Type 2 diabetes: what's next after metformin?
With a range of blood glucose-lowering medicines on the market, it can be hard to decide what to prescribe for patients needing more than metformin.
For consumers, check out Medicines and type 2 diabetes
Key points
- Adherence is a critical issue to address with patients who are prescribed metformin.
- Choice of second- and third-line medicines for addition to metformin should be individualised, guided by each patient's clinical considerations and each medicine's characteristics.
- Usual second-line options are sodium-glucose linked transporter 2 (SGLT2) inhibitors, dipeptidyl peptidase 4 (DPP-4) inhibitors, sulfonylureas and glucagon-like peptide 1 (GLP-1) receptor agonists.
- Treatment algorithms reflect the complexity of treatment decisions but offer consistent guidance on a stepped/progressive approach to blood glucose control.
Quality improvement opportunities for patients with diabetes and CVD
The relationship between diabetes and increased risk of mortality from cardiovascular disease (CVD) is well established. What opportunities still remain in general practice to identify at risk patients and optimise their management?
NPS RADAR Insulin glargine 100 IU/mL injections: PBS listing changes
A new brand of insulin glargine has been listed to replace brands going off the market. Information for health professionals to support their patients with diabetes that may be affected by the changes.
Read the full article
Australian Prescriber: Second steps in managing type 2 diabetes
Dr Carolyn Petersons
Aust Prescr 2018;41:141-4
Metformin is still first choice for type 2 diabetes, but what comes next? In the October 2018 issue of Australian Prescriber, Dr Carolyn J Petersons sorts out the second steps in managing type 2 diabetes.
Episode 36 – Dhineli Perera interviews Dr Carolyn Petersons about the second- and third-line drugs for type 2 diabetes. After metformin, what comes next?
Empagliflozin indications extended
Empagliflozin is now TGA-approved for reducing cardiovascular deaths in patients with type 2 diabetes with established cardiovascular disease.
What is the evidence, and what does this mean in clinical practice?
NPS RADAR: Insulin glargine 300 IU/mL solution (Toujeo) for diabetes mellitus
Insulin glargine 300 IU/mL (Gla-300) solution is another option for adults with type 1 or type 2 diabetes requiring a long-acting basal insulin. Gla-300 is a concentrated formulation of the PBS-listed Gla-100.
Metabolic syndrome and diabetes: how much blame does sugar deserve?
An increasing number of journal articles and media stories are highlighting the potential role of dietary sugar, and particularly added fructose, as a major contributor to ill health, from cardiovascular disease to type 2 diabetes to metabolic syndrome.
Find out more about the evidence for the role of sugar in these conditions.
CPD options
Consolidate your knowledge about type 2 diabetes, brush up on current guidelines and practices and earn CPD points through our learning activities.
For GPs:
Webinar: CV risk in patients with type 2 diabetes and CVD: Getting to the heart of diabetes
Listen to our multidisciplinary panel of experts discuss the prevention of CV events in patients with both type 2 diabetes and CVD. Discussion covers:
- Evidence-based strategies to reduce CV risk for patients with diabetes and CVD
- Advice on how to individualise choice of blood glucose-lowering agents
- The latest Australian blood glucose treatment algorithm for type 2 diabetes
- An update on the latest CV outcome trial data and how this impacts your practice
Listen to the webinar on demand
This program was funded by Boehringer Ingelheim Pty Limited and Eli Lilly Australia Pty Limited and managed through VentureWise, a wholly owned commercial subsidiary of NPS MedicineWise. The program has been designed, developed and implemented by NPS MedicineWise with complete independence and editorial control and is based on best practice guidelines.
- Evidence-based strategies to reduce CV risk for patients with diabetes and CVD
- Advice on how to individualise choice of blood glucose-lowering agents
- The latest Australian blood glucose treatment algorithm for type 2 diabetes
- An update on the latest CV outcome trial data and how this impacts your practice
For your patients: Lifestyle and metformin decision aid
This decision aid is for people who have been diagnosed with type 2 diabetes, have tried lifestyle changes and are deciding whether to continue with lifestyle changes alone or start metformin. It can be used before a consultation to learn about the options, during the consultation to discuss and jointly decide on an option or at another time with discussion at a follow-up consultation.
