© IDF (Europe) 1999

Sections 8-14: Control of blood glucose, blood lipid, blood pressure and arterial risk factors

8 Assessing blood glucose, blood lipid, and blood pressure control
9 Providing nutritional advice
10 Physical exercise
11 Therapy for high blood glucose concentrations
12 Therapy for abnormal blood lipid concentrations
13 Therapy for raised blood pressure
14 Managing arterial risk factors including smoking

TYPE 2 DIABETES - 8 - VASCULAR RISK ASSESSMENT LEVELS

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8 ASSESSING BLOOD GLUCOSE, BLOOD LIPID, AND BLOOD PRESSURE CONTROL

( Blood glucose ) ( Blood lipids ) ( Blood pressure )

8.1 Using assessment levels to set targets

Use the assessment levels for glucose, lipids, and blood pressure :

• as an integral part of diabetes care - do not manage diabetes on symptoms alone
• to indicate need for further intervention
• as the basis for short-term and longer-term individualized targets
• as an educational tool to help the person with diabetes

Ask yourself the following at consultations :

• Is it possible for the individual to approach each target more closely,
  without a counter-balancing deterioration in quality of life?

Be concerned about targets :

• Failure to attempt to reach agreed targets is inadequate care,
  unless this would lead to deterioration in quality of life

8.2 Assessment of blood glucose, blood lipid, and blood pressure control

Measure :

• glycated haemoglobin 2-6 monthly
• the blood lipid profile ( total, LDL, and HDL cholesterol, and triglycerides ) 2-6 monthly if
  previously above assessment levels ( see below ), otherwise annually
• blood pressure at each consultation unless known to be below assessment levels

Use the assessment levels ( below )

to set individual blood glucose, blood lipid and blood pressure targets, depending on overall risk
and what it may be possible to achieve within a foreseeable time period

Modify individual targets at least yearly

in the light of past success, and if any change in clinical circumstances

( Top of 'Assessing diabetes control' )

8.3 Blood glucose control assessment levels

( Top of 'Assessing diabetes control' )

8.4 Blood lipid control assessment levels

8.5 Blood pressure control assessment level

( Top of 'Assessing diabetes control' )

TYPE 2 DIABETES - 8 - VASCULAR RISK ASSESSMENT LEVELS

TYPE 2 DIABETES - 9 - PROVIDING NUTRITIONAL ADVICE

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9 PROVIDING NUTRITIONAL ADVICE

9.1 Reviewing dietary management

Review dietary management regularly :

• Is healthy eating a normal part of life-style?
• Is calorie intake appropriate to desired body weight?
• Is alcohol intake moderate? Could it be exacerbating hypertension or hypertriglyceridaemia?
  Could it be contributing to early or late hypoglycaemia?
  Is this understood by the person with diabetes?
• Is money being spent unnecessarily on special 'diabetes' food products?
• Does calorie distribution reflect the patient's life-style and preferences, as well as glucose lowering therapy and regional eating habits?
• Do raised blood pressure or kidney damage suggest a benefit from special recommendations
  ( protein intake <0.8 g/kg, salt intake <6 g/day, respectively )?

Make recommendations and review eating :

• at diagnosis
• at each consultation if overweight or vascular risk factor control sub-optimal
• formally every other year as a routine, or more often as required
• on beginning insulin therapy
• on request

9.2 Healthy eating

Advise carbohydrate intake should be higher, and fat intake lower than that of most Europeans, but not different from recommendations for the population in general :

• Saturated fat : <10 % of calories
• Polyunsaturated fat : <10 % of calories
• Carbohydrate: : use foods containing soluble fibre in a carbohydrate rich diet
• Simple sugars : need not be rigorously excluded from the diet, but should be limited
• Protein : <15 % of calories
• Monounsaturated fat : use to maintain palatability and balance calorie intake
• Total calories : as required for normal body mass index
• Fresh fruit / vegetables : encouraged as part of meal-time calorie intake
• Alcohol : if desired, as part of total daily calorie intake

