not reached: o Increase simvastatin to 80 mg daily. o Consider intensifying therapy with a more effective statin or ezetimibe if there is existing or newly diagnosed CV disease (HDL-C should not exceed 1.4m mol/L) or increased albumin excretion rate. If becoming pregnant is a possibility, discuss issues surrounding statin use and agree the next step with the woman. High serum triglyceride (TG): o Assess possible secondary causes (including poor glycaemic control) and treat if identified.

o If TG remains >4.5 mmol/L (despite optimised glycaemic control), offer f ibrate (if there is acute need, it may be necessary to start fibrate before stat in). o If lifestyle measures and fibrate therapy have proved to be ineffective, consider a trial of highly concentrated, licensed omega-3 fish oils. Antithrombotic therapy The NICE guideline recommends offering low-dose (75 mg) daily aspirin (or clopid ogrel if there is clear aspirin intolerance) if:[7] Age 50+ years and BP <145/90 mm Hg; or Age <50 years and significant other CV risk factors. Secondary prevention of cardiovascular disease. However a very recent multicentre, randomised, double-blind, placebo-controlled trial did not find evidence to support the use of aspirin or antioxidants in the primary prevention of cardiovascular events and mortality in people with diabet es.[12] Monitoring for kidney damage[7] See the separate article Diabetic Nephropathy. Arrange annual ACR estimation ideally on a first-pass urine sample, measure seru m creatinine and eGFR. If there is abnormal ACR (in the absence of proteinuria/UTI): repeat the test at the next two clinic visits and within 3-4 months; microalbuminuria is confirmed if at least one out of two or more results is also abnormal. Suspect renal disease other than diabetic nephropathy and consider further inves tigation or referral if ACR is raised and: o There is no significant or progressive retinopathy; or o BP is particularly high or resistant to treatment; or o There is heavy proteinuria (ACR >100 mg/mmol) but ACR previously documen ted as normal, or significant haematuria; or o GFR has worsened rapidly; or o The person is systemically ill. If diabetic nephropathy is confirmed, offer an ACE inhibitor with dose titration ; substitute an angiotensin-II receptor antagonist if ACE inhibitors are poorly tolerated. Maintain BP <130/80 mm Hg if there is an abnormal ACR. Eye screening[7] See the separate article Diabetic Retinopathy and Diabetic Eye Problems. Arrange or perform eye screening at or around the time of diagnosis. Use a quality-assured digital retinal photography programme with appropriately t rained staff. Repeat structured eye surveillance annually, unless findings requi re other action. Perform visual acuity testing as a routine part of eye surveillance programmes. Emergency review by an ophthalmologist is appropriate for: o Sudden loss of vision o Rubeosis iridis o Pre-retinal or vitreous haemorrhage o Retinal detachment. Rapid review by an ophthalmologist for new vessel formation. Refer to an ophthalmologist if: o There are features of maculopathy, including: ? Exudate or retinal thickening within one disc diameter of the centre of the fovea ? Circinate or group of exudates within the macula ? Any microaneurysm or haemorrhage within one disc diameter of the centre of the fovea, if associated with a best visual acuity of 6/12 or worse o There are features of pre-proliferative retinopathy, including: ? Any venous beading ? Any venous loop or reduplication ? Any intraretinal microvascular abnormalities ? Multiple deep, round or blot haemorrhages ? Any unexplained drop in visual acuity

