Type 2 Diabetes Cardiovascular Renal Metabolic Review Checklist

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

Identifying People at High Risk of Prediabetes

Subclinical Hypothyroidism

Extra-Glycaemic Indications of SGLT2 Inhibitors

Diagnosis and Classification of Diabetes

Comparison of ADA/EASD and NICE Recommendations on ManagingType 2 Diabetes

Management of Hyperglycaemia in Type 2 Diabetes and CKD

What Next After Metformin?

September 2023:

• new recommendation added to identify people at high risk of T2D (see Lifestyle Considerations section)
• the recommendation for people with T2D and CKD who have persistent albuminuria has been adjusted to ACR >3 (see Kidneys section), and a further reference (reference 8) added
• inclisiran has been added as a further combination lipid-lowering therapy (see Lipids section)
• all references to non-alcoholic fatty liver disease have been updated to metabolic dysfunction-associated steatotic liver disease.

• new recommendation to consider the addition of finerenone to reduce the risk of adverse kidney and CV outcomes in people with T2D and CKD who have persistent albuminuria despite use of maximally tolerated ACEi/ARB and SGLT2i (see Kidneys section)
• new recommendation to consider icosapent ethyl in patients with established CVD (secondary prevention) and on statins with fasting TG ≥1.7 mmol/l and LDL-C between 1.04 and ≤2.60 mmol/l (see Lipids section)
• new statement on the impact of lifestyle changes on grade 1 hypertension (see Blood Pressure section).

• Identify people at high risk of T2D
• Assess weight (e.g. BMI or WHR) and discuss individualised weight loss goals as appropriate. Remember to ethnically adjust these goals where indicated^[1]
• Discuss the importance of 24-hour physical behaviours for T2D^[2]
  • sitting/breaking up prolonged sitting
  • sweating
  • strengthening
  • sleep
  • stepping
• Strive for remission of T2D if possible,^[3] irrespective of weight.^[4] Weight loss of 5–10% confers metabolic improvement; weight loss of 10–15% or more can have a disease-modifying effect and lead to remission of T2D^[2]

• Review the person’s current HbA_1c and trend, and consider other factors when individualising HbA_1c goals, e.g.:
  • risks potentially associated with hypoglycaemia and other drug adverse effects
  • life expectancy
  • comorbidities
  • established vascular complications
  • patient preference, resources, and support systems^[5]
• See the expert consensus statement on diabetes and frailty for individualising management in older adults and/or adults with frailty and T2D

• Individualise HbA_1c targets in people with diabetic kidney disease
  • be aware that all SGLT2is have negligible glucose-lowering effect once eGFR falls below 45 ml/min, so consider adding in an additional glucose-lowering medication such as a GLP-1 RA
• If eGFR <60 ml/min/1.73 m² or clinically significant proteinuria (ACR ≥3 mg/mmol) and on maximally tolerated dose of ACEi/ARB: consider adding SGLT2i with renal protective benefits^[2] irrespective of HbA_1c
  • see the Primary Care Hack, Extra-Glycaemic Indications of SGLT2 Inhibitors
• In people with T2D and CKD who have persistent albuminuria (ACR >3) despite use of maximally tolerated ACEi/ARB and SGLT2i, consider adding finerenone to reduce the risk of adverse kidney and CV outcomes^{[6] [7] [8]}
• If CKD present, offer atorvastatin 20 mg for primary or secondary prevention of CVD^[9]
• Offer aspirin or clopidogrel to adults with CKD for the secondary prevention of CVD,^[10] but be aware of the risk of bleeding
• Consider referral as per NICE criteria, or if 5-year risk of requiring renal replacement therapy is >5% (measured using the Four-Variable Kidney Failure Risk Equation)

• For grade 1 hypertension (people with a clinic SBP 140–159 mmHg and/or a clinic DBP 90–99 mmHg), effective lifestyle changes may delay or prevent the need for pharmacological treatment
  • for information on effective lifestyle changes, see the Primary Care Hack, Lifestyle Changes for Managing Hypertension
• First instance: aim for a HBPM average target of <135/85 mmHg (<140/90 mmHg clinic target) in all people^[11] 
• Provided treatment is well tolerated: then aim for HBPM average of 125/75 mmHg (130/80 mmHg clinic target) or lower in most people^[11]
• For adults aged >80 years: consider a clinic BP target of <150/90 mmHg^[12]
• For people living with T2D: start drug treatment with an ACEi/ARB,^[12] irrespective of age or ethnic background 
• Measure sitting and standing BP in people with hypertension and T2D.^[12] In those with a significant postural drop in BP (i.e., ≥20 mmHg systolic and/or ≥10 mm Hg diastolic that occurs on standing^[13]), treat to a BP target based on the standing BP

