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Summary for primary care

Type 2 Diabetes in Adults: Management

NICE

This Guidelines summary covers care and management for adults (aged 18 and over) with type 2 diabetes. It focuses on patient education, dietary advice, managing cardiovascular risk, managing blood glucose levels, and identifying and managing long-term complications. This is a summary of key recommendations for primary care. For the complete set of recommendations, refer to the full guideline.

Further Guidelines summaries on NICE diabetes guidance:

Type 1 Diabetes in Adults: Diagnosis and Management

Type 1 Diabetes in Children and Young People: Diagnosis and Management

Type 2 Diabetes in Children and Young People: Diagnosis and Management

Type 2 Diabetes: Prevention in People at Risk

Diabetes in Pregnancy: Management From Preconception to the Postnatal Period.

Latest Guidance Updates (June 2022)

  • New recommendations on periodontitis in the section on Managing Complications.

Individualised Care

  • Adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of adults with type 2 diabetes, taking into account their personal preferences, comorbidities, and risks from polypharmacy, and their likelihood of benefitting from long-term interventions. Such an approach is especially important in the context of multimorbidity.
  • Reassess the person’s needs and circumstances at each review and think about whether to stop any medicines that are not effective.
  • Take into account any disabilities, including visual impairment, when planning and delivering care for adults with type 2 diabetes.

Education

  • Offer structured education to adults with type 2 diabetes and their family members or carers (as appropriate) at the time of diagnosis, with annual reinforcement and review. Explain to people and their carers that structured education is an integral part of diabetes care. 
  • Ensure that any structured education programme for adults with type 2 diabetes:
    • is evidence-based, and suits the needs of the person
    • has specific aims and learning objectives, and supports the person and their family members and carers to develop attitudes, beliefs, knowledge and skills to self-manage diabetes
    • has a structured curriculum that is theory-driven, evidence-based and resource-effective, has supporting materials and is written down
    • is delivered by trained educators who:
      • have an understanding of educational theory appropriate to the age and needs of the person
      • are trained and competent to deliver the principles and content of the programme
    • is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency
    • has outcomes that are audited regularly.
  • Ensure that education programmes for adults with type 2 diabetes provide the necessary resources to support the educators, and that educators are properly trained and given time to develop and maintain their skills.
  • Offer adults with type 2 diabetes group education programmes as the preferred option. Provide an alternative of equal standard for people who are unable or prefer not to take part in group education.
  • Ensure that education programmes for adults with type 2 diabetes meet the cultural, linguistic, cognitive and literacy needs of people in the local area.
  • Ensure that all members of the diabetes healthcare team are familiar with the education programmes available locally for adults with type 2 diabetes, and that these programmes are integrated with the rest of the care pathway.
  • Ensure that adults with type 2 diabetes and their family members and carers (as appropriate) have the opportunity to contribute to the design and provision of local education programmes for adults with type 2 diabetes.

Dietary Advice and Bariatric Surgery

  • Provide individualised and ongoing nutritional advice from a healthcare professional with specific expertise and competencies in nutrition.
  • Provide dietary advice in a form sensitive to the person’s needs, culture and beliefs, being sensitive to their willingness to change and the effects on their quality of life.
  • Encourage adults with type 2 diabetes to follow the same healthy eating advice as the general population, which includes:
    • eating high-fibre, low-glycaemic-index sources of carbohydrates, such as fruit, vegetables, wholegrains and pulses
    • choosing low-fat dairy products
    • eating oily fish
    • controlling their intake of saturated and trans fatty acids.
  • Integrate dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification such as increasing physical activity and losing weight.
  • For adults with type 2 diabetes who are overweight, discuss and agree an initial body weight loss target of 5% to 10%. Remember that a small amount of weight loss may still be beneficial, and a larger amount will have advantageous metabolic impact in the long term.
  • Individualise recommendations for carbohydrate and alcohol intake, and meal patterns. Make reducing the risk of hypoglycaemia a particular aim for people using insulin or an insulin secretagogue.
  • Advise adults with type 2 diabetes that they can substitute a limited amount of sucrose-containing foods for other carbohydrate in the meal plan but should take care to avoid excess energy intake.
  • Discourage adults with type 2 diabetes from using foods marketed specifically for people with diabetes.
  • When adults with type 2 diabetes are admitted as inpatients to hospital or any other care setting, implement a meal planning system that provides consistency in the carbohydrate content of meals and snacks.
  • For recommendations on lifestyle advice, see the NICE guidelines on preventing excess weight gain, weight management, obesity, physical activity, and tobacco.
  • For recommendations on bariatric surgery for people with recent-onset type 2 diabetes, see the section on bariatric surgery for people with recent-onset type 2 diabetes in the NICE guideline on obesity.

