Type 2 diabetes - priorities and targets
Published in MedicineWise News
Date published: About this date
- Address blood pressure and lipids as a priority in people with type 2 diabetes
- Individualise blood glucose targets based on patient factors and duration of disease
- When intensifying glycaemic therapy, consider the effectiveness of glucose-lowering medicines in reducing diabetes-related complications and mortality
Address blood pressure and lipids as a priority
Type 2 diabetes is progressive and requires long-term management and regular monitoring of multiple cardiovascular and microvascular risk factors.1
Statins and antihypertensives reduce rates of coronary events, stroke and death in people with cardiovascular disease and in those otherwise at high risk of cardiovascular events.2-4 People with or without diabetes, regardless of lipid or blood pressure levels gain similar benefits.A,3-6 In the short-term (3–5 years), these treatments are likely to reduce cardiovascular risk more than improvements to blood glucose control for people with type 2 diabetes.7
Assess cardiovascular risk to guide treatment
A formal cardiovascular risk assessment will help identify people without known cardiovascular disease who are at increased risk of a cardiovascular event.2 Assess absolute cardiovascular risk if a person with diabetes is aged 45 years and older (≥ 35 years for Aboriginal and Torres Strait Islander peoples).2 Consider all risk factors including modifiable (e.g. smoking status, waist circumference) and non-modifiable (e.g. ethnicity) to guide lifestyle changes and, if needed, drug therapy.2
Assume a high cardiovascular risk if the person has a known high-risk condition (Box 1).2 Otherwise, estimate an individual’s risk of a cardiovascular event in the next 5 years using a risk tool (go to our Cardiovascular disease risk tools page for links). Bear in mind that these tools estimate the minimum cardiovascular risk for people with diabetes; categorise risk as low (< 10%), moderate (10% to 15%) or high (> 15%).2
Base treatment on cardiovascular risk
Start statin and antihypertensive treatment together with lifestyle changes for people with diabetes who are at high cardiovascular risk.2 (Note: patients with established cardiovascular disease are already at high risk.8,9) People assessed at moderate cardiovascular risk, according to the risk calculator, who have certain additional risk markers should be considered to be at high risk (Box 2).2A. Uncertain benefit with antihypertensive drug therapy if BP < 110/70 mm Hg.4
Box 1: Known high-risk conditions2
- Diabetes mellitus and age 60 years or with microalbuminuria
- Moderate or severe chronic kidney disease (persistent proteinuria or eGFR < 45 mL/min/1.73 m2)
- Familial hypercholesterolaemia
- Systolic blood pressure ≥ 180 mm Hg or diastolic blood pressure ≥ 110 mm Hg
- Serum total cholesterol > 7.5 mmol/L
Box 2: Additional risk markers to consider in moderate cardiovascular risk
- People of Aboriginal or Torres Strait Islander origin
- Populations where risk tools may underestimate risk (people of Southern Asian, Maori and Pacific Islander, or Middle Eastern origin)
- Persistent blood pressure > 160/100 mm Hg
- Family history of premature cardiovascular disease
Prescribe a 3–6 month trial of lifestyle changes before considering drug treatment for people with moderate absolute cardiovascular risk.2 For those at low cardiovascular risk, lifestyle changes with regular assessment of cardiovascular risk are the priority.2 Antihypertensive drug therapy should be considered if blood pressure is persistently ≥ 160/100 mm Hg in any patient.2
Offer patients support to improve adherence
Prescribing of statins and antihypertensives has increased for people with diabetes, but many do not persist with treatment.10 After 2 years, only 2 in 3 people (with or without diabetes) are still taking their statin and less than 4 in 5, their ACE inhibitor or angiotensin II-receptor antagonist.11 Younger patients (< 65 years) with type 2 diabetes and people with co-morbidities may be more likely to stop taking these drugs, while socioeconomic disadvantage is a predictor of poor adherence to statins.11,12
Regularly ask patients if they have missed any doses.13 If a patient has difficulty remembering doses, consider:
- reducing the number of daily doses
- using a multi-compartment medicine container
- setting up automatic reminders (e.g. NPS iPhone Medicines List app).13-15