Individualize intake to match needs, preferences and culture

( Top of 'Nutrition' )

TYPE 2 DIABETES - 9 - PROVIDING NUTRITIONAL ADVICE

TYPE 2 DIABETES - 10 - PHYSICAL EXERCISE

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10 PHYSICAL EXERCISE

10.1 Assessment of physical activity

Review :

• activity at work, and in getting to and from the workplace
• physical activity practice and opportunities in domestic activities and hobbies
• the possibility of formal physical exercise on a regular basis
• Examples :
• brisk walking 30 min per day
• active swimming for 1 h three times a week

10.2 Management

Advise that physical exercise :

• can benefit insulin sensitivity, blood pressure, and blood lipid control
• should be taken at least every 2-3 days for optimum effect
• may increase the risk of acute and delayed hypoglycaemia

Manage physical exercise using :

• formal recording of levels of physical activity
• identification of new exercise opportunities ( see above ), and encouragement to develop these
• appropriate self-monitoring, additional carbohydrate, and dose adjustment
  of glucose lowering therapy for those using insulin or insulin secretagogues
• warnings :
• about delayed hypoglycaemia, especially with more prolonged, severe, or unusual exercise
  for those using insulin therapy
• that alcohol may exacerbate the risk of hypoglycaemia after exercise
• about risks of foot damage from exercise
• need to consider ischaemic heart disease in those beginning new exercise programmes

( Top of 'Physical exercise' )

TYPE 2 DIABETES - 10 - PHYSICAL EXERCISE

TYPE 2 DIABETES - 11 - GLUCOSE LOWERING THERAPY

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11 THERAPY FOR HIGH BLOOD GLUCOSE CONCENTRATIONS

11.1 Using oral glucose-lowering drugs

( For insulin therapy see below )

Begin oral agent therapy when :

• an adequate trial of life-style intervention / education has been given
• either ( usually ) :
• HbA_1c >6.5 %, fasting venous plasma glucose >6.0 mmol/l ( >=110 mg/dl )
• or ( occasionally ) if thin and no other arterial risk factor :
• HbA_1c >7.5 %, fasting venous plasma glucose >=7.0 mmol/l ( >125 mg/dl )

Use :

• metformin
• insulin secretagogues ( sulphonylureas and repaglinide )
• alpha-glucosidase inhibitors
• thiazolidinediones and related PPARgamma-agonists

Choice of agents

Metformin :

strong evidence base in the overweight, lowers LDL cholesterol, but gastro-intestinal side effects in some patients; dose titration may help tolerance

• contraindicated ( risk of lactic acidosis ) if renal impairment, overt liver disease,
  or severe cardiac failure; monitor renal function at least yearly

Sulphonylureas :

good evidence base, provided patient has useful islet B-cell function

• hypoglycaemia a significant problem :
  glibenclamide > glipizide = chlorpropamide > gliclazide > tolbutamide (some other agents lack data);
  avoid glibenclamide / chlorpropamide particularly if renal impairment or in the thin insulin-sensitive patient ( especially if elderly )

Repaglinide :

new rapid-acting insulin secretagogue; possible advantage in hypoglycaemia avoidance and control of post-prandial glucose excursions

Alpha-glucosidase inhibitors :

effective control of post-prandial hyperglycaemia, but poorly tolerated by many patients; dose titration may help tolerance

PPARgamma-agonists :

new agents, offering effective glucose-lowering particularly in combination with insulin and insulin secretagogues

• contraindicated if any history of liver disease, and require organized monitoring of
  liver function tests until hepatic safety assured

A number of new drugs are currently entering clinical practice; we anticipate the need to modify the above advice as the role of such drugs becomes better understood

( Top of 'Oral glucose-lowering drugs' )

11.2 Maintaining good blood glucose control with oral glucose-lowering drugs

Monitor ( see Clinical monitoring ) :

