Stratégie médicamenteuse du contrôle glycémique du diabète de type 2

Objectives

Individualise glycated haemoglobin (HbA1c) targets to each person’s clinical profile and review them over time. For most people with type 2 diabetes, aim for an HbA1c level of 7% or below, and initiate or reassess treatment when HbA1c exceeds 7%.[1]

• Reassess lifestyle and dietary measures, therapeutic education and medicines regularly, with effective lifestyle and dietary measures forming the basis of glycaemic management before medicines are used.[1]
• Select medicines according to the gap from the HbA1c target, expected effectiveness, tolerability, safety and cost.[1]
• Use metformin as first-line monotherapy, prioritise metformin combined with a sulphonylurea for dual therapy, and use insulin where oral and other non-insulin treatments do not achieve the glycaemic target.[1]
• Adapt targets for particular circumstances, including more stringent targets for some newly diagnosed people and women planning pregnancy, and less stringent targets for people with severe comorbidity, limited life expectancy, advanced complications, frailty or advanced renal impairment.[2][3]
• Promote good glycaemic control before and during pregnancy, including through pregnancy-specific glycaemic thresholds.[2][3]

Implementation

Deliver care through an iterative, person-centred combination of lifestyle and dietary measures, therapeutic education and medicines, recognising that type 2 diabetes is progressive and that the treatment strategy requires regular review.[1]

• Combine pharmacological treatment with lifestyle and dietary measures and therapeutic education rather than treating medicines as a stand-alone intervention.[1]
• Discuss insulin initiation with the person and, where appropriate, relatives or carers as part of therapeutic education; provide training and ideally introduce self-monitoring of blood glucose before insulin is started.[1]
• Use self-monitoring of blood glucose only where results may lead to changes in lifestyle measures or medication, and avoid routine use for people taking antidiabetic medicines that do not cause hypoglycaemia.[1]
• Inform women of childbearing age about the importance of good glycaemic control before and during pregnancy.[1]
• Refer people to an endocrinologist where setting or achieving the appropriate glycaemic target is difficult.[1]
• Involve patients, relatives or carers where appropriate, clinicians, therapeutic education providers and endocrinologists in delivery.[1]
• Incorporate medicine cost into treatment selection alongside clinical effectiveness, tolerability and safety.[1]

Monitoring & Evaluation

Clinical monitoring centres on individualised glycated haemoglobin (HbA1c) targets, regular reassessment of care, and selective use of self-monitoring of blood glucose to guide changes in lifestyle measures or treatment.[1]Targets should be adapted to patient characteristics and clinical circumstances, including age, cardiovascular history, renal function, complications, frailty, life expectancy and pregnancy.[2][3]

• Set an HbA1c target for each person and review it over time; for most people with type 2 diabetes, use a target of 7% or below.[1]
• Reassess medication when HbA1c exceeds the applicable target and review lifestyle measures, dietary measures, therapeutic education and medicines regularly.[1]
• Apply more stringent or less stringent glycaemic targets according to clinical circumstances, including newly diagnosed diabetes, pregnancy planning, severe comorbidity, advanced complications, frailty and advanced renal impairment.[2][3]
• Monitor fasting and two-hour post-prandial glucose during pregnancy using the thresholds specified for pregnancy-related glycaemic management.[2][3]
• Use self-monitoring of blood glucose only where its results are likely to lead to changes in lifestyle measures or medication; avoid routine use for people receiving antidiabetic medicines without hypoglycaemia risk.[1]
• Support insulin initiation through therapeutic education, patient and carer discussion where appropriate, training, and ideally prior self-monitoring of blood glucose.[1]

No formal monitoring framework, reporting schedule, surveillance system, audit indicator set, accountability mechanism, institutional evaluation process or evaluation timetable is specified beyond regular clinical review and glycaemic monitoring.[1][2][3]

Costing & Financing

Cost is one of the stated factors for selecting glucose-lowering medicines, alongside the extent to which HbA1c is above target, anticipated effectiveness, tolerability and safety.[1]The treatment approach prioritises metformin as first-line monotherapy, metformin plus a sulphonylurea as preferred dual therapy, and insulin when oral and other non-insulin treatments do not achieve the glycaemic target.[1]

• Consider medicine cost when choosing treatment, together with clinical effectiveness and safety considerations.[1]
• Use lifestyle and dietary measures and therapeutic education as components of care alongside medication, which may affect resource requirements although no cost estimate is provided.[1]
• Provide education, training and, where appropriate, self-monitoring support when initiating insulin, without specified associated funding or prices.[1]
• Refer women to an endocrinologist when establishing or achieving the glycaemic target is difficult, without specification of referral financing or service capacity.[1]

No budget, programme costing, allocation, medicine price, reimbursement arrangement, financing mechanism, funding source, resource-mobilisation plan, funding gap, cost-effectiveness analysis or economic assumption is specified.[1][2][3]