Management of foot problems See the separate articles Diabetic Neuropathy and Diabetic Foot. Related blog posts Living well with type 2 diabetes Say no to hypos who should? How to tackle tiredness More from the blogs ? Neuropathic pain management See the separate article Neuropathic Pain and its Management. Ask about neuropathic symptoms at diagnosis and at every review. If required, offer a tricyclic drug, starting at low doses and titrate as tolera ted. If symptoms are not adequately controlled, offer a trial of the cheapest (at max imum dose) of duloxetine, gabapentin or pregabalin; stop if ineffective at the m aximally tolerated dose; try another of the drugs if side-effects limit dose tit ration.[7] If symptoms are still not adequately controlled, consider a trial of opiate anal gesia. If symptoms are controlled, consider reducing dosage or stopping therapy followi ng discussion and agreement with the person concerned. If symptoms remain uncontrolled, discuss with the person and seek the assistance of the local chronic pain management team. Other management issues See the separate article Assessment of the Patient with Established Diabetes. People with diabetes should be offered influenza vaccination and pneumococcal va ccination. Managing diabetes and intercurrent illness is covered in the separate article Di abetes and Intercurrent Illness. Depression screening; early detection, support and effective management. There is a separate article on Precautions with Patients with Diabetes Undergoin g Surgery. Be alert for the potential development of metabolic syndrome. Management of features of autonomic neuropathy - eg, gastroparesis, erectile dys function, loss of warning signs for hypoglycaemia, unexplained diarrhoea (especi ally at night) and unexplained bladder-emptying problems. Prevention This is covered in detail in the separate article Prevention of Type 2 Diabetes Mellitus. iabetes management: How lifestyle, daily routine affect blood sugar Diabetes management requires awareness. Know what makes your blood sugar level r ise and fall and how to control these day-to-day factors. By Mayo Clinic staff Controlling Your Diabetes Subscribe to our Controlling Your Diabetes e-newsletter to stay up to date on di abetes topics. Sign up now When it comes to diabetes management, blood sugar control is often the central t heme. After all, keeping your blood sugar level within your target range can hel p you live a long and healthy life. But do you know what makes your blood sugar level rise and fall? The list is sometimes surprising. Food Healthy eating is a cornerstone of any diabetes management plan. But it's not ju st what you eat that affects your blood sugar level. How much you eat and when y ou eat matters, too. What to do: Keep to a schedule. Your blood sugar level is highest an hour or two after you e at, and then begins to fall. But this predictable pattern can work to your advan tage. You can help lessen the amount of change in your blood sugar levels if you eat at the same time every day, eat several small meals a day or eat healthy sn acks at regular times between meals.

Make every meal well-balanced. As much as possible, plan for every meal to have the right mix of starches, fruits and vegetables, proteins, and fats. It's espec ially important to eat about the same amount of carbohydrates at each meal and s nack because they have a big effect on blood sugar levels. Talk to your doctor, nurse or dietitian about the best food choices and appropriate balance. Eat the right amount of foods. Learn what portion size is appropriate for each t ype of food. Simplify your meal planning by writing down portions for the foods you eat often. Use measuring cups or a scale to ensure proper portion size. Coordinate your meals and medication. Too little food in comparison to your diab etes medications especially insulin may result in dangerously low blood sugar (h ypoglycemia). Too much food may cause your blood sugar level to climb too high ( hyperglycemia). Talk to your diabetes health care team about how to best coordin ate meal and medication schedules. Exercise Physical activity is another important part of your diabetes management plan. Wh en you exercise, your muscles use sugar (glucose) for energy. Regular physical a ctivity also improves your body's response to insulin. These factors work togeth er to lower your blood sugar level. The more strenuous your workout, the longer the effect lasts. But even light activities such as housework, gardening or bein g on your feet for extended periods can lower your blood sugar level. What to do: Talk to your doctor about an exercise plan. Ask your doctor about what type of e xercise is appropriate for you. If you've been inactive for a long time, your do ctor may want to check the condition of your heart and feet before advising you. He or she can recommend the right balance of aerobic and muscle-strengthening e xercise. Keep an exercise schedule. Talk to your doctor about the best time of day for yo u to exercise so that your workout routine is coordinated with your meal and med ication schedules. Know your numbers. Talk to your doctor about what blood sugar levels are appropr iate for you before you begin exercise. Check your blood sugar level. Check your blood sugar level before, during and af ter exercise, especially if you take insulin or medications that lower blood sug ar. Be aware of warning signs of low blood sugar, such as feeling shaky, weak, c onfused, lightheaded, irritable, anxious, tired or hungry. Stay hydrated. Drink plenty of water while exercising because dehydration can af fect blood sugar levels. Be prepared. Always have a small snack or glucose pill with you during exercise in case your blood sugar drops too low. Wear a medical identification bracelet w hen you're exercising. Adjust your diabetes treatment plan as needed. If you take insulin, you may need to adjust your insulin dose before exercising or wait a few hours to exercise a fter injecting insulin. Your doctor can advise you on appropriate changes in you r medication. You may need to adjust treatment if you've increased your exercise routine. Medication Insulin and other diabetes medications are designed to lower your blood sugar le vel when diet and exercise alone aren't sufficient for managing diabetes. But th e effectiveness of these medications depends on the timing and size of the dose. And any medications you take for conditions other than diabetes can affect your blood sugar level, too. What to do: Store insulin properly. Insulin that's improperly stored or past its expiration date may not be effective. Report problems to your doctor. If your diabetes medications cause your blood su gar level to drop too low, the dosage or timing may need to be adjusted. Be cautious with new medications. If you're considering an over-the-counter medi cation or your doctor prescribes a new drug to treat another condition such as h igh blood pressure or high cholesterol ask your doctor or pharmacist if the medi cation may affect your blood sugar level. Sometimes an alternate medication may

be recommended.