Introduction

Advice

The NICE clinical guideline on the management of type 2 diabetes states that the management of type 2 diabetes is complex. It requires an individualised, multifactorial approach that addresses blood pressure, blood lipids, and lifestyle issues (for example, smoking cessation, exercise, losing weight and a healthy diet). Controlling blood glucose requires a careful balance between the intensity of the treatment regimen and avoiding hypoglycaemia. The NICE clinical guideline recommends that patients should be involved in setting their individualised HbA_1c target level, which may be above the general target of 48 mmol/mol (6.5%). The guideline also recommends that pursuing highly intensive management to HbA_1c levels below 48 mmol/mol (6.5%) should be avoided.

Clinical trial evidence suggests there are small absolute benefits for intensive blood glucose control compared with conventional control in people with type 2 diabetes on some macrovascular outcomes. Intensive control has been shown to reduce coronary heart disease, but the evidence is less clear for the benefits on stroke, death from cardiovascular disease or death from all causes. This needs to be balanced against the increased risk of severe hypoglycaemia with intensive blood glucose control. Studies have also shown a reduction in certain microvascular events with intensive blood glucose control. However, these results have been inconsistent, and some end points were disease-oriented surrogate outcomes rather than patient-oriented clinical outcomes. See the MeReC Bulletin on type 2 diabetes (March 2012), the type 2 diabetes key therapeutic topic and the NICE pathway on diabetes for more information. See also the Clinical Knowledge Summary on type 2 diabetes for a general overview of prescribing considerations.