Blood pressure management in diabetes
If no history of hypertension or renal disease, check annually. If controlled hypertension, check every 4 – 6 months (that’ll be a nice bit of extra work for somebody. Pun not intended.)
Remember lifestyle advice.
If BP is >150/90, recheck in 1/12. If it’s between 150/90 and 140/80, recheck in 2/12. In the case of renal, eye, or cerebrovascular damage, aim for a BP below 130/80 (recheck in 2/12).
1st-line treatment for a woman who may become pregnant is a calcium channel blocker. For a person of Afro-Caribbean origin who is not planning a pregnancy, it’s combined treatment with an ACE inhibitor and either a diuretic or calcium channel blocker. For anyone else, it’s an ACE inhibitor. If ACE inhibitors aren’t tolerated, try a sartan, unless the reason was hyperkalaemia or renal dysfunction.
Second/third-line treatment should be a diuretic and CCB, in either order.
Fourth-line treatment is either a beta-blocker, an alpha-blocker, or a potassium-sparing diuretic (to be used with caution in combination with an ACE or sartan).
The guidelines advise letting patients choose their own targets and then go right on to advise on targets we should be aiming for, so that’s sort of confusing – maybe they felt obliged to sound as though they were being patient-centred but couldn’t keep it up for the whole guideline? Anyway, recommended targets are:
- For adults who are only on lifestyle/diet +/- one non-hypoglycaemic-inducing drug, 48% (the old 6.5%).
- For adults on potentially hypoglycaemia-inducing drugs, 53% (7%)
- For people with poor life expectancy, multiple comorbidities, or a high risk of side-effects from hypoglycaemia, work on individualised targets which may be higher.
If someone has an HbA1c level below their target, encourage them to maintain it as long as they’re not suffering hypoglycaemia.
Drug treatments – what happens after metformin?
Second-line treatments if metformin not sufficient: DPP inhibitor, sulfonylurea, or pioglitazone. However, be aware of circumstances in which pioglitazone is contraindicated:
- Bladder cancer or unexplained haematuria
- Hepatic impairment
Third-line treatment options:
- Metformin + sulfonylurea + pioglitazone
- Metformin + sulfonylurea + DPP inhibitor
- Starting insulin
A back-up third-line treatment option is metformin + sulfonylurea + GLP1-mimeticbut there are some complicated guidelines around the patient being over particular weight thresholds/in a position to benefit from weight loss, and showing certain amounts of benefit in a trial of the GLP1-mimetic.
And what if metformin isn’t tolerated?
First-line: sulfonylurea, DPP, or pioglitazone. Flozins (SGLT2 inhibitors) are an alternative monotherapy to DPP, but only if neither sulfonylurea or pioglitazone can be appropriately used.
Second-line: Any two of the above in combination
Third-line: Consider insulin.
For patients with a QRISK >10%, offer Atorvastatin 20 mg od. We’re meant to aim for ‘a greater than 40% reduction in non-HDL cholesterol’, but someone didn’t think the complexities of that all the way through.
Follow-up of gestational diabetes
A fasting glucose can be done between 6 and 13 weeks post-pregnancy, or an HbA1c from 13 weeks post-pregnancy. HbA1c should then be done annually thereafter.
Planning a pregnancy with pre-existing diabetes
Prior to conception, women should aim for plasma glucose levels of 5 – 7mmol/l on walking and 4 – 7 mmol/l before meals.
(NICE guidelines Type 2 DM, plus Pulse Learning module)