Principles for pharmacological management of type 2 diabetes
Metformin is the usual first-choice medicine for people with type 2 diabetes and is used alongside lifestyle modifications such as changing diet and increasing physical activity.1-4 It is started either at diagnosis or after 2–3 months of lifestyle modifications depending on each patient’s clinical circumstances.1,3 Sulfonylureas may be used if metformin is contraindicated or cannot be tolerated.2
Guidelines recommend intensifying treatment if individualised HbA1c targets are not achieved.2 A second medicine is usually added if the patient’s target HbA1c levels have not been reached with a single medicine after 3 months of treatment.1-3
The choice of second- and third-line medicine should be individualised1,3 guided by:
- clinical considerations, such as presence or high risk of cardiovascular disease, heart failure, chronic kidney disease, hypoglycaemia
- medicine adverse effect profile
- contraindications, and
- cost.2
Other important considerations are PBS restrictions and patient preference.1
Usual second-line options are:
- sodium-glucose linked transporter 2 (SGLT2) inhibitors
- dipeptidyl peptidase 4 (DPP-4) inhibitors
- sulfonylureas and
- glucagon-like peptide 1 (GLP-1) receptor agonists.2
Before adding a second or third blood glucose-lowering medicine, other comorbidities or concurrent medications affecting blood glucose control should be reviewed, as well as lifestyle factors and adherence to treatment.2,4
Insulin is not usually considered until doctor and patient are selecting a third-line medicine1-3 although some patients may need to add or change to insulin sooner.1,2
Published clinical guidelines on managing type 2 diabetes
- The Royal Australian College of General Practitioners and Diabetes Australia. General practice management of type 2 diabetes 2016-18.
- National Vascular Disease Prevention Alliance: Guidelines for the management of absolute cardiovascular disease risk 2012.
- Baker IDI Heart and Diabetes Institute. National evidence-based guideline on secondary prevention of cardiovascular disease in type 2 diabetes (part of the guidelines on management of type 2 diabetes) 2015.
- International Diabetes Federation (IDF): Clinical Practice Guidelines.
- National Health and Medical Research Council, Diabetes Australia and The University of Sydney. National evidence based guideline for diagnosis, prevention and management of chronic kidney disease in type 2 diabetes 2009.
- National Health and Medical Research Council, Diabetes Australia and The University of Sydney. National evidence based guideline for the detection and diagnosis of type 2 diabetes 2009.
- National Health and Medical Research Council, Diabetes Australia and The University of Sydney. National evidence based guideline for blood glucose control in type 2 diabetes 2009.
- Australian Diabetes Society. Australian Type 2 diabetes Management Algorithm. 2020.
Evidence summary on type 2 diabetes
The prevalence of diabetes is increasing, with an estimated 6% of Australians currently diagnosed with the chronic disease.5
Diabetes impacts quality of life, life expectancy and morbidity as a result of microvascular complications (retinopathy, nephropathy and neuropathy) and the increased risk of macrovascular complications (ischaemic vascular disease, stroke and peripheral vascular disease).6
Good glycaemic control reduces the development or progression of diabetes complications and can improve quality of life.26
About 60% of people with type 2 diabetes have cardiovascular disease and around 65% of all cardiovascular disease deaths in Australia occur in people with diabetes.7
Addressing lifestyle factors, blood pressure and blood lipids are just as essential, as they seem even more effective than glycaemic control in reducing the risk of cardiovascular complications.8
Reducing risk of cardiovascular events in people with type 2 diabetes requires concurrent management of lifestyle factors, blood pressure, lipids and blood glucose.5
References
- Expert group for diabetes. Therapeutic Guidelines: Diabetes version 1. West Melbourne: Therapeutic Guidelines Ltd, 2019 (accessed 13 February 2020).
- Australian Diabetes Society: Australian blood glucose treatment algorithm for type 2 diabetes. Sydney: ADS, 2020 (accessed 13 February 2020).
- Australian Medicines Handbook. Endocrine drugs. Adelaide: AMH Pty Ltd, 2020 (accessed 13 February 2020).
- Royal Australian College of General Practitioners. General practice management of type 2 diabetes 2016–18. East Melbourne: RACGP, 2016 (accessed 13 February 2020).
- Australian Institute of Health and Welfare. Diabetes. Canberra: AIHW, 2016 (accessed 24 February 2020)
- Colagiuri S, Dickinson S, Girgis S, Colagiuri R. National Evidence Based Guideline for Blood Glucose Control in Type 2 Diabetes. Canberra: Diabetes Australia and the National Health and Medical Research Council, 2009. [Online] (accessed 26 July 2012).
- Shaw J, Tanamas S. Diabetes: the silent pandemic and its impact on Australia. Melbourne, Baker IDI Heart and Diabetes Institute, 2012 (accessed 25 July 2012).
- National Prescribing Centre UK. Improving outcomes in type 2 diabetes. MeReC Bulletin vol 21 no 5: Liverpool, UK: National Institute for Health and Clinical Excellence, June 2011.