The Modern

Management of
Type 2 Diabetes
Kevin Fernando FRCGP FRCP Edin. FAcadMEd MSc Diabetes
University of Edinburgh Medical School 2000

GP Partner North Berwick Health Centre

Specialist Interests in Diabetes/CVRM & Medical Education

Content Advisor, Medscape Global & UK

Honorary Clinical Reader

@drkevinfernando
@DrKevinFernando @drkevinfernando
 Disclosures 2023/24

Speaker fees: AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi

Sankyo, Lilly, Menarini, Novartis, Roche Diagnostics, Embecta

Advisory Board fees: Dexcom, Bayer, Lilly, Roche, Roche

Diagnostics

Conference attendance: Menarini, Lilly, Daiichi Sankyo

Medscape UK. Guidelines
Primary Care Hacks: Type 2
Diabetes Cardiovascular Renal
Metabolic Review Checklist.
Available at:
https://www.medscape.co.uk/v
iewarticle/type-2-diabetes-
cardiovascular-renal-metabolic-
review-2023a100060c.
Accessed September 2023.
Medscape UK. Guidelines
Primary Care Hacks: Extra-
Glycaemic Indications of
SGLT2 Inhibitors. Available at:
https://www.medscape.co.
uk/viewarticle/primary-care-
hacks-extra-glycaemic-
indications-sglt2-
2022a10021mt.
Case study

Patient Age: 52 years

characteristics Sex: Male
BMI: 31 kg/m2
Ethnicity: Caucasian
Family history None of note

Medical history Type 2 diabetes diagnosed 6 months ago, hypertension

Current treatments Metformin 1g bd, lisinopril 20mg od, atorvastatin 20mg od

Assessments HbA1c: 58 mmol/mol; TC:HDL 3.9

BP: 129/79 mmHg; eGFR: >60 mL/min
Current status Works as an architect. Ex-smoker. Referred to DESMOND but didn’t
summary attend. Social alcohol intake

Grant Patient views Admits leads a sedentary lifestyle

What might you consider doing next with respect to his management?

No to current drug regimen & reinforce lifestyle advice

change

Add in a sulphonylurea

Add in pioglitazone

Add in a gliptin

Add in a SGLT2 inhibitor

Add in a GLP-1 receptor agonist

Do something else?
Case study

Patient Unfortunately recently suffered a NSTEMI and underwent PCI & stenting
characteristics

Current treatments Metformin 1g bd, lisinopril 20mg od, atorvastatin 80mg, bisoprolol 10mg,
aspirin 75mg, clopidogrel 75mg (for 12 months)
Assessments BMI 30kg/m2 HbA1c: 64 mmol/mol; TC 3.9mmol/L; LDL-C 1.8mmol/L
BP: 126/74 mmHg; eGFR: >60 mL/min

Grant
What might you consider doing next with respect to his management?

No change to current drug regimen & reinforce lifestyle advice

Add in a sulphonylurea

Add in pioglitazone

Add in a gliptin

Add in a SGLT2 inhibitor

Add in a GLP-1 receptor agonist

Intensify lipid therapy

Intensify antihypertensive therapy

Do something else?
“
‘The good physician
treats the disease; the
great physician treats
the patient who has
the disease’ Photo credit: Wellcome Library

Sir William Osler 1849–1919

 NICE NG28 2022 guidance in adults with
type 2 diabetes: Individualised care
• Adopt an individualised approach to diabetes care
• Tailored to the needs and circumstances of adults with type 2 diabetes
• Taking into account their personal preferences, comorbidities and risks from polypharmacy, and their
likelihood of benefiting from long-term interventions
• Such an approach is especially important in the context of multimorbidity [2015, amended 2022]
• Reassess the person's needs and circumstances at each review and think about whether to
stop any medicines that are not effective. [2015]
• Take into account any disabilities, including visual impairment, when planning and delivering
care for adults with type 2 diabetes. [2015]

