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Clinical Pathways - Diabetes Management


Glycaemic Control

(From NZ Guidelines Group & Primary Care Handbook 2012 - page 57 )

Notes

  1. Acarbose can also be used as a first line drug therapy, if tolerated.
  2. Medsafe is currently monitoring the safety of pioglitazone following reports of increased adverse effects. See Medsafe
    for latest updates. Special authority for pioglitazone may be sought if: i) patient has not achieved glycaemic control on maximum
    dose of metformin or sulphonylurea or where either or both are contraindicated or not tolerated; or ii) patient is on insulin.
  3. DPP-IV inhibitor may be an alternative agent if patient is at significant risk of hypoglycaemia or weight gain is a concern.
    At time of publication (2011), DPP-IV inhibitors are not subsidised.
  4. DPP-IV inhibitor and GLP-1 agonist are possible alternatives. GLP-1 agonists may be used if BMI >30 kg/m2 or there is a desire
    to lose weight. At time of publication (2011), neither DPP-IV inhibitors nor GLP-1 agonists are subsidised.

Management of Blood Pressure

(From NZ Guidelines Group & Primary Care Handbook 2012)

  • Target BP is < 130/80 for someone with diabetes
  • Hypertension should be treated aggressivly with lifestyle modification including dietary salt restriction and drug therapy.
  • Evidence suggests a blood pressure target <120 mm Hg may be harmful. Care should be taken to estimate likely treatment response for patients when BP approaches the target of <130 mm Hg.

Approach to Management

  • If hypertensive, intensive monthly follow-up and stepwise protocol adjustments to medication are advised until consistently below target.
  • BP should be reviewed at least 6 monthly once at target.
  • Refer to Appendix C for the recommended method of BP measurement.

ACE Inhibitor: angiotensin converting enzyme inhibitor
ARB: angiotensin 2 receptor blocker
CCB: calcium channel blocker

Note 1. Consider patient age. In younger people tighter control should be considered given their higher lifetime risk of diabetes-related complications.
Note 2. ACE inhibitor or ARB medication are contraindicated in pregnancy.


Preventing Complications

(From NZ Guidelines Group & Primary Care Handbook 2012)


Renal Complications

  • Patients with confirmed microalbuminuria should be treated with an ACE inhibitor or angiotensin 2 receptor blocker whether or not hypertension is present.
  • Mäori, Pacific Island and South Asian peoples are at higher risk of renal complications. More frequent monitoring of renal status is indicated.
  • Any evidence of renal disease based on decreasing eGFR should be treated with urgency.

Starting Insulin in Primary Care

(From NZ Guidelines Group & Primary Care Handbook 2012 - page 61 )

Notes to figure on initiation of insulin in primary care - pages 62-63 in Handbook

 

 

 

 


Waitemata DHB's Clinical Pathway - Treatment Algorithm for Management of Type 2 Diabetes

(Click on image to open pathways document - includes Starting on Insulin)

 


Patient Resources 

 

Links to Samoan version

Starting Insulin for Type 2 Diabetes

 

Links to online booklet

More resources in multiple languages

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Last updated on October 22, 2014