Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
The management of a patient with newly diagnosed type 2 diabetes mellitus and concurrent hypertension should adopt an individualized and patient-centred approach, tailored to their specific needs and circumstances [1, 2, NICE, 2020a]. This approach emphasizes shared decision-making and empowering the person for self-care [1, 2, Cosentino, 2020].
- Education and Self-Management: It is crucial to refer the patient to a structured education programme, such as DESMOND or an equivalent, to provide them with the necessary knowledge and skills for self-management [1, 2, NICE, 2020a]. These programmes have been shown to improve blood glucose control, clinical outcomes, and reduce hospital admissions and mortality risk [1, 2, Davies, 2018].
- Lifestyle Modifications: Offer comprehensive lifestyle advice, including dietary guidance and encouragement for increased physical activity NICE NG28. Being overweight or obese is a primary contributing factor to type 2 diabetes NICE. Lifestyle interventions can significantly reduce the progression to type 2 diabetes in individuals with impaired glucose tolerance NICE.
- Blood Glucose Management (Type 2 Diabetes):
- HbA1c Targets: Discuss and agree upon an individual HbA1c target with the patient NICE NG28. For adults managed by lifestyle and diet alone, or with a single drug not associated with hypoglycaemia, aim for an HbA1c level of 48 mmol/mol (6.5%) NICE NG28. If the patient is on a drug associated with hypoglycaemia, the target should be 53 mmol/mol (7.0%) NICE NG28. These targets should be individualized based on the person's preferences, risk of adverse effects, frailty, and co-morbid conditions [1, 2, Davies, 2018].
- HbA1c Monitoring: Measure HbA1c levels every 3 to 6 months until stable on unchanging therapy, then every 6 months once stable NICE NG28.
- First-line Drug Treatment: Offer standard-release metformin as the first-line treatment, unless it is contraindicated NICE CKS,NICE CKS.
- Self-monitoring of Blood Glucose: Self-monitoring of blood glucose levels is generally not beneficial for people with type 2 diabetes, except for specific groups such as those using insulin therapy [1, 2, NICE, 2020a]. Short-term self-monitoring may be considered when starting corticosteroid treatment NICE CKS,NICE CKS.
- Hypertension Management:
- Blood Pressure Targets: The diagnosis, treatment, and monitoring of hypertension are broadly similar for people with type 2 diabetes as for other individuals NICE NG28. For people under 80 years old with hypertension (with or without type 2 diabetes), the clinic blood pressure target is below 140/90 mmHg NICE NG136. For those aged 80 and over, the target is below 150/90 mmHg NICE NG136. If the patient has chronic kidney disease with an albumin to creatinine ratio of 70 mg/mmol or more, the target is below 130/80 mmHg NICE NG136.
- Monitoring: Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment NICE NG136. It is important to check for postural hypotension in people with type 2 diabetes NICE NG136. If the patient chooses to self-monitor their blood pressure at home (HBPM), provide training and advice on its use NICE NG136.
- Antiplatelet Therapy: Do not offer antiplatelet therapy (aspirin or clopidogrel) to adults with type 2 diabetes who do not have established cardiovascular disease NICE NG28.