NICE. Type 2 diabetes in adults: management. Clinical Guideline Update (NG28). National Institute for Health and Care Excellence, 2022. Published February 2022.
Clinical trials investigated the effect of glucose-lowering
drugs on cardiovascular outcomes
Key:
DDP-4 inhibitors
SGLT2 inhibitors LEADER6 DECLARE-TIMI 5811 CAROLINA13
GLP-1 receptor agonists Liraglutide vs placebo Dapagliflozin vs placebo Linagliptin vs glimepiride

EXAMINE2 TECOS4 EXSCEL8 CARMELINA10

Alogliptin* vs placebo Sitagliptin vs placebo Exenatide vs placebo Linagliptin vs placebo

2013 2014 2015 2016 2017 2018 2019 2020

ELIXA3 SUSTAIN-67 REWIND12

Lixisenatide vs placebo Semaglutide vs placebo Dulaglutide vs placebo

SAVOR-TIMI 531 EMPA-REG OUTCOME5 CANVAS PROGRAM9 VERTIS-CV (2020)14

Saxagliptin vs placebo Empagliflozin vs placebo Canagliflozin vs placebo Ertugliflozin vs placebo

*Not indicated as monotherapy. DPP-4: dipeptidyl peptidase-4; GLP-1: glucagon-like peptide-1; SGLT2: sodium–glucose co-transporter-2
1. Scirica BM et al. N Engl J Med 2013;369:1317–1326; 2. White WB et al. N Engl J Med 2013;369:1327–1335; 3. Pfeffer MA et al. N Engl J Med 2015;373:2247–2257; 4. Green JB et al. N Engl J Med 2015;373:232–242; 5.
Zinman B et al. N Engl J Med 2015;373:2117–2128; 6. Marso SP et al. N Engl J Med 2016;375:311–322; 7. Marso SP et al. N Engl J Med 2016;375:1834–1844; 8. Holman R et al. N Engl J Med 2017;377:1228–1239; 9. Neal B
et al. N Engl J Med 2017;377:644–657; 10. Rosenstock J et al. JAMA 2019;321:69–79; 11. Wiviott SD et al. N Engl J Med 2019;380:347–357; 12. Gerstein HC et al. Lancet 2019;394:121–130; 13. Rosenstock J et al. JAMA
2019;322:1155–1166; 14. Cannon C et al. N Engl J Med 2020;383:1425–1435.
2023 ESC Guidelines for the
management of
cardiovascular disease in
patients with diabetes
Official ESC Guidelines slide set
Figure 1
Management of
cardiovascular
disease in patients
with type 2 diabetes:
clinical approach and
key recommendations

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
 Figure 2

The American Journal of Pathology 2020 1901596-1608DOI: (10.1016/j.ajpath.2020.04.006)

Copyright © 2020 American Society for Investigative Pathology Terms and Conditions
 Initiation and optimisation of the Four Pillars of Heart Failure.

Sam Straw et al. Open Heart 2021;8:e001585

©2021 by British Cardiovascular Society

Case study

Patient Unfortunately, recently suffered a NSTEMI and underwent PCI & stenting
characteristics

Current treatments Metformin 1g bd, lisinopril 20mg od, atorvastatin 80mg, bisoprolol 10mg,
aspirin 75mg, clopidogrel 75mg (for 12 months)
Assessments BMI 30kg/m2 HbA1c: 64 mmol/mol; TC 3.9mmol/L; LDL-C 1.8mmol/L
BP: 126/74 mmHg; eGFR: >60 mL/min

Commenced an SGLT2 inhibitor with proven CV benefit

consistent with NICE NG28 (2022)

Grant
The epidemiology
of diabetic
kidney disease

CKD, chronic kidney disease; T2D, type 2 diabetes.

1. Nephron 2018;139(suppl1):13–46 DOI: 10.1159/000490959; 2. Hill CJ et al. Diabet Med 31:448–454 doi: 10.1111/dme.12312; 3. Foley RN et al. J Am Soc
Nephrol 16: 489-495, 2005. doi: 10.1681/ASN.2004030203
Chronic kidney disease, indicated by an
eGFR <60 mL/min/1.73m2,* means that your
patient....
• Is more likely to have ischaemic heart disease, heart failure,
peripheral vascular disease or cerebrovascular disease2
• Has a higher risk of cardiovascular mortality2
• Can find it more difficult to achieve blood pressure targets3
• May be prone to ankle swelling and fluid retention4
• May be at increased risk of sustaining a hip fracture5
• Is at increased risk of hypoglycaemia6

