By Tim Holt, Sudhesh Kumar

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5% Monitor for deterioration Only continue exenatice if reduction in HbA1c of at least 1 percentage point and weight loss of at least 3% of initial body weight at 6 months. 5 percentage points in 6 months. Offer once-daily sulphonylurea if adherence is a problem. uk/CG43). With active dose titration. Or individually agreed target. 5% Monitor for deterioration • blood glucose control is inadequate with high-dose insulin • a thiazolidinedione has previously had a marked glucose-lowering effect, or Consider pioglitazone with insulin if: Increase insulin dose and intensify regimen over time, 2 • BMI < 35 kg/m and insulin is unacceptable because of occupational implications or weight loss would benefit other comorbidities.

Whilst broad principles are similar, there may be significant differences between different guidelines issued by various professional bodies. Initial management If a patient has been diagnosed early, with no symptoms or complications and an HbA1c <7% at diagnosis, and if they prefer a time without drug therapy, then an initial 3 months of behavioural adaptation is appropriate. However, a patient with symptoms or a raised HbA1c at diagnosis has probably had diabetes for some ABC of Diabetes, 6th edition.

4 (a) Glycaemic control improves microvascular outcomes. (b) Blood pressure control reduces risk of both macro- and microvascular complications. Reproduced from Irene M Stratton, Amanda I Adler, H Andrew W Neil. BMJ 2000;321:405–12 with permission from the BMJ Publishing Group Ltd. 5). This study also demonstrated that metformin therapy provided additional CVD benefit over and above the glucose-lowering effect, and therefore should be initiated in all type 2 patients along with the life-style advice.

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