Identifying People at High Risk of Type 2 Diabetes

Hyponatraemia

Hypernatraemia

Interpreting Iron Studies

Lifestyle Changes for Managing Hypertension

DOAC Dosing for Stroke Prevention in Nonvalvular AF and Renal Impairment

Identification and Management of People with MASLD and MASH

Subclinical Hypothyroidism

Extra-Glycaemic Indications of SGLT2 Inhibitors

Diagnosis and Classification of Diabetes

Type 2 Diabetes Cardiovascular Renal Metabolic Review Checklist

Comparison of ADA/EASD and NICE Recommendations on Managing Type 2 Diabetes

Management of Hyperglycaemia in Type 2 Diabetes and CKD

What Next After Metformin?

• Prediabetes refers to raised blood glucose levels above normal but not above the diagnostic threshold for type 2 diabetes (T2D). HbA_1c values of 42–47 mmol/mol indicate prediabetes^[1] and a single test is sufficient. People living with prediabetes have an increased risk of developing T2D
• Depending on what test is used, prediabetes can also be referred to as:^[2]
  • non-diabetic hyperglycaemia (HbA_1c 42–47 mmol/mol^[3])
  • impaired fasting glucose (fasting plasma glucose [FPG] ≥6.1 and <6.9 mmol/l^[4])
  • impaired glucose tolerance (2-hour oral glucose tolerance test ≥7.8 and <11.1 mmol/l^[4])
• Prediabetes is associated with an increased risk of all-cause mortality and cardiovascular disease (CVD) in the general population and in those with atherosclerotic CVD.^[5] This has implications for the screening and management of prediabetes in the primary and secondary prevention of CVD^[5]
• Prediabetes is more than just dysglycaemia. A recent prospective cohort study found that reversion to normoglycaemia in those with prediabetes was only associated with lower risks of death and a longer life expectancy when accompanied by significant lifestyle change such as high levels of physical activity, not smoking, and maintaining a healthy bodyweight.^[6]

1. A risk assessment should be offered using a validated computer-based risk assessment tool, which can use routinely available data from individuals’ electronic health records such as QDiabetes-2018
2. For those with high-risk scores for developing T2D (e.g., QDiabetes-2018 score ≥10%), a blood test for HbA_1c should be offered

Gestational Diabetes

• Women with a history of gestational diabetes mellitus (GDM) are almost 10 times more likely to develop T2D over their lifetime than women without a history of GDM^[7]
• For women previously diagnosed with GDM and whose blood glucose levels return to normal after birth, NICE recommends:^[8]
  • lifestyle advice (including weight management, diet, and exercise)
  • offer a FPG 6–13 weeks after delivery to exclude T2D (HbA_1c should not be used until 3 months postpartum). Practically, this can be part of the 6-week postnatal check
    • if FPG <6.0 mmol/l, there is a low probability of T2D. Lifestyle advice should be reinforced and ensure under recall for lifelong annual HbA_1c to check for progression to T2D
    • if FPG 6.0–6.9 mmol/l, the individual is at high risk of developing T2D and the Matching Interventions to Risk flowchart should be followed
    • if FPG ≥7.0 mmol/l, a diagnosis of T2D is likely, and Matching Interventions to Risk flowchart should be followed.

Polycystic Ovary Syndrome

• Women living with polycystic ovary syndrome (PCOS) are 1.4 times more likely to develop T2D over their lifetime than women without PCOS^[3]
• This increased risk is independent of baseline bodyweight;^[9] NICE recommends assessing glycaemic status with an HbA_1c blood test at baseline in all women living with PCOS. Thereafter, glycaemic assessment should take place every 1–3 years lifelong, depending on the presence of other risk factors for developing T2D.^[10]

People Living with Severe Mental Illness

• People living with severe mental illness (SMI) are 1.3 times more likely to develop T2D over their lifetime than people without SMI^[3]
• The Lester UK adaptation: positive cardiometabolic health resource 2023 update gives recommendations relating to monitoring physical health in people living with SMI such as psychosis and schizophrenia.^[11] The aim of this resource is to help reduce the health inequality of a 15–20-year mortality gap in people living with SMI^[12]
• For all people in the ‘red zone’ as depicted in the Lester UK adaptation: positive cardiometabolic health resource intervention framework for people experiencing psychosis and schizophrenia, including those with HbA_1c ≥42 mmol/mol: don’t just screen, intervene!
• Care should always be person-centred, tailoring discussion to the needs of the person to enable shared decision-making. Refer for investigation, diagnosis, and treatment as appropriate
• For those at high risk of T2D (HbA_1c 42–47 mmol/mol), offer referral to an evidence-based lifestyle change programme. If ineffective, offer metformin modified release if safe and appropriate. Aim for HbA_1c <42 mmol/mol.

Metformin

• NICE recommends we use our clinical judgement on whether (and when) to offer metformin to support lifestyle changes in people at risk of T2D with rising HbA_1c blood tests. Consider metformin if:^[4]
  • HbA_1c continues to rise despite participation in an intensive lifestyle change programme
  • the individual is unable to participate in a lifestyle change programme, particularly if BMI is >35 kg/m²
• If commencing metformin, start low and go slow, e.g. 500 mg once daily and increase gradually as tolerated to 2000 mg daily. If the individual is intolerant of standard-release metformin, consider using modified-release metformin^[4]
• Prescribe metformin for 6–12 months initially. Check HbA_1c at 3-month intervals and stop metformin if no benefit is seen.^[4]

• By making changes to diet, increasing physical activity and losing weight, around half of cases of T2D can be prevented or delayed^[13]
• Review co-existing risk factors such as blood pressure, lipids, and smoking status.

For Patients

• Diabetes UK: Prediabetes
• Diabetes UK: Weight loss and diabetes
• Diabetes UK: Type 2 diabetes—know your risk
• QDiabetes-2018risk calculator
• Diabetes Research Centre: Could you have type 2 diabetes?

For Healthcare Professionals

• Diabetes UK: Information prescriptions for healthcare professionals
• UK Chief Medical Officers’ physical activity guidelines
• Gardner M, Wang J, Hazlehurt J et al. Risk of progression from prediabetes to type 2 diabetes in a large UK adult cohort. Diabet Med 2023; 40: e14996
• Babysteps online programme for GDM.