Diabetes is a relatively common and very serious disease. The treatment of diabetes tends to focus upon the diagnostic measures for the disease, those of blood sugar assessment. Despite this the United Kingdom Prospective Diabetes Study1 (UKPDS) has shown the tight blood sugar control should be a secondary target to tight blood pressure control.
Tight blood pressure control was found to contribute to reductions in deaths from long term complications, strokes and serious deterioration in vision. Tight blood glucose control contributes to a reduction in eye disease and renal damage. It is clear from this that the focus should be upon saving lives not purely preserving renal function and vision.
Another key finding of UKPDS was that in addition to the glucose benefits of Metformin there are additional reductions in the risk of myocardial infarction in comparison to other anti-diabetic agents. Metformin should therefore be the first line anti-diabetic drug in all patients with Type II Diabetes.
NICE appraised the place of the Glitazones in August 2003. This appraisal recommended the use of Glitazones when patients cannot tolerate or are contraindicated to either Metformin or Sulphonyureas. Since this appraisal the evidence supporting the use of Glitazones has grown beyond demonstrated effects in lowering blood sugar. Given that Sulphonylureas tend to cause weight gain as they cause insulin secretion and therefore stimulate appetite, perhaps a more pragmatic approach should now be used when HbA1c remains sub-optimal.
- Metformin for all patients, titrate to maximum tolerated dose
- If BMI < 25 Kg/M2 use a Sulphonylurea (Glicalazide or Glipizide)
- If BMI > 25 Kg/M2 use a Glitazone (Pioglitazone or Rosiglitazone)
- Refer for, or initiate Insulin (Triple therapy is licensed but not recommended for Primary Care. The combination carries extra risks for Heart Failure and Hypoglycaemia and therefore requires close monitoring
Action: Prescribers should aim to control blood pressure in preference to blood glucose in patients with Type II Diabetes.
Treatment of blood glucose should be initially managed with Metformin in all patients with type II Diabetes.
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