Diagnosing and Managing Hypertension

The recommendations on diagnosing and managing hypertension have been removed. For recommendations on hypertension in people with type 2 diabetes, see the NICE guideline on hypertension in adults. Diagnosis, treatment and monitoring of hypertension is broadly the same for people with type 2 diabetes as for other people. When a different approach is needed for people with type 2 diabetes, this is specified in the hypertension guideline. 

Antiplatelet Therapy

Blood Glucose Management

HbA1c Measurement and Targets

Measurement

  • Measure HBA1c levels in adults with type 2 diabetes every:
    • 3 to 6 months (tailored to individual needs) until HbA1c is stable on unchanging therapy
    • 6 months once the HbA1c level and blood glucose lowering therapy are stable.
  • Measure HbA1c using methods calibrated according to International Federation of Clinical Chemistry (IFCC) standardisation.
  • If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using one of the following:
    • quality-controlled plasma glucose profiles
    • total glycated haemoglobin estimation (if abnormal haemoglobins)
    • fructosamine estimation.
  • Investigate unexplained discrepancies between HbA1c and other glucose measurements. Seek advice from a team with specialist expertise in diabetes or clinical biochemistry.

Targets

NICE has produced a patient decision aid on agreeing HbA1c targets, which also covers factors to weigh up when discussing HbA1c targets with patients.
  • Discuss and agree on an individual HbA1c target with adults with type 2 diabetes (see the second to the fifth recommendations in this section). Encourage them to reach their target and maintain it, unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target impair their quality of life. Think about using the NICE patient decision aid on weighing up HbA1c targets to support these discussions.
  • Offer lifestyle advice and drug treatment to support adults with type 2 diabetes to achieve and maintain their HbA1c target (see the sections on dietary advice and bariatric surgery and choosing drug treatments). For more information about supporting adherence, see the NICE guideline on medicines adherence.
  • For adults whose type 2 diabetes is managed either by lifestyle and diet, or lifestyle and diet combined with a single drug not associated with hypoglycaemia, support them to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support them to aim for an HbA1c level of 53 mmol/mol (7.0%).
  • In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
    • reinforce advice about diet, lifestyle and adherence to drug treatment and
    • support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and
    • intensify drug treatment.
  • Consider relaxing the target HbA1c level (see the third and fourth recommendations in this section and NICE's patient decision aid) on a case-by-case basis and in discussion with adults with type 2 diabetes, with particular consideration for people who are older or frailer, if:
    • they are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
    • tight blood glucose control would put them at high risk if they developed hypoglycaemia, for example, if they are at risk of falling, they have impaired awareness of hypoglycaemia, or they drive or operate machinery as part of their job
    • intensive management would not be appropriate, for example if they have significant comorbidities.
  • If adults with type 2 diabetes reach an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example deteriorating renal function or sudden weight loss.
  • For guidance on HbA1c targets for women with type 2 diabetes who are pregnant or planning to become pregnant, see the NICE guideline on diabetes in pregnancy.

Self-monitoring of Capillary Blood Glucose

These recommendations relate to self-monitoring by capillary blood glucose monitoring.
  • Take the Driver and Vehicle Licensing Agency (DVLA)'s Assessing fitness to drive: a guide for medical professionals  into account when offering self-monitoring of capillary blood glucose levels for adults with type 2 diabetes.
  • Do not routinely offer self-monitoring of capillary blood glucose levels for adults with type 2 diabetes unless:
    • the person is on insulin or
    • there is evidence of hypoglycaemic episodes or
    • the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery or
    • the person is pregnant or is planning to become pregnant (see the NICE guideline on diabetes in pregnancy).
  • Consider short-term self-monitoring of capillary blood glucose levels in adults with type 2 diabetes, reviewing treatment as necessary:
    • when starting treatment with oral or intravenous corticosteroids or
    • to confirm suspected hypoglycaemia.
  • Be aware that adults with type 2 diabetes who have acute intercurrent illness are at risk of worsening hyperglycaemia. Review treatment as necessary.
  • If adults with type 2 diabetes are self-monitoring their capillary blood glucose levels, carry out a structured assessment at least annually. The assessment should include:
    • the person’s self-monitoring skills
    • the quality and frequency of testing
    • checking that the person knows how to interpret the blood glucose results and what action to take
    • the impact on the person’s quality of life
    • the continued benefit to the person
    • the equipment used.