Persistence with statins may be worse than with glucose-lowering medicines because people are less convinced of the benefits.12,16,17 Inform patients that statins and/or antihypertensives:
- are probably more effective than glucose-lowering drugs in reducing their risk of heart attack and stroke7
- need to be taken continuously to be effective — benefits diminish if control of blood pressure or cholesterol is lost.18,19
If side effects are a problem check for drug interactions, and consider adjusting the dose or switching to another medicine.13
Reserve fenofibrate for elevated triglyceride levels
For people with diabetes but no cardiovascular disease, consider fenofibrate if triglyceride levels remain elevated despite adequate glycaemic control, lifestyle changes and statin therapy; also take into account their absolute cardiovascular risk.2 For people with diabetes and cardiovascular disease, consider fenofibrate if triglycerides are > 2.3 mmol/L and HDL cholesterol < 1 mmol/L.2
In the ACCORD study, fenofibrate did not reduce the risk of major cardiovascular events in people with diabetes, but there was a possible benefit for those with high triglyceride and low HDL cholesterol levels.20
Use targets as a guide
The goal of blood pressure and cholesterol treatments is to reduce an individual’s overall cardiovascular risk.2 Aim towards blood pressure and lipid targets but recognise that drug-related risks increase as therapy is intensified.21,22 Assess the benefits and harms before intensifying an individual’s treatment (Box 3).2
People at highest risk of a cardiovascular event, such as those with established cardiovascular disease, are likely to achieve the greatest reduction in absolute cardiovascular risk from statins and antihypertensives.23 Intensive blood pressure therapy is particularly important for those at increased risk of stroke.21
Box 3: Blood pressure and lipid targets for people with type 2 diabetes2
||≤ 130/80 mm Hg for everyone with diabetes, regardless of macro- or micro-albuminuria
|Total cholesterol||< 4 mmol/L|
|HDL cholesterol||≥ 1 mmol/L|
|LDL cholesterol||< 2 mmol/L|
|Non HDL cholesterol||< 2.5 mmol/L|
|Triglycerides||< 2 mmol/L|
Individualise blood glucose targets
Good control of blood glucose reduces the risk of microvascular events, but not everyone benefits from lowering blood glucose to near normal levels.24,25 Individualise HbA1c targets by taking into account patient and treatment factors (Table 1). Since diabetes is progressive, a patient’s HbA1c target may need to be modified over time.26
Consider tight control for people with recent diagnosis
Tight blood glucose control for people recently diagnosed with type 2 diabetes improves long-term cardiovascular outcomes.27 Consider treating to HbA1c ≤ 42 mmol/mol (≤ 6.0%)B (Table 1) for those with a recent diagnosis, long life expectancy and no known cardiovascular disease, taking into account the individual’s drug treatment and risk of hypoglycaemia.26,28
Use HbA1c target ≤ 53 mmol/mol (7%) for people with long-standing diabetes
In the short-term (3–5 years), tight glucose control has a limited effect on cardiovascular outcomes.30 For people with advanced diabetes (who are likely to be receiving multiple glucose-lowering medicines) this small benefit may be offset by the risk of hypoglycaemia.7,30 Avoid treating to a low HbA1c target (≤ 42 mmol/mol [≤ 6.0%]) in people with long-standing diabetes or with cardiovascular disease, as this has been associated with increased risk of death.25
Set higher targets for those at risk of hypoglycaemia
For people with recurrent severe hypoglycaemia or hypoglycaemia unawareness, severe hypoglycaemia may increase morbidity and mortality and outweighs the benefit of tighter glucose control.26
There is no need to have an HbA1c target for people with a limited life expectancy; management of hyperglycaemia should focus on improving symptoms and avoiding ketosis.26B. HbA1c levels are now reported in SI units of millimoles of HbA1c per mole of total haemoglobin (mmol/mol).29 See our online unit converter
||HbA1c mmol/mol (%)
Diabetes of recent onset and no clinical cardiovascular disease
|General target||≤ 53 (≤ 7.0)|
|Diabetes that is long-standing or clinical cardiovascular disease (any therapy)D||≤ 53 (≤ 7.0)|
|Recurrent severe hypoglycaemia or hypoglycaemia unawareness (any therapy)||≤ 64 (≤ 8.0)|
Consider the long-term outcomes of glucose-lowering medicines
