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    Patient education.

    Offer structured education to adults with type 2 diabetes and/or their family members or carers (as appropriate) at and around 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 includes the following components:

    • It is evidence-based, and suits the needs of the person
    • It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self?manage diabetes.
    • It has a structured curriculum that is theory?driven, evidence?based and resource?effective, has supporting materials, and is written down.
    • It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme.
    • It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.
    • The outcomes are audited regularly.

    Dietary advice

    Integrate dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification, such as increasing physical activity and losing weight.

    Blood pressure management

    Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage).

    Monitor blood pressure every 1–2 months, and intensify therapy if the person is already on antihypertensive drug treatment, until the blood pressure is consistently below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage).

    Blood glucose management

    Involve adults with type 2 diabetes in decisions about their individual HbA1c target. Encourage them to achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life.

    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.

    Do not routinely offer self?monitoring of 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. For more information, see the NICE guideline on diabetes in pregnancy. [new 2015]

    Drug treatment

    Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes.

    In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, consider initial drug treatment with:

    • a dipeptidyl peptidase?4 (DPP?4) inhibitor or
    • pioglitazone or
    • a sulfonylurea.

    Be aware that, if metformin is contraindicated or not tolerated, repaglinide is both clinically effective and cost effective in adults with type 2 diabetes.
    However, discuss with any person for whom repaglinide is being considered, that there is no licensed non?metformin?based combination containing repaglinide that can be offered at first intensification.

    When prescribing pioglitazone, exercise particular caution if the person is at high risk of the adverse effects of the drug.
    Pioglitazone is associated with an increased risk of heart failure, bladder cancer and bone fracture. Known risk factors for these conditions, including increased age, should be carefully evaluated before treatment: see the manufacturers’ summaries of product characteristics for details.
    UK guidance advises that ‘prescribers should review the safety and efficacy of pioglitazone in individuals after 3–6 months of treatment to ensure that only patients who are deriving benefit continue to be treated’.

    to be continued.

    G Mohan.

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