*Chronic kidney disease may also be diagnosed in patients with an eGFR >60 mL/min/1.73m2 but who have markers of kidney damage (micro- or macroalbuminuria)
1. Wang Y, et al. Kidney Int. 2014; 85(5): 1192–1199; 2. Wright J and Hutchison A. Vasc Health Risk Manag. 2009; 5:713–722; 3. McCullough PA et al. Curr Diab Rep. 2011;
11(1):47–55; 4. Renal Resource Centre. Understanding Chronic Kidney Disease. Available at: https://kidney.org.au/cms_uploads/docs/rrc-understanding-chronic-kidney-disease.pdf
(Accessed July 2020) 5. Nickolas TL et al. J Am Soc Nephrol. 2006; 17(11):3223–3232; 6. Moen MF et al. Clin J Am Soc Nephrol. 2009;4(6):1121–1127.
Case study

Patient Age: 67 years

characteristics Sex: Male
BMI: 28 kg/m2
Ethnicity: Scottish
Past medical history Type 2 diabetes diagnosed 6 years ago, hypertension, background
diabetic retinopathy, CKD stage G3b A3 (known to renal virtual clinic)
Current treatments Metformin 500mg bd, irbesartan 300mg od, atorvastatin 10mg od,
bisoprolol 7.5mg od, doxazosin mr 8mg od
Assessments HbA1c: 58 mmol/mol; TC:HDL 7.4
HBPM average: 126/70mmHg; eGFR: 34mL/min (46ml/min last year)
UACR 106mg/mmol; K 5mmol/L; Calcium 2.4mmol/L; Hb 121g/L
No evidence fluid overload on clinical examination
Current status Retired gardener. Married. Functionally independent. Ex-smoker
summary
Russell
Patient views Worried he may have to start dialysis
What do you do next?

Pray that his next renal review is imminent

Look up GPnotebook before realising you’ve used up your 3 open access pages

Add in aspirin 75mg od

Optimise lipid profile

Optimise his antihypertensive therapy

Optimise his glycaemic control

Do something else?
CLASSIFY CKD TO DETERMINE RISK OF DISEASE
PROGRESSION AND MANAGEMENT

Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 Clinical Practice
Guideline for Diabetes Management in Chronic Kidney Disease. Kidney International 2020;98:S1-115.
https://kdigo.org/guidelines/diabetes-ckd/
FREQUENCY OF MONITORING

Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 Clinical Practice
Guideline for Diabetes Management in Chronic Kidney Disease. Kidney International 2020;98:S1-115.
https://kdigo.org/guidelines/diabetes-ckd/
KDIGO 2022 CLINICAL PRACTICE GUIDELINE
ON DIABETES MANAGEMENT IN CKD
SLIDE SET

KDIGO GUIDELINE CO-CHAIRS:

IAN DE BOER, MD, MS
PETER ROSSING, MD, DMSC
COMPREHENSIVE CARE IN PATIENTS WITH DIABETES AND
CKD
Practice Point 1.1.1: Patients
with diabetes and chronic
kidney disease (CKD) should
be treated with a
comprehensive strategy to
reduce risks of kidney disease
progression and cardiovascular
disease (Figure 1 and 2).
 KEY TAKEAWAYS FROM THE KDIGO
2024 CLINICAL PRACTICE GUIDELINE FOR
THE EVALUATION AND MANAGEMENT OF
CKD
KDIGO GUIDELINE CO-CHAIRS:
ADEERA LEVIN, MD, FRCPC
PAUL E. STEVENS, MB, FRCP
MANAGEMENT – RASI AND SGLT2I
Treatments that delay progression of CKD with a strong evidence base include RASi and
SGLT2i. In people with CKD and heart failure, SGLT2i confer benefits irrespective of
albuminuria.
Case study