Continuous Glucose Monitoring

  • Offer intermittently scanned continuous glucose monitoring (isCGM, commonly referred to as 'flash') to adults with type 2 diabetes on multiple daily insulin injections if any of the following apply:
    • they have recurrent hypoglycaemia or severe hypoglycaemia
    • they have impaired hypoglycaemia awareness
    • they have a condition or disability (including a learning disability or cognitive impairment) that means they cannot self-monitor their blood glucose by capillary blood glucose monitoring but could use an isCGM device (or have it scanned for them)
    • they would otherwise be advised to self-measure at least 8 times a day.For guidance on continuous glucose monitoring (CGM) for pregnant women, see the NICE guideline on diabetes in pregnancy.
  • Offer isCGM to adults with insulin-treated type 2 diabetes who would otherwise need help from a care worker or healthcare professional to monitor their blood glucose.
  • Consider real-time continuous glucose monitoring (rtCGM) as an alternative to isCGM for adults with insulin-treated type 2 diabetes if it is available for the same or lower cost.
  • CGM should be provided by a team with expertise in its use, as part of supporting people to self-manage their diabetes. 
  • Advise adults with type 2 diabetes who are using CGM that they will still need to take capillary blood glucose measurements (although they can do this less often). Explain that is because:
    • they will need to use capillary blood glucose measurements to check the accuracy of their CGM device
    • they will need capillary blood glucose monitoring as a back-up (for example when their blood glucose levels are changing quickly or if the device stops working). Provide them with enough test strips to take capillary blood glucose measurements as needed.
  • If a person is offered rtCGM or isCGM but cannot or does not want to use any of these devices, offer capillary blood glucose monitoring.
  • Ensure CGM is part of the education provided to adults with type 2 diabetes who are using it (see the section on education). 
  • Monitor and review the person's use of CGM as part of reviewing their diabetes care plan (see the section on individualised care). 
  • If there are concerns about the way a person is using the CGM device:
    • ask if they are having problems using their device
    • look at ways to address any problems and concerns to improve their use of the device, including further education and emotional and psychological support.
  • Commissioners, providers and healthcare professionals should address inequalities in CGM access and uptake by:
    • monitoring who is using CGM
    • identifying groups who are eligible but who have a lower uptake
    • making plans to engage with these groups to encourage them to consider CGM.

Drug Treatment

Recommendations in this section that cover dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) mimetics, sulfonylureas and sodium–glucose cotransporter-2 (SGLT2) inhibitors refer to each of these groups of drugs at class level unless otherwise stated.

Choosing Drug Treatments

See Algorithm 1 and Algorithm 2 for an overview of the recommendations and additional information to support medicines choice.

Algorithm 1: How to Choose First-line Medicines

 

Algorithm 2: How to Choose Further Medicines

 
  • Discuss with adults with type 2 diabetes the benefits and risks of drug treatment and the options available. Base the choice of drug treatments on: 
    • the person's individual clinical circumstances, for example comorbidities, contraindications, weight, and risks from polypharmacy 
    • the person's individual preferences and needs 
    • the effectiveness of the drug treatments in terms of metabolic response and cardiovascular and renal protection 
    • safety and tolerability of the drug treatment 
    • monitoring requirements 
    • the licensed indications or combinations available 
    • cost (if 2 drugs in the same class are appropriate, choose the option with the lowest acquisition cost). 

      See the NICE guideline on shared decision making and the section on safety of medicines for diabetes before and during pregnancy in the NICE guideline on diabetes in pregnancy.

Rescue Therapy at Any Phase of Treatment

  • If an adult with type 2 diabetes is symptomatically hyperglycaemic, consider insulin (see the section on insulin-based treatments) or a sulfonylurea, and review treatment when blood glucose control has been achieved.

First-line Drug Treatment

Also see Algorithm 1 for an overview of the recommendations and additional information to support medicines choice.

For adults with type 2 diabetes and chronic kidney disease, follow recommendations on SGLT2 inhibitors in the section on chronic kidney disease in the full guideline.
 