• dietary quality and quantity, physical exercise level
• HbA_1c ( or fasting venous plasma glucose ), and self-test results
• body weight
• other vascular risk factors ( blood lipids, blood pressure )

Adjust therapy :

• Increase dose of individual agent at each visit up to maximum tolerated / effective dose,
  if targets are not met
• Decrease dose of individual agent, if therapy-related problems arise, or if glucose control
  well into the non-diabetic range

Combination therapy

• Add another agent of therapy when maximum dose of current drugs reached
• Use triple therapy when control targets cannot be reached on maximum tolerated doses
  of two agents

( For combination therapy with insulin see below )

( Top of 'Oral glucose-lowering drugs' )

11.3 Insulin therapy in Type 2 diabetes

Begin when HbA1c has deteriorated to >7.5 % after maximum attention to dietary control and oral glucose-lowering therapy ( unless poor life-expectancy and asymptomatic )

• Arrange dietary review when starting insulin therapy
• Review ( or start ) self-monitoring of blood glucose before starting insulin
• Continue therapy with metformin / insulin secretagogues / PPARgamma-agonists

Use :

• NPH insulin at night with oral glucose-lowering drugs in people with good insulin secretory reserve
• pre-mixed insulin twice daily in the majority of people
• twice daily NPH insulin in people with high pre-breakfast blood glucose concentrations relative
  to their HbA_1c

Adjust therapy :

• frequently at first, using self-monitored results, until insulin dose is adequate to
  reach blood glucose targets, or hypoglycaemia becomes a risk
• Consider more intensive insulin regimens
• in the more active patient if control remains sub-optimal
• if control remains sub-optimal due to hypoglycaemia ( but not if due to insulin insensitivity )
• to assist achievement of more flexible life-styles

See Desktop Guide to Type 1 Diabetes, 1998

( Top of 'Glucose lowering therapy' )

TYPE 2 DIABETES - 11 - GLUCOSE LOWERING THERAPY

TYPE 2 DIABETES - 12 - LIPID LOWERING THERAPY

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12 THERAPY FOR ABNORMAL BLOOD LIPID CONCENTRATIONS

12.1 Using blood lipid lowering drugs

Monitor ( see Clinical monitoring ) :

• dietary quality and quantity ( including alcohol )
• physical exercise level
• body weight
• blood glucose control
• lipid profile including triglycerides and LDL cholesterol

Begin :

• Optimize blood glucose control as far as is possible
• Establish lipid profile before beginning a trial of therapy

Use :

• a statin if : LDL cholesterol >=3.0 mmol/l ( >=115 mg/dl )
  ( >4.0 mmol/l ( >155 mg/dl ) if low risk including thin elderly )
• a fibrate if : triglyceride >2.2 mmol/l ( >200 mg/dl )
  and LDL cholesterol <3.0 mmol/l ( <115 mg/dl )
• a fibrate first if triglyceride markedly elevated ( >6.8 mmol/l ( >600 mg/dl ) );
  check thyroid, renal, and liver function ( and apoE genotype if available );
  consider combination therapy with a statin if LDL cholesterol remains elevated
• combination therapy beginning with statin for high LDL cholesterol and triglyceride

Choice of agents

Statin :

choice will usually be determined by relative cost-effectiveness locally

Fibrates :

ciprofibrate and fenofibrate are probably more effective than bezafibrate in lowering triglycerides

Other drugs :

in general not recommended, unless severe hyperlipidaemia and intolerance to statins and/or fibrates

( Top of 'Lipid lowering therapy' )

TYPE 2 DIABETES - 12 - LIPID LOWERING THERAPY

TYPE 2 DIABETES - 13 - BLOOD PRESSURE LOWERING THERAPY

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13 THERAPY FOR RAISED BLOOD PRESSURE

13.1 Using anti-hypertensive drugs

Monitor ( see Clinical monitoring ) :