• LDL-C targets for people living with T2D:^[15]
  • moderate risk: <2.6 mmol/l
  • high risk: ≥50% reduction from baseline and <1.8 mmol/l
  • very high risk: ≥50% reduction from baseline and <1.4 mmol/l
• Patient’s QRISK3 is ≥10%: offer atorvastatin 20 mg for primary prevention of CVD^{[9] [16]}
• If LDL-C targets are not achieved on maximally tolerated dose statin, consider combination lipid-lowering therapy e.g., add in ezetimibe, bempedoic acid, PCSK9 inhibitor,^[15] or inclisiran
• Consider icosapent ethyl if the individual has established CVD (secondary prevention) and on statins with fasting TG ≥1.7 mmol/l and LDL-C between 1.04 and ≤2.60 mmol/l^{[16] [17]}
• For secondary prevention of CVD, offer atorvastatin 80 mg^[15]   
   

• Noninvasive tests for liver fibrosis risk may be advisable due to the strong association of T2D with MASLD^{[18] [19] [20]}
• Consider FIB-4 test to assess for underlying fibrosis risk in people aged 35–65 years
• If identified as intermediate or high risk, consider referral to secondary care gastroenterology for transient elastography (FibroScan)
• Strongly encourage and facilitate weight loss where possible: weight loss 3–5% reduces hepatic steatosis, ≥5–7% can lead to resolution of NASH, and ≥10% improves hepatic fibrosis^[21]
• There is emerging evidence for the benefits of metabolic surgery and GLP-1 RAs, and pioglitazone^[2] for MASLD

• Consider presence of:
  • CVD or high risk of CVD:^{[2] [22]}
    • ASCVD (i.e. IHD/TIA/stroke/PVD): if present, offer early combination therapy with metformin and an SGLT2i, irrespective of HbA_1c^[22] 
    • all subtypes of HF: if present, offer early combination therapy with metformin and an SGLT2i, irrespective of HbA_1c^[22]
    • QRISK3 ≥10% and age >40 years, or presence of hypertension, dyslipidaemia, smoking, obesity, or family history (in a first-degree relative) of premature cardiovascular disease: consider early combination therapy with metformin and an SGLT2i, irrespective of HbA_1c^[22]
  • CKD and proteinuria^{[2] [22]} (see Kidney section)
  • obesity:^{[2] [22]} both SGLT2i and GLP-1 RA can facilitate weight loss in people living with T2D
  • retinopathy:^[22] be aware of the possibility of worsening of pre-existing retinopathy if HbA_1c is rapidly lowered
  • OSAHS; these conditions are commonly associated with T2D.^{[2] [23]} Consider using the Epworth sleepiness scale and the STOP–BANG questionnaire to exclude underlying OSAHS
• Educate women of childbearing age that many medications (e.g. ACEis, ARBs, statins, SGLT2is, and GLP-1 RAs) are contraindicated in pregnancy, and counsel them regarding contraception.^{[24] [25]} If planning pregnancy, refer to pre-pregnancy services
• Consider age, functional and frailty status, occupation, literacy level, and other social determinants of health during shared decision making^{[2] [10 [22]}

• Discuss adherence and if necessary explore barriers/preferences^{[2] [22] [25]}
• Review history of hypoglycaemia/hypoglycaemia awareness, DVLA adherence, and CBG monitoring where appropriate, and consider CGM in all people with T2D on insulin^{[2] [22]}
• Sick-day guidance^{[24] [25]}
  • for people with T2D on insulin
  • review the SADMANS mnemonic. Consider temporarily pausing these drugs during any significant intercurrent illness, but remind individuals to restart once they are eating and drinking normally and recovered from their illness
• SGLT2i or GLP-1 RA commenced:
  • consider reduction in SU or insulin dose. If on insulin, consider cautiously reducing insulin dose, increase CBG monitoring, and contact DSN as required^{[22] [26] [27]}
  • consider adjustment of any dose of diuretic when introducing an SGLT2i^{[24] [28] [29]}
• Ensure appropriate/optimal prescribing; consider de-intensifying in the context of functional dependence and frailty^[30]

• DSMES (e.g. DESMOND or X-Pert)
• Consider any locally available physical activity referral pathway
• Regular retinopathy screening
• Regular foot screening
• Consider secondary care as required, e.g., diagnostic uncertainty or treatment option advice
• Consider dietician referral, and psychological counselling for diabetes distress

• Code identified conditions as ‘priority 1’
• Do not code ‘diabetes resolved’; instead, code ‘diabetes in remission’

• Goal setting—Diabetes UK information prescriptions can help to facilitate goal setting, information sharing, and care planning
• Set a defined timescale for follow up and consider regular monitoring as clinically indicated
• Regular monitoring of weight, BP, HbA_1c, renal function (both eGFR and urinary ACR), and lipid profile as clinically indicated (at least annually).