The aims of managing hyperglycaemia are to prevent symptoms and to prevent or delay long-term diabetes complications.1,28 Diet, physical activity and weight control are the foundations of management, but eventually most people will also require drug treatment. Metformin, sulfonylureas and insulin are the only glucose-lowering medicines that have clear evidence for preventing diabetes complications and should be considered ahead of other medicines.28
Start drug therapy with metformin
Metformin reduces the risk of diabetic complications and mortality, is weight neutral, has a low risk of hypoglycaemia and improves lipid levels.31-33 Start therapy with metformin if a person with type 2 diabetes has inadequate glycaemic control after 3 months of lifestyle changes and there are no contraindications.1,34
Consider a sulfonylurea if metformin is inadequate or not tolerated
Sulfonylureas reduce microvascular complications and are as effective in lowering HbA1c as any of the newer oral glucose-lowering medicines, either as monotherapy or when combined with metformin.24,33,35 Consider adding a sulfonylurea to metformin if the HbA1c target is not met despite 3–6 months at the maximum tolerated dose of metformin.1,36-38 If metformin is contraindicated or not tolerated, consider sulfonylurea monotherapy ahead of other treatments.1,36,39
Don’t delay starting insulin
Consider adding a night-time dose of basal insulin to metformin monotherapy (or to metformin plus a sulfonylurea) if blood glucose remains above target.1,28 Insulin is highly effective at lowering HbA1c, reduces microvascular complications and has a well-established safety profile.24,37 See the RACGP’s Diabetes Management in General Practice: Guidelines for Type 2 Diabetes for a guide to starting insulin for people with type 2 diabetes.1
Take particular care with patient selection for newer drugs
Apart from insulin, there are a number of other glucose-lowering medicines that can be used as part of dual therapy if either metformin or a sulfonylurea is contraindicated or not tolerated (Table 2). Some can also be used as part of triple therapy if target HbA1c is not reached with metformin plus a sulfonylurea.28 None has robust evidence of improvements in vascular outcomes when used as monotherapy or in combination with metformin or a sulfonylurea.33
Assess the suitability of newer drugs for the individual, taking into account the patient’s HbA1c level, co-morbidities, risk of hypoglycaemia, importance of weight gain, patient preferences and the adverse effect profile of the drug.28 For more information, see Advantages and disadvantages of glucose-lowering drugs in NPS News August 2012). Type 2 diabetes is a progressive condition and most people will eventually require insulin.24
Table 2: PBS listings of newer glucose-lowering medicines
||Dual therapy with metformin or a sulfonylureaE||Triple therapy with metformin and a sulfonylurea
Dr Joey Kaye Director of Diabetes Services Sir Charles Gairdner Hospital, Nedlands, WA.
Dr Pat Phillips Endocrinologist Queen Elizabeth Specialist Centre Woodville, SA.
- Diabetes Australia. Diabetes management in general practice: guidelines for type 2 diabetes. 17th edition 2011/12. Diabetes Australia, RACGP, 2011. (accessed 22 June 2012).
- National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012. (accessed 22 June 2012).
- Kearney PM, Blackwell L, Collins R, et al. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Lancet 2008;371:117–25.
- Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009;338:b1665.
- Turnbull F, Neal B, Algert C, et al. Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch Int Med 2005;165:1410–9.
- Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360:7–22.
- Yudkin JS, Richter B, Gale EA. Intensified glucose lowering in type 2 diabetes: time for a reappraisal. Diabetologia 2010;53:2079–85.
- National Heart Foundation of Australia. Guide to management of hypertension 2008: Updated December 2010. (accessed 10 May 2012).
- Tonkin A, Barter P, Best J, et al. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Position statement on lipid management 2005. Heart Lung Circ 2005;14:275–91.
- Miller G, Valenti L. Type 2 diabetes. In: Britt H & Miller GC (eds). General practice in Australia, health priorities and policies 1998 to 2008. General practice series no. 24. Cat. no. GEP 24. Canberra: Australian Institute of Health and Welfare, 2009. (accessed 20 June 2012).
