Guideline: Management of type 2 diabetes - A handbook for general practice (2020)

Question 1

Goals - Lifestyle Modification:

• Goals to encourage for all T2DM patients?

Answer 1

• Diet
• BMI: 5–10% weight loss for people who are overweight or obese with type 2 diabetes
• Physical activity
  
  • Children and adolescents: at least 60 min/day of moderate-to-vigorous physical activity, plus muscle- and bone-strengthening activities at least three days/week
  • Adults: 150 minutes of aerobic activity, plus 2–3 sessions of resistance exercise (to a total ≥60 minutes) per week
• Cigarettes: 0
• Alcohol: Advise ≤2 standard drinks (20 g of alcohol) per day for men and women
• BGL monitoring:
  
  • Advise 4–7 mmol/L fasting and 5–10 mmol/L postprandial
  • SMBG is recommended for patients with type 2 diabetes who are using insulin
  • For people not on insulin, the need for and frequency of SMBG should be individualised

Question 2

Clinical management goals for T2DM?

Answer 2

• HbA1c: Generally ≤7% (53 mmol/mol)
• Lipids: Pharmcotherapy commencement depends on absolute cardiovascular risk assessment. Targets below
  
  • Total cholesterol: <4.0 mmol/L
  • HDL-C: ≥1.0 mmol/L
  • LDL-C: <2.0 mmol/L; <1.8 mmol/L if established CVD is present
  • Non-HDL-C: <2.5 mmol/L
  • Triglycerides: <2.0 mmol/L
• Blood pressure: ≤140/90 mmHg
  
  • Lower blood pressure targets may be considered for younger people and for secondary prevention in those at high risk of stroke
  • diabetes and albuminuria/proteinuria remains <130/80 mmHg
• Urine albumin excretion:
  
  • women: <3.5 mg/mmol
  • men: <2.5 mg/mmol
• Vaccination: influenza, pneumococcus, diphtheria-tetanus-acellular pertussis (dTpa).
  
  • Consider: hepatitis B (if travelling), herpes zoster

Question 3

When is screening for diabetes required in the following populations and how is screening performed?:

• General/not at high risk?
• ATSI?
• Individuals with any ONE of the following risk factors:
  
  • AUSDRISK score of ≥12
  • all people with a history of a previous cardiovascular event (acute myocardial infarction or stroke)
  • women with a history of gestational diabetes mellitus
  • women with polycystic ovary syndrome
  • patients on antipsychotic drugs
• Individuals with impaired glucose tolerance test or fasting glucose (not limited by age)

Answer 3

• General/not at high risk: Q3yearly from 40 years of age using the Australian type 2 diabetes risk assessment tool (AUSDRISK)
• ATSI: annually with blood testing (fasting plasma glucose, random venous glucose or glycated haemoglobin [HbA1c]) from 18 years of age
• Individuals with any ONE of the following risk factors (AUSDRISK 12 or more, previous cardiovascular event, prev GDM, PCOS, on antipsychotics): fasting blood glucose (FBG) or HbA1c every three years
• Individuals with impaired glucose tolerance test or fasting glucose (not limited by age): with FBG or HbA1c every 12 months

Question 4

What is the goal for lifestyle intervention programs in people with impaired glucose tolerance or impaired fasting glucose?

Answer 4

• achieve and maintain a 7% reduction in weight
• increase moderate-intensity physical activity to at least 150 minutes per week

Question 5

Lifestyle intervention - Physical Activity:

• What is the goal amount and intensity of physical activity for children and adolescents with type 1 or type 2 diabetes OR at high risk of type 2 diabetes

Answer 5

Children and adolescents with type 1 or type 2 diabetes or at high risk of type 2 diabetes should engage in 60 min/day or more of moderate-
or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least three days/week

Question 6

Lifestyle intervention - Physical Activity:

• What is the goal physical activity duration and intensity for adults with T2DM?

Answer 6

• Most adults with type 2 diabetes should engage in 150 minutes or more of moderate-to-vigorous intensity aerobic activity per week, spread over at least three days/week, with no more than two consecutive days without activity
• Additionally, adults with type 2 diabetes should engage in resistance exercise:
  
  • 2–3 sessions/week on non-consecutive days
  • for a total of at least 60 minutes per week

Question 7

Lifestyle intervention - Physical Activity:

• At what interval should prolonged sitting be interrupted for adults with T2DM?

Answer 7

Prolonged sitting should be interrupted every 30 minutes for blood glucose benefits, particularly in adults with type 2 diabetes

Question 8

Lifestyle intervention - Physical Activity:

• How often is flexibility training recommended for older adults with diabetes?

Answer 8

Flexibility training and balance training are recommended 2–3 times/week for older adults with diabetes; yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength and balance

Question 9

Lifestyle intervention - Diet:

• What foods are associated with reduced risk of type 2 diabetes?

Answer 9

• Consumption of cereal foods (especially three serves/day of wholegrains) is associated with reduced risk of type 2 diabetes
• Consumption of at least 1.5 serves/day of dairy foods (eg milk, yoghurt, cheese) is associated with reduced risk of type 2 diabetes

Question 10

When should metabolic surgery be recommended to manage type 2 diabetes?

Answer 10

Metabolic surgery should be recommended to manage type 2 diabetes:

• in people with a body mass index (BMI) ≥40 kg/m2
• in people with a BMI 35.0–39.9 kg/m2 when hyperglycaemia is inadequately controlled by lifestyle and optimal medical therapy
• for patients with type 2 diabetes and BMI 30.0–34.9 kg/m2 if hyperglycaemia is inadequately controlled despite optimal treatment with either oral or injectable medications

Question 11

Glucose Monitoring:

• When should self blood glucose monitoring be used?