Patient Age: 67 years

characteristics Sex: Male
BMI: 28 kg/m2
Ethnicity: Scottish
Past medical history Type 2 diabetes diagnosed 6 years ago, hypertension, background
diabetic retinopathy, CKD stage G3b A3 (known to renal virtual clinic)
Current treatments Metformin 500mg bd, irbesartan 300mg od, atorvastatin 10mg od,
bisoprolol 7.5mg od, doxazosin mr 8mg od
Assessments HbA1c: 58 mmol/mol; TC:HDL 7.4
HBPM average: 126/70mmHg; eGFR: 34mL/min (46ml/min last year)
UACR 106mg/mmol; K 5mmol/L; Calcium 2.4mmol/L; Hb 121g/L
No evidence fluid overload on clinical examination
Current status Retired gardener. Married. Functionally independent. Ex-smoker
summary
Russell
Patient views Worried he may have to start dialysis

Increased atorvastatin to 20mg od. Commenced SGLT2 inhibitor with proven

renal benefit. Emailed renal team
SGLT2 inhibitors (canagliflozin,
dapagliflozin, empagliflozin & ertugliflozin)
• Insulin-independent mode of action: inhibit renal reabsorption of glucose
• Potent glucose-lowering agent with secondary benefits of weight reduction
& BP reduction and overall low risk of hypoglycaemia
• Proven CV (HF & ASCVD) & renal benefits
• Can be used as monotherapy & combination therapy (also alongside
insulin) in T2D
• Baseline eGFR & indication important when initiating SGLT2 inhibitors
• Limited glycaemic efficacy if eGFR subsequently falls below 60ml/mins
• No need to routinely recheck U&Es after initiation of SGLT2 inhibitor
The glucose-lowering efficacy of
all SGLT2 inhibitors is dependent
on renal function and is negligible
when eGFR <45

If eGFR falls <45, additional

glucose-lowering treatment should
be considered in people living with
T2D
“
Poison is in
everything, and no
thing is without
poison. The dosage
makes it either a
poison or a remedy
Paracelsus 1493-1541
SGLT2 inhibitors

• Side-effects of SGLT2i’s similar to symptoms & signs of T2D!

• Mycotic genital infections, UTIs & osmotic symptoms (e.g. thirst, polyuria,
light-headedness & fatigue)
• Volume depletion or even clinical dehydration can also occur
• No signal for AKI (appears quite the opposite…Diab Obes Metab August
2019)
• Reinforce adequate hydration & good personal hygiene
SGLT2 Inhibitor Safety Update
• MHRA 2016: SGLT2 inhibitors & risk of DKA
• DKA is a rare adverse event between 1:1000 to 1:10000
• The benefits outweigh the risks
• Can be associated with normal or near normal glucose levels – euglycaemic
DKA
• Warn individuals taking SGLT2 inhibitors of symptoms and signs of DKA
• If suspect DKA, test for ketones (ideally blood) if even glucose levels are normal
• No need to issue ketone testing strips to those on SGLT2 inhibitors
• Reinforce sick day guidance with SGLT2 inhibitors; temporarily stop during any
acute dehydrating illness
• “SADMAN” mnemonic – temporarily stop SGLT2 inhibitors, ACEI, Diuretics, Metformin,
ARB & NSAIDs during any acute dehydrating illness and restart once eating and drinking
normally (usually 24-48 hours later)
Temporarily pause the
SADMAN drugs during any
acute dehydrating illness
and restart once eating and
drinking normally to prevent
DKA
SGLT2 Inhibitor Safety Update
• MHRA February 2019: SGLT2 inhibitors: reports of Fournier’s gangrene
(necrotising fasciitis of the genitalia or perineum)

• Only 6 Yellow Card reports in nearly 550,000 patient years of treatment

• No significant imbalance in cases of Fournier’s gangrene in all major SGLT2i
studies
• Patients taking SGLT2 inhibitors should be advised to seek urgent medical
attention if they experience severe pain, tenderness, erythema, or swelling in the
genital or perineal area accompanied by fever or malaise
• Reinforce the importance of good personal hygiene
“
The past is a foreign country:
they do things differently
there

L.P. Hartley “The Go-

Between” Published 1957
Thank you for listening &
please get in touch if you
have any questions
kevinfernando@doctors.org.uk
@drkevinfernando
Kevin Fernando
56