Type 2 Diabetes

Diagnosis, Management & Treatment Goals

Diagnostic Criteria

  • Type 2 diabetes (i):
  Fasting plasma glucose
mmol/L (mg/dL)(ii)
Oral glucose tolerance test
(OGTT) 2-h value mmol/L (mg/dL)(iii)
HbA1c(iv) (mmol/mol)
Diabetes ≥ 7.0 (126) OR → ≥ 11.1 (200) ≥ 6.5 % (≥ 48)
Impaired glucose tolerance (IGT) < 7.0 (126) AND → 7.8 – 11.0 (140 – 199) Prediabetes
5.7-6.4 % (39-47)
Impaired fasting glucose (IFG) 5.7– 6.9 AND (100 – 125) < 7.8 (140)
  1. As defined by WHO, [8] and [9]
  2. An abnormal finding should be repeated before confirming the diagnosis
  3. Recommended in PLWH with fasting blood glucose of 5.7 - 6.9 mmol/L (100-125 mg/dL) as it may identify persons with overt diabetes
  4. Do not use HbA1c in presence of haemoglobinopathies, increased erythrocyte turnover and severe liver or kidney dysfunction. Falsely high values are measured under supplementation with iron, vitamin C and E as well as older age (age > 70: HbA1c + 0.4%). HbA1c values in treated PLWH, particularly when on ABC, tend to underestimate type 2 diabetes. Both IGT and IFG increase CVD morbidity and mortality and increase the risk of developing diabetes by 4-6-fold. These persons should be targeted for lifestyle intervention, and their CVD risk factors must be evaluated and treated

Management

  • Type 2 Diabetes (i):
If modification of lifestyle measures is insufficient
Metformin(ii) start dose (500-850 mg qd), increase to maximum tolerated dose of 2(-3) g/day over 4-6 weeks(iii)
HbA1c > 6.5-7% (> 48-53 mmol/mol)
Metformin(ii) + sulfonylureas or thiazolidinedione or DPP-4 inhibitor or SGLT-2 inhibitor or GLP-1 agonist or insulin
HbA1c > 6.5-7% (> 48-53 mmol/mol)
Refer to specialist for triple therapy – use insulin

Treatment goals

Prevention of hyper-/hypoglycaemia, glucose control (HbA1c < 6.5-7% without hypoglycaemia), fasting plasma glucose 4-6 mmol/L (73-110 mg/dL), prevention of long-term complications

Notes:

  1. Type 1 diabetes should be treated according to national guidelines
  2. Metformin may worsen lipoatrophy
    No data for any oral anti-diabetic agents in terms of CVD prevention in PLWH. Incretins (DDP-4 inhibitors [e.g. linagliptin, saxagliptin (reduce dose when given with a booster), sitagliptin and vildagliptin], GLP-1 agonists [liraglutide, exenatide], and SGLT-2 inhibitors [e.g. dapagliflozin, canagliflozin, empagliflozin] have not been evaluated in PLWH, but some (e.g empagliflozin, canaglifozin, dapaglifozin, liraglutide) have shown to reduce mortality from CVD; choice of drugs dependent on a variety of individual- & disease-specific factors; no clinically significant drug-drug-interaction or adverse effects on CD4 counts expected; clinical use of pioglitazone questioned by its side effects; HbA1c targets up to 7.5% can be considered for older PLWH with long-standing type 2 diabetes and evidence of CVD
  3. Consider lower dose in PLWH with mild to moderate CKD or individuals receiving DTG