Type 2 diabetes - priorities and targets

Published in MedicineWise News

Date published: About this date

Clinical content may change after this date. This information is not intended as a substitute for medical advice from a qualified health professional. Health professionals should rely on their own expertise and enquiries when providing medical advice or treatment.

Key messages

  • 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).2

A. 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:

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

Blood pressure
≤ 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.26

B. 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

Table 1: Some recommended HbA1c targetsC for people with type 2 diabetes26

Clinical condition
HbA1c mmol/mol (%)
Diabetes of recent onset and no clinical cardiovascular disease
  • requiring lifestyle modification with or without metformin
  • requiring glucose-lowering drugs other than metformin or insulin
  • requiring insulin

≤ 42 ( ≤ 6.0)C
≤ 48 (≤ 6.5)C
≤ 53 (≤ 7.0)C

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)
C. HbA1c targets must be balanced against the risk of severe hypoglycaemia, especially for older people.
D. In an older adult long-standing might be considered to be > 10 to 20 years, but for a person who develops type 2 diabetes at a young age this may be considerably longer.

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
Drug class
Dual therapy with metformin or a sulfonylureaE Triple therapy with metformin and a sulfonylurea
DPP-4 inhibitors

saxagliptin X
sitagliptin X
vildagliptin X

rosiglitazone X
Alpha-glucodase inhibitors

GLP-1 agonists

E. Only where either metformin or a sulfonylurea is contraindicated or not tolerated; acarbose does not have this restriction.
Expert reviewers

Dr Joey Kaye Director of Diabetes Services Sir Charles Gairdner Hospital, Nedlands, WA.

Dr Pat Phillips Endocrinologist Queen Elizabeth Specialist Centre Woodville, SA.

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