- Australian Institute of Health and Welfare. Medicines for cardiovascular health: are they used appropriately? Cardiovascular disease series no. 27. Cat. no. 36. Canberra: AIHW, 2007. (accessed December 2010).
- Yang Y, Thumula V, Pace PF, et al. Predictors of medication nonadherence among patients with diabetes in Medicare Part D programs: a retrospective cohort study. Clin Ther 2009;31:2178–88.
- National Institute for Health and Clinical Excellence. Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence (quick guidance). NICE clinical guideline. London: NICE, 2009. (accessed 20 June 2012).
- Schroeder K, Fahey T, Ebrahim S. Interventions for improving adherence to treatment in patients with high blood pressure in ambulatory settings. Cochrane Database Syst Rev 2004:CD004804.
- Schedlbauer A, Davies P, Fahey T. Interventions to improve adherence to lipid lowering medication. Cochrane Database Syst Rev 2010:CD004371.
- Zhang Q, Zhao C, Davies MJ, et al. Compliance and persistence with concomitant statin and oral antihyperglycemic therapy. Am J Manag Care 2011;17:746–52.
- Lamberts EJ, Nijpels G, Welschen LM, et al. Discontinuation of statins among patients with type 2 diabetes. Diabetes Metab Res Rev 2012;28:241–5.
- Holman RR, Paul SK, Bethel MA, et al. Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med 2008;359:1565–76.
- Daskalopoulou SS, Delaney JA, Filion KB, et al. Discontinuation of statin therapy following an acute myocardial infarction: a population-based study. Eur Heart J 2008;29:2083–91.
- Ginsberg HN, Elam MB, Lovato LC, et al. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med 2010;362:1563–74.
- Bangalore S, Kumar S, Lobach I, et al. Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials. Circulation 2011;123:2799–810.
- Josan K, Majumdar SR, McAlister FA. The efficacy and safety of intensive statin therapy: a meta-analysis of randomized trials. CMAJ 2008;178:576-84.
- Law MR, Wald NJ. Risk factor thresholds: their existence under scrutiny. BMJ 2002;324:1570–6.
- UKPDS Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837–53.
- Gerstein HC, Miller ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545–59.
- Cheung NW, Conn JJ, d'Emden MC, et al. Position statement of the Australian Diabetes Society: individualisation of glycated haemoglobin targets for adults with diabetes mellitus. Med J Aust 2009;191:339–44.
- Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577–89.
- Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes care 2012. (accessed 22 June 2012).
- Jones GR, Barker G, Goodall I, et al. Change of HbA1c reporting to the new SI units. Med J Aust 2011;195:45–6.
- Turnbull FM, Abraira C, Anderson RJ, et al. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia 2009;52:2288–98.
- UKPDS Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:854–65.
- Saenz A, Fernandez-Esteban I, Mataix A, et al. Metformin monotherapy for type 2 diabetes mellitus. Cochrane Database Syst Rev 2005:CD002966.
- Bennett WL, Maruthur NM, Singh S, et al. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Annals of Internal Medicine 2011;154:602–13.
- Australian Medicines Handbook. Adelaide, 2012.
- Karagiannis T, Paschos P, Paletas K, et al. Dipeptidyl peptidase-4 inhibitors for treatment of type 2 diabetes mellitus in the clinical setting: systematic review and meta-analysis. BMJ 2012;344:e1369.
- Colagiuri S, Dickinson S, Girgis S, et al. National evidence based guideline for blood glucose control in type 2 diabetes. Diabetes Australia and the NHMRC, Canberra 2009. (accessed 22 June 2012).
- Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycaemia in type 2 diabetes mellitus: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2009;52:17–30.
- Endocrinology Expert Group. Therapeutic Guidelines: Endocrinology. Version 4 ed. Melbourne: Therapeutic Guidelines Ltd, 2009.
- National Collaborating Centre for Chronic Conditions. Type 2 diabetes: the management of type 2 diabetes. London: National Institute for Health and Clinical Excellence; 2009. (NICE clinical guideline 87). (accessed 22 June 2012).