  • Offer standard-release metformin as first-line drug treatment to adults with type 2 diabetes.
  • Assess the person's cardiovascular status and risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of developing cardiovascular disease. 
  • See the recommendations on using risk scores and QRISK2 to assess cardiovascular disease risk in adults with type 2 diabetes in NICE's guideline on cardiovascular disease: risk assessment and reduction, including lipid modification.
  • Based on the cardiovascular risk assessment for the person with type 2 diabetes:
    • If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.
    • If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.
  • When starting an adult with type 2 diabetes on dual therapy with metformin and an SGLT2 inhibitor as first-line therapy, introduce the drugs sequentially, starting with metformin and checking tolerability. Start the SGLT2 inhibitor as soon as metformin tolerability is confirmed.
  • Gradually increase the dose of standard-release metformin over several weeks to minimise the risk of gastrointestinal side effects in adults with type 2 diabetes.
  • If an adult with type 2 diabetes experiences gastrointestinal side effects with standard-release metformin, consider a trial of modified-release metformin.
  • For first-line drug treatment in adults with type 2 diabetes, if metformin is contraindicated or not tolerated:
    • If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit
    • If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit.
  • For first-line drug treatment in adults with type 2 diabetes, if metformin is contraindicated or not tolerated and if they are not in either of the groups in the previous recommendation, consider:
  • Before starting an SGLT2 inhibitor, check whether the person may be at increased risk of diabetic ketoacidosis (DKA), for example if:
    • they have had a previous episode of DKA
    • they are unwell with intercurrent illness
    • they are following a very low carbohydrate or ketogenic diet.
  • Address modifiable risks for DKA before starting an SGLT2 inhibitor. For example, for people who are following a very low carbohydrate or ketogenic diet, they may need to delay treatment until they have changed their diet.
  • Advise adults with type 2 diabetes who are taking an SGLT2 inhibitor about the need to minimise their risk of DKA by not starting a very low carbohydrate or ketogenic diet without discussing it with their healthcare professional, because they may need to suspend SGLT2 inhibitor treatment.

Reviewing Drug Treatments

  • When reviewing or considering changing treatments for adults with type 2 diabetes, think about and discuss the following with the person:
    • how to optimise their current treatment regimen before thinking about changing treatments, taking into account factors such as:
      • adverse effects
      • adherence to existing medicines
      • the need to revisit advice about diet and lifestyle
      • prescribed doses and formulations
    • stopping medicines that have had no impact on glycaemic control or weight, unless there is an additional clinical benefit, such as cardiovascular or renal protection, from continued treatment (see the note below on off-label use)
    • whether switching rather than adding drugs could be effective
    • the considerations about treatment choice in the first recommendation in the section Choosing drug treatments.

      In February 2022, using ertugliflozin to reduce cardiovascular risk when blood glucose is well controlled was off-label. See NICE's information on prescribing medicines.

      Also see the recommendations on medication review in the NICE guideline on medicines optimisation and on reviewing medicines and supporting adherence in the NICE guideline on medicines adherence.

Adding an SGLT2 Inhibitor at Any Stage After First-line Treatment has been Started

  • For adults with type 2 diabetes at any stage after they have started first-line treatment:
    • If they have or develop chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to current treatment or replace an existing drug with the SGLT2 inhibitor.
    • If they are or become at high risk of developing cardiovascular disease, consider adding an SGLT2 inhibitor with proven cardiovascular benefit to current treatment or replacing an existing drug with the SGLT2 inhibitor.

      Take into account the person's current treatment regimen and preferences and make a shared decision about switching treatments or adding an SGLT2 inhibitor, as appropriate (also see the recommendations above on starting an SGLT2 inhibitor).

      In February 2022, using ertugliflozin to reduce cardiovascular risk when blood glucose is well controlled was off-label. See NICE's information on prescribing medicines.

Treatment Options if Further Interventions are Needed

Also see Algorithm 2 for an overview of the recommendations and additional information to support medicines choice.
 
  • Introduce drugs used in combination therapy in a stepwise manner, checking for tolerability and effectiveness of each drug.
  • For adults with type 2 diabetes, if monotherapy has not continued to control HbA1c to below the person's individually agreed threshold for further intervention, consider adding:
  • For adults with type 2 diabetes, if dual therapy with metformin and another oral drug has not continued to control HbA1c to below the person's individually agreed threshold for further intervention consider either:
  • In adults with type 2 diabetes, if metformin is contraindicated or not tolerated and dual therapy with 2 oral drugs has not continued to control HbA1c to below the person's individually agreed threshold for intervention, consider insulin-based treatment (see the section on insulin-based treatments).
  • If triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated, consider triple therapy by switching one drug for a GLP-1 mimetic for adults with type 2 diabetes who:
    • have a body mass index (BMI) of 35 kg/m2 or higher (adjust accordingly for people from Black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity or
    • have a BMI lower than 35 kg/m2 and:
      • for whom insulin therapy would have significant occupational implications or
      • weight loss would benefit other significant obesity-related comorbidities.
  • Only continue GLP-1 mimetic therapy if the adult with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and weight loss of at least 3% of initial body weight in 6 months).
  • For adults with type 2 diabetes, only offer combination therapy with a GLP-1 mimetic and insulin along with specialist care advice and ongoing support from a consultant-led multidisciplinary team.