Answer 11

1. Patients with type 2 diabetes who are using insulin and have been educated in appropriate alterations in insulin dose
2. If not on insulin therapy, use when glycaemic control is not being achieved.
   
   • should include periodic pre- and post-prandial measurements and training of healthcare providers and people with diabetes in methods to modify health behaviours and glucose-lowering medications in response to SMBG values
   *

Question 12

What is the goal HbA1c?

Answer 12

• A reasonable HbA1c goal for many non-pregnant adults is <7% (53 mmol/mol)
• Less stringent HbA1c goals (such as <8% [64 mmol/mol]) may be appropriate for patients with
  
  • a history of severe hypoglycaemia,
  • limited life expectancy,
  • advanced microvascular or macrovascular complications,
  • extensive comorbid conditions, or
  • long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin

Question 13

Glucose monitoring:

• What are the goals for self-monitored blood glucose?

Answer 13

Targets for self-monitoring of blood glucose levels are

• 4.0–7.0 mmol/L for fasting and preprandial, and
• 5.0–10.0 mmol/L for two-hour postprandial

Question 14

Medical Management of Glycaemia:

• How long should you trial healthy behaviour interventions alone before starting glucose-lowering therapy?

Answer 14

If glycaemic targets are not achieved using healthy behaviour interventions alone within three months, glucose-lowering therapy should be added to reduce the risk of microvascular complications

Question 15

Medical Management of Glycaemia:

• What is the initial glucose-lowering therapy to trial?

Answer 15

Metformin should be chosen over other agents due to its low risk of hypoglycaemia and weight gain

Question 16

Medical Management of Glycaemia:

What are three examples of metabolic decompensation that would necessitate insulin therapy commencement to correct relative insulin deficiency?

Answer 16

• Marked hyperglycaemia
• Ketosis
• Unintentional weight loss

Question 17

Type 2 diabetes and cardiovascular risk:

• Which conditions do not require absolute CVD risk assessment using the Framingham risk equation because they are already known to be at clinically determined high risk of CVD?:

Answer 17

• diabetes and aged >60 years
• diabetes with microalbuminuria (>20mcg/minor urine albumin-to-creatinine ratio [UACR] >2.5 mg/mmol for men and >3.5 mg/mmol for women)
• moderate or severe chronic kidney disease (persistent proteinuria or estimated glomerular filtration rate [eGFR] <45 mL/min/1.73 m2)
• a previous diagnosis of familial hypercholesterolaemia
• systolic blood pressure ≥ 180mmHg or diastolic blood pressure ≥ 110mmHg
• serum total cholesterol >7.5 mmol/L

Question 18

Type 2 diabetes and cardiovascular risk:

• When is the addition of a sodium glucose co-transporter 2 (SGLT2) inhibitor beneficial?

Answer 18

Sodium glucose co-transporter 2 (SGLT2) inhibitors are recommended
in patients with type 2 diabetes in the setting of CVD and insufficient glycaemic control despite metformin, to decrease the risk of cardiovascular events and decrease the risk of hospitalisation for heart failure

Question 19

Type 2 diabetes and cardiovascular risk:

• What is the blood pressure target in a patient with diabetes and hypertension?

Answer 19

• In patients with diabetes and hypertension, a blood pressure target of <140/90 mmHg is recommended
  
  • Antihypertensive therapy is strongly recommended in patients with diabetes and systolic blood pressure ≥140 mmHg
  • In patients with diabetes and hypertension, any of the first-line antihypertensive drugs that effectively lower blood pressure are recommended
• A systolic blood pressure target of <120 mmHg may be considered for patients with diabetes in whom prevention of stroke is prioritised

Question 20

Type 2 diabetes and cardiovascular risk:

• What treatment-related adverse effects should be monitored for when aiming <120 mmHg systolic in diabetic patients (priorisiting stroke risk reduction)?

Answer 20

• In patients with diabetes where treatment is being targeted to <120 mmHg systolic, close follow-up is recommended to identify treatment-related adverse effects including
  
  • hypotension,
  • syncope,
  • electrolyte abnormalities and
  • acute kidney injury

Question 21

Type 2 diabetes and cardiovascular risk:

• How do you titrate statin therapy in diabetic patients with known previous cardiovascular disease?

Answer 21

• All adults with type 2 diabetes and known prior CVD (except haemorrhagic stroke) should receive the maximum tolerated dose of a statin, irrespective of their lipid levels
• Note: The maximum tolerated dose should not exceed the maximum available dose (eg 80 mg atorvastatin, 40 mg rosuvastatin)

Question 22

Type 2 diabetes and cardiovascular risk:

• In people with type 2 diabetes and known prior CVD, when should fibrates be commenced either in addition to a statin or on their own (if intolerant to statins)?

Answer 22

In people with type 2 diabetes and known prior CVD, fibrates should be commenced in addition to a statin or on their own (for those intolerant to statin) when fasting triglycerides are greater than or equal to 2.3 mmol/L, or high-density lipoprotein cholesterol (HDL-C) is low†

Note: When used in combination with statins, fenofibrate presents a lower risk of adverse events than other fibrates combined with statins

Question 23

Type 2 diabetes and cardiovascular risk:

• What pharmacotherapy options are there for patients with type 2 diabetes and known prior CVD who are already on maximally tolerated statin doses or intolerant of statin therapy and their fasting LDL remains ≥1.8 mmol/L

Answer 23

For adults with type 2 diabetes and known prior CVD already on maximally tolerated statin dose or intolerant of statin therapy, if fasting low-density lipoprotein cholesterol (LDL-C) levels remain ≥1.8 mmol/L, consider commencing one of:

• ezetimibe
• bile acid binding resins, or
• nicotinic acid