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Diabetes – type 2

Jul 25, 2019

Diabetes type 2 is diagnosed if patient has

  • Random blood glucose level more than 200 mg/dl.
  • HbA1c is more than 6.5%
  • Fasting blood sugar (FBS) level more than 126 mg/dl on two different test results preferably done 7 days apart.
  • 2 hours post meal blood sugar more than 200 mg/dl after a 75 grams oral glucose load
  • Excessive thirst, hunger and urination

Main principles of treatment

  • Check blood sugars regularly to assess effect of treatment
  • Aim for FBS between 90 – 110 mg/dl
  • Aim for post lunch blood sugar between 130 – 150 mg/dl

Medications (stepwise treatment):

  • Step 1 – Tab. Glycomet 500SR (Metformin 500 mg) – 1 tablet twice a day. Gradually increase by 500 mg per week up to a maximum 1000 mg twice a day if tolerable. Adjust doses for patients with renal insufficiency, liver disease. Consider cap. Becosule Z (Vitamin B 12 and Folic acid) 1 tablet a day along with Metformin.
  • Step 2 – If optimum diabetic control is not achieved after four to six weeks; combine tab. Glycomet with tab. Voglibite-0.3 (Voglibose 0.3 mg) – 1 tablet with lunch. Increase by 0.3 mg every week up to maximum total dose of 0.3 mg three times a day with meal if tolerable. Avoid in patients with diabetic ketoacidosis, intestinal obstruction, inflammatory bowel disease, severe renal insufficiency and liver disease.
  • Step 3 – If optimum diabetic control is not achieved after six weeks with step 2, combine tab.Glycomet, tab. Voglibite and add tab. Path 7.5 (Pioglitazone 7.5 mg) – 1 tablet with breakfast. Increase by 7.5 mg every week to the maximum dose of 45 mg per day. Avoid Pioglitazone in patients with liver disease, congestive heart failure, osteoporosis and bladder cancer and monitor liver function tests.
  • Step 4 – If optimum diabetic control is not achieved after six weeks with step 3, combine tab. Glycomet, tab. Voglibite, tab. Path and add tab. Dianorm-OD 30 (Gliclazide 30 mg) -1  tablet with breakfast. Increase by 30 mg every week to the maximum dose of 120 mg per day (into 2 divided doses) if tolerable.
  • Step 5 – If optimum diabetic control is not achieved after six weeks with step 4, combine tab. Glycomet, tab. Voglibite, tab. Path, tab. Dianorm and add tab. Ondero 5 (Linagliptin 5 mg) -1 tablet once a day with breakfast. Avoid Linagliptin in patients with congestive heart failure, prior history of malignancy and of childbearing age.

If oral anti-diabetics and lifestyle management are ineffective and or in patients with acute illness, weight loss or pregnancy, consider insulin. Extreme caution needs to be observed when combining oral anti-diabetics with insulin regime. The advice for using insulin is as follows:

  • Long acting (basal insulin) – inj. Lantus (Glargine U-100) – Initially 0.1 units/kg subcutaneously after dinner. Increase dose by 1 to 2 units every 3 days until fasting blood glucose is less than 130 mg/dl (maximum dose – 0.5 units/Kg).
  • If optimum diabetic control is not achieved after maximum dose of long acting insulin; add rapid acting insulin (with meals) – inj. Apidra (Insulin Glulisine U-100) – 4 units subcutaneously with largest meal. Increase this dose by 1 unit every 3 days until post meal blood glucose is between 130 mg -150 mg/dl.
  • Keep insulin dose split into 50% long acting insulin and 50% short acting insulin.

If above types of Insulin not available or practical, consider Inj. Human Mixtard 70/30 (intermediate acting insulin – Isophane 70%; short acting Insulin – Actrapid 30%) (use insulin syringe only) depending on the HbA1c:

  • HbA1c is less than 8 – 0.1 units/kg 30 mins before breakfast and 0.1 units/kg 30 mins before dinner
  • HbA1c between 8 and 10 – 0.2 units/kg 30 mins before breakfast and 0.2 units/kg 30 mins before dinner
  • HbA1c more than 10 – 0.3 units/kg 30 mins before breakfast and 0.3 units/kg 30 mins before dinner
  • Increase dose by 1 unit every 3 days until fasting blood glucose and post meal blood glucose targets are achieved.

General advice:

  • Regular aerobic exercise – preferably 45 minutes each day
  • Diabetic diet
  • Stop smoking and reduce intake of alcohol
  • Reduce stress levels

Investigations:

  • Regular fasting blood sugar and postprandial blood sugars.
  • HbA1c – to evaluate long term diabetic control.
  • Lipid profile (to rule out raised cholesterol) – Please refer to hyperlipidaemia guidelines.
  • Liver function test – if patient is on Pioglitazone. Stop in case of deranged liver functions.
  • Serum creatinine and estimated glomerular filtration rate – to adjust the dose of Metformin and Gliclazide.
  • Urinary albumin creatinine ratio – to rule out diabetic nephropathy.
  • Thyroid function test – to rule out hypothyroidism which could be an associated condition.

Referrals:

Consider further referral to diabetologist if patient fails to improve or presents with additional complications.