Insulin-based Treatments

  • For adults with type 2 diabetes starting insulin therapy, provide a structured programme using active insulin dose titration that encompasses:
    • injection technique, including rotating injection sites and avoiding repeated injections at the same point within sites
    • continuing telephone support
    • self-monitoring
    • dose titration to target levels
    • dietary advice
    • the DVLA's Assessing fitness to drive: a guide for medical professionals
    • managing hypoglycaemia
    • managing acute changes in plasma glucose control
    • support from an appropriately trained and experienced healthcare professional.
  • For adults with type 2 diabetes starting insulin therapy, continue to offer metformin for people without contraindications or intolerance. Review the continued need for other blood glucose lowering therapies.
  • Start insulin therapy for adults with type 2 diabetes from a choice of the following insulin types and regimens:
    • Offer neutral protamine Hagedorn (NPH) insulin injected once or twice daily according to need.
    • Consider starting both NPH and short-acting insulin (particularly if the person’s HbA1c is 75 mmol/mol [9.0%] or higher), administered either:
      • separately or
      • as a pre-mixed (biphasic) human insulin preparation.
    • Consider, as an alternative to NPH insulin, using insulin detemir or insulin glargine if:
      • the person needs help from a carer or healthcare professional to inject insulin, and use of insulin detemir or insulin glargine would reduce the frequency of injections from twice to once daily or
      • the person’s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes or
      • the person would otherwise need twice-daily NPH insulin injections in combination with oral glucose-lowering drugs
    • Consider pre-mixed (biphasic) preparations that include short-acting insulin analogues, rather than pre-mixed (biphasic) preparations that include short-acting human insulin preparations, if:
      • a person prefers injecting insulin immediately before a meal or
      • hypoglycaemia is a problem or
      • blood glucose levels rise markedly after meals.
  • Consider switching to insulin detemir or insulin glargine from NPH insulin in adults with type 2 diabetes:
    • who do not reach their target HbA1c because of significant hypoglycaemia or
    • who experience significant hypoglycaemia on NPH insulin irrespective of the level of HbA1c reached or
    • who cannot use the device needed to inject NPH insulin but could administer their own insulin safely and accurately if a switch to one of the long-acting insulin analogues was made or
    • who need help from a carer or healthcare professional to administer insulin injections and for whom switching to one of the long-acting insulin analogues would reduce the number of daily injections.
  • Monitor adults with type 2 diabetes who are on a basal insulin regimen (NPH insulin, insulin detemir or insulin glargine) for the need for short-acting insulin before meals (or a pre-mixed [biphasic] insulin preparation).
  • Monitor adults with type 2 diabetes who are on pre-mixed (biphasic) insulin for the need for a further injection of short-acting insulin before meals or for a change to a basal-bolus regimen with NPH insulin or insulin detemir or insulin glargine, if blood glucose control remains inadequate.
  • When starting an insulin for which a biosimilar is available, use the product with the lowest acquisition cost.
  • Ensure the risk of medication errors with insulins is minimised by following the Medicines and Healthcare products Regulatory Agency (MHRA) guidance on minimising the risk of medication error with high strength, fixed combination and biosimilar insulin products, which includes advice for healthcare professionals when starting treatment with a biosimilar.
  • When people are already using an insulin for which a lower cost biosimilar is available, discuss the possibility of switching to the biosimilar. Make a shared decision with the person after discussing their preferences.
For guidance on using insulin in combination with SGLT2 inhibitors, see:

Insulin Delivery

Managing Complications

Periodontitis

  • Advise adults with type 2 diabetes at their annual review that:
    • they are at higher risk of periodontitis
    • if they get periodontitis, managing it can improve their blood glucose control and can reduce their risk of hyperglycaemia.
  • Advise adults with type 2 diabetes to have regular oral health reviews (their oral healthcare or dental team will tell them how often, in line with the NICE guideline on dental checks: intervals between oral health reviews).

