Open Access
Feature Article

Type 2 diabetes: tailoring a treatment approach

Open Access
Feature Article

Type 2 diabetes: tailoring a treatment approach

Kharis Burns, N. Wah Cheung

Figures

Dr Burns is a Consultant Endocrinologist in the Department of Diabetes and Endocrinology at Westmead Hospital, Sydney; and Clinical Associate Lecturer at Sydney Medical School, The University of Sydney. Professor Cheung is an Endocrinologist and Director of the Department of Diabetes and Endocrinology at Westmead Hospital, Sydney; and Clinical Professor at Sydney Medical School, The University of Sydney, Sydney, NSW.

Metformin is contraindicated if eGFR falls below 30 mL/min because of a risk of lactic acidosis. Sulfonylureas have a higher risk of hypoglycaemia with renal impairment. SGLT2 inhibitors rely on renal function for their mechanism of action and should be avoided if eGFR is below 45 to 60 mL/min, depending on the agent. Within the class of DPP-4 inhibitors, sitagliptin can be used up until stage 4 CKD with dose reduction and linagliptin can be used regardless of eGFR and can be used in patients on dialysis.19 Insulin is safe to use, but downtitration of dose may be necessary.

Elderly patients

In elderly patients, glycaemic control should be individualised based on life expectancy, polypharmacy and the risk of hypoglycaemia. In many cases, symptom control should be the sole focus of therapy. A decline in renal function, often seen in this age group, requires caution or dose reduction with multiple therapies.

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Conclusion

The key principle in managing type 2 diabetes is individualised treatment. Metformin remains the first-line recommended therapy, unless contraindicated, and insulin may be commenced at any stage in therapy. Beyond these recommendations, clinicians have a wide choice in management options. Targets for HbA1c and treatment choices should be guided by patient comorbidities, life expectancy, acceptability of administration, cost and patient preference. MT

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COMPETING INTERESTS: None.
 

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