Create an individualised care plan

Good glycaemic control is valuable in promoting fewer complications in patients with T2DM, but good individualised glycaemic control is a based on an appreciation of the below factors:

• life expectancy
• disease duration
• important co-morbidities
• established vascular complications
• patient preference
• resources and support system

The figure below (based on ADA³¹ and NICE², and supported by SIGN 154¹) shows characteristics and considerations that individuals and clinicians can consider together to assess “what matters to me” (step 