Therapy for High Blood Glucose Concentrations

Life-style management of raised blood glucose levels should be given a good trial before beginning glucose lowering drugs

	See also :	Patient education
	See also :	Self-monitoring
	See also :	Blood glucose targets
	See also :	Dietary management
	See also :	Physical exercise

Using oral glucose-lowering drugs ( for insulin therapy see below )

Begin oral agent therapy when :
		an adequate trial of life-style intervention / education has been given
		either ( usually ) : HbA1c >6.5 %, fasting venous plasma glucose >6.0 mmol/l ( >=110 mg/dl )
		or ( occasionally ) if thin and no other arterial risk factor : HbA1c >7.5 %, fasting venous plasma glucose >=7.0 mmol/l ( >125 mg/dl )
Use :
		metformin
		insulin secretagogues ( sulphonylureas and repaglinide )
		a-glucosidase inhibitors
		thiazolidinediones and related PPARy-agonists
Choise of agents
	Metformin : strong evidence base in the overweight, lowers LDL cholesterol, but gastro-intestinal side effects in some patients; dose titration may help tolerance
			contraindicated ( risk of lactic acidosis ) if renal impairment, overt liver disease, or severe cardiac failure; monitor renal function at least yearly
	Sulphonylureas : good evidence base, provided patient has useful islet B-cell function
			hypoglycaemia a significant problem glibenclamide > glipizide chlorpropamide > gliclazide > tolbutamide ( some other agents lack data ); avoid glibenclamide / chlorpropamide particularly if renal impairment or in the thin insulin-sensitive patient ( especially if elderly )
	Repaglinide : new rapid-acting insulin secretagogue; possible advantage in hypoglycaemia avoidance and control of post-prandial glucose excursions
	a-Glucosidase inhibitors : effective control of post-prandial hyperglycaemia, but poorly tolerated by many patients; dose titration may help tolerance
	PPARy-agonists : new agents, offering effective glucose-lowering particularly in combination with insulin and insulin secretagogues
			contraindicated if any history of liver disease, and require organized monitoring of liver function tests until hepatic safety assured
	A number of new drugs are currently entering clinical practice; we anticipate the need to modify the above advice as the role of such drugs becomes better understood

Maintaining good blood glucose control with oral glucose-lowering drugs

Expect :
	continuous deterioration of glucose control with time
	a need to increase therapy and add new agents with time
	insulin therapy to be needed in many patients after a variable number of years

Monitor ( see also : Organization of Clinical Monitoring ) :

dietary quality and quantity, physical exercise level

HbA1c ( or fasting venous plasma glucose ), and self-test results

body weight

other vascular risk factors ( blood lipids, blood pressure )

Adjust therapy :

Increase dose of individual agent at each visit up to maximum tolerated / effective dose, if targets are not met

Decrease dose of individual agent, if therapy-related problems arise, or if glucose control well into the non-diabetic range

Combination therapy

Add another agent of therapy when maximum dose of current drugs reached

Use triple therapy when control targets cannot be reached on maximum tolerated doses of two agents

( For combination therapy with insulin see next box )

Insulin therapy in Type 2 diabetes

Begin when HbA_1c has deteriorated to >7.5 % after maximum attention to dietary control and oral glucose-lowering therapy ( unless poor life-expectancy and asymptomatic )
		Arrange dietary review when starting insulin therapy
		Review ( or start ) self-monitoring of blood glucose before starting insulin
		Continue therapy with metformin / insulin secretagogues / PPARy-agonists
Use :
		NPH insulin at night with oral glucose-lowering drugs in people with good insulin secretory reserve
		pre-mixed insulin twice daily in the majority of people
		twice daily NPH insulin in people with high pre-breakfast blood glucose concentrations relative to their HbA_1c
Adjust therapy :
		frequently at first, using self-monitored results, until insulin dose is adequate to reach blood glucose targets ( see also : Blood glucose control assessment levels ), or hypoglycaemia becomes a risk
		Consider more intensive insulin regimens
		in the more active patient if control remains sub-optimal if control remains sub-optimal due to hypoglycaemia ( but not if due to insulin insensitivity ) to assist achievement of more flexible life-styles
	See also : Guide to Type 1 Diabetes, 1998 - Using Insulin Effectively

Therapy for Abnormal Blood Lipid Concentrations