Management of diabetes

This guideline is for:

• Healthcare professionals
• Commissioners and providers
• Adults with type 2 diabetes (and their families and carers)

Recommendations outlined:

1. Individual care:
   • Diabetes care for adults with type 2 diabetes should be individualized, considering personal preferences, comorbidities, polypharmacy risks, and potential long-term benefits, especially for those with multiple conditions. Regularly reassess needs and consider discontinuing ineffective medications. Accommodate any disabilities, such as visual impairment, when planning and providing care.
2. Education:
   • Structured education should be offered to adults with type 2 diabetes and their families/ carers at diagnosis and reinforced annually at reviews.
   • The programme must be evidence-based, tailored to individual needs, and have clear objectives to support self-management. It should include a structured, theory-driven curriculum delivered by trained educators and be quality-assured with regular audits.
   • Group education is preferred, with alternatives for those who need them.
   • Programmes should accommodate cultural, linguistic, cognitive, and literacy needs and be integrated into the local care pathway.
   • Patients and their families should have opportunities to contribute to programme design and delivery.
3. Dietary advice and bariatric surgery:
   • Adults with type 2 diabetes should receive individualized, culturally sensitive dietary advice from qualified professionals, integrated into a comprehensive diabetes management plan.
   • Encourage a high-fibre, low-glycaemic diet with low-fat dairy, oily fish, and controlled intake of saturated fats. Provide specific guidance on carbohydrates, meal patterns and alcohol. Discourage diabetes-specific foods, and ensure consistent carbohydrate meal planning in hospital or other care settings.
   • Adults with type 2 diabetes who are overweight should discuss and agree an initial weight loss target of 5-10%.
   • Bariatric surgery may be considered for those with recent-onset diabetes, as per NICE obesity guidelines.
   • Lifestyle modifications, including physical activity and smoking cessation, should support dietary guidance.
4. Diagnosing and managing hypertension:
   • Generally, hypertension management is similar for those with and without type 2 diabetes. Any specific differences for diabetic patients are highlighted within the ‘NICE guideline on hypertension in adults’
5. Antiplatelet therapy:
   • Do not offer antiplatelet therapy (aspirin or clopidogrel) to adults with type 2 diabetes who do not have cardiovascular disease.
   • For primary and secondary prevention of cardiovascular disease in these patients, refer to the ‘NICE guidelines on cardiovascular disease’ and ‘acute coronary syndromes.’
6. Blood glucose management:
   • For adults with type 2 diabetes, HbA1c levels should be measured every 3-6 months until stable, then every 6 months.
   • Use IFCC-standardized methods.
   • If HbA1c monitoring is invalid, use alternative glucose control measures.
   • Individual HbA1c targets should be set, aiming for:
   • 48 mmol/mol (6.5%) for those on lifestyle or single non-hypoglycaemic drugs
   • 53 mmol/mol (7.0%) for those on a drug associated with hypoglycaemia
   • For adults with type 2 diabetes whose HbA1c levels exceed 58 mmol/mol (7.5%) despite single-drug therapy, reinforce dietary, lifestyle, and medication adherence advice. Encourage them to aim for an HbA1c target of 53 mmol/mol (7.0%) and consider intensifying drug treatment to improve control.
   • Consider relaxing targets for older or frailer individuals with risks – for example, risk of falling, if they operate machinery, if they have significant co-morbidities
   • Self-monitoring is recommended for insulin users, those at risk of hypoglycaemia, those that are pregnant or planning to become pregnant.
   • Offer continuous glucose monitoring (CGM) for specific insulin-treated type 2 diabetes patients.
7. Drug treatment:
   • See the full guideline
8. Complications:
   • For adults with type 2 diabetes, NICE guidelines recommend managing complications across multiple areas:
   • Periodontitis: Advise on increased risk and the benefits of managing periodontitis for glycaemic control, with regular oral health reviews and treatment as needed.
   • Gastroparesis: Consider gastroparesis in cases of erratic blood glucose or unexplained symptoms. There is no strong evidence for antiemetics. Consider alternating erythromycin and metoclopramide. Use domperidone only as a last resort if it’s the only effective option, following MHRA safety guidelines.
   • Neuropathy: Address painful neuropathy and autonomic neuropathy symptoms with targeted interventions.
   • Diabetic foot health: See ‘Diabetic foot problems: prevention and management’
   • Chronic kidney disease: Offer angiotensin receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor. Supplement with a SGLT2 inhibitors in specific instances
   • Erectile dysfunction: Discuss erectile dysfunction as part of annual reviews. Consider a phosphodiesterase-5 inhibitor for erectile dysfunction, with referrals for medical, surgical or psychological management if required.
   • Eye disease: Refer for eye screening at diagnosis, encourage attendance, and arrange urgent ophthalmology care for sudden visual issues.