• dietary quality and quantity ( including alcohol ), physical exercise level, body weight
• sitting blood pressure ( after 5 min rest, 1st and 5th phase )
• Use :
• family doctor / occupational health services to obtain monthly records
• patient-held record card to provide cumulative record of progress
• self-monitoring devices if available

Use :

• single agent therapy at rising doses until target achieved ( or intolerance )
• multiple therapy if targets not reached on maximum doses of single agents
• once daily drug administration regimens

Available drug classes

ACE-inhibitors :

good evidence base in diabetes, advancing renal disease, cardiac failure

• monitor renal function / K+ ( risk of renal artery stenosis with arterial disease )

Beta-adrenergic blockers :

good evidence base in diabetes and useful where angina or previous myocardial infarction

• avoid combination with thiazides ( metabolic deterioration ), and if peripheral
  vascular disease. Ask about tiredness and impotence

Calcium channel antagonists :

some evidence base in diabetes and in advancing renal disease

• use only long-acting preparations
• fluid retention a problem with some agents ( avoid if history of foot ulceration )

Thiazides :

some evidence base in diabetes

• use low doses only and avoid combination with beta-adrenergic blockers ( metabolic
  deterioration ). Ask about impotence

Loop diuretics :

useful synergistic action with ACE-inhibitors

Alpha-adrenergic blockers :

effective blood pressure lowering and metabolically beneficial

• use only long-acting drugs ( postural hypotension )

Angiotensin II receptor blockers :

no special advantages

Choice of agents - summary

• Multiple therapy is often required; add loop diuretic to ACE-inhibitor, and avoid thiazides with
  beta-adrenergic blocker; otherwise most combinations neutral
• Many older and less expensive agents are as effective as newer agents
• If abnormal albumin excretion, particularly if progressive, begin with ACE-inhibitor, or calcium channel
  antagonist if ACE-inhibitor not tolerated
• If ischaemic heart disease, consider beta-adrenergic blocker first

( Top of 'Blood pressure lowering therapy' )

TYPE 2 DIABETES - 13 - BLOOD PRESSURE LOWERING THERAPY

TYPE 2 DIABETES - 14 - ARTERIAL RISK MANAGEMENT

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14 MANAGING ARTERIAL RISK FACTORS INCLUDING SMOKING

14.1 Integrated management of arterial risk

Review arterial risk factors :

• at diagnosis
• yearly
• more frequently if abnormal or treated

Define risk level as :

	Average risk :	any one arterial risk factor
or	High risk :	established disease or any two arterial risk factors
or	Very high risk :	established disease + any arterial risk factor
		or any three arterial risk factors

Manage as follows:

If	High risk :	manage blood glucose, blood lipids, blood pressure to assessment levels
If	Very high risk :	manage blood glucose, blood lipids, blood pressure to lowest possible risk levels
If	Smoking :	manage problem aggressively ( Smoking )

Educate people :

• about the risks of heart disease / stroke from the time of diagnosis
• about not smoking and smoking cessation programmes
• about healthy eating

Prescribe :

• a programme of regular physical exercise
• glucose, lipid, and blood pressure lowering therapy as indicated
• low-dose aspirin for those in the High risk or Very high risk categories
• selective beta-adrenergic blockers if known ischaemic heart disease

Consider :

• hormone replacement therapy post-menopausally ( if agreed )

Diagnose :

• silent myocardial ischaemia in higher risk patients

( Top of 'Arterial risk' )

14.2 Smoking target: Stop, or reduce to as low as possible

Identify smoking habits :

• at diagnosis / referral and Annual Review

Emphasize importance :

• at diagnosis and if critical events occur
• at every appropriate opportunity

Provide information on :

• health risks and benefits of stopping / reducing
• techniques for reducing tobacco consumption
• use of pharmacological substitutes
• formal smoking cessation programmes

( Top of 'Arterial risk' )

TYPE 2 DIABETES - 14 - ARTERIAL RISK MANAGEMENT

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