Gastroparesis

  • Think about a diagnosis of gastroparesis in adults with type 2 diabetes who have erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses.
  • For adults with type 2 diabetes who have vomiting caused by gastroparesis, explain that:
    • there is no strong evidence that any available antiemetic therapy is effective
    • some people have had benefit with domperidone, erythromycin or metoclopramide
    • the strongest evidence for effectiveness is for domperidone, but prescribers must take into account its safety profile, in particular its cardiac risk and potential interactions with other medicines.

      In December 2015, the use of erythromycin was off-label. See NICE's information on prescribing medicines.
       
  • To treat vomiting caused by gastroparesis in adults with type 2 diabetes:
    • consider alternating the use of erythomycin and metoclopramide
    • consider domperidone only in exceptional circumstances (if domperidone is the only effective treatment) and in accordance with MHRA guidance on domperidone.
  • If gastroparesis is suspected, consider referring adults with type 2 diabetes to specialist services if:
    • the differential diagnosis is in doubt or
    • the person has persistent or severe vomiting.

Painful Diabetic Neuropathy

Autonomic Neuropathy

  • Think about the possibility of contributory sympathetic nervous system damage in adults with type 2 diabetes who lose the warning signs of hypoglycaemia.
  • Think about the possibility of autonomic neuropathy affecting the gut in adults with type 2 diabetes who have unexplained diarrhoea that happens particularly at night.
  • For adults with type 2 diabetes and autonomic neuropathy who are taking tricyclic drugs and antihypertensive drug treatments, be aware of the increased likelihood of side effects such as orthostatic hypotension. For guidance on safe prescribing of antidepressants (such as tricyclic drugs) and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms.
  • For adults with type 2 diabetes who have unexplained bladder-emptying problems, investigate the possibility of autonomic neuropathy affecting the bladder.
  • In managing autonomic neuropathy symptoms, include specific interventions indicated by the manifestations (for example, for abnormal sweating or nocturnal diarrhoea).

Diabetic Foot Problems

Chronic Kidney Disease

  • For adults with chronic kidney disease (CKD) and type 2 diabetes, offer an angiotensin receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor (titrated to the highest licensed dose that the person can tolerate) if albumin-to-creatinine ratio (ACR) is 3 mg/mmol or more, as recommended in the section on pharmacotherapy for CKD in adults, children, and young people with related persistent proteinuria in the NICE guideline on chronic kidney disease.
  • For adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate), offer an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if: 
    • ACR is over 30 mg/mmol and  
    • they meet the criteria in the marketing authorisation (including relevant estimated glomerular filtration rate [eGFR] thresholds).

      In November 2021, not all SGLT2 inhibitors were licensed for this indication. See NICE's information on prescribing medicines. 
       
  • For adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate), consider an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if: 
    • ACR is between 3 and 30 mg/mmol and
    • they meet the criteria in the marketing authorisation (including relevant eGFR thresholds).

      In November 2021, not all SGLT2 inhibitors were licensed for this indication. See NICE's information on prescribing medicines.
       
  • For further guidance on managing kidney disease in adults with type 2 diabetes, see the NICE guideline on chronic kidney disease.

Erectile Dysfunction

  • Offer men with type 2 diabetes the opportunity to discuss erectile dysfunction as part of their annual review.
  • Assess, educate and support men with type 2 diabetes who have problematic erectile dysfunction, addressing contributory factors such as cardiovascular disease as well as possible treatment options.
  • Consider a phosphodiesterase-5 inhibitor to treat problematic erectile dysfunction in men with type 2 diabetes. Initially choose the drug with the lowest acquisition cost and take into account any contraindications.
  • After discussion, refer men with type 2 diabetes to a service offering other medical, surgical or psychological management of erectile dysfunction if treatment (including a phosphodiesterase-5 inhibitor, as appropriate) has been unsuccessful.

Eye Disease

  • When adults are diagnosed with type 2 diabetes, refer them immediately to the local eye screening service.
  • Encourage adults to attend eye screening, and explain that it will help them to keep their eyes healthy and help to prevent problems with their vision. Explain that the screening service is effective at identifying problems so that they can be treated early.
  • Arrange emergency review by an ophthalmologist for:
    • sudden loss of vision
    • rubeosis iridis
    • pre-retinal or vitreous haemorrhage
    • retinal detachment.
  • Refer to an ophthalmologist in accordance with the UK National Screening Committee criteria and timelines for any large sudden unexplained drop in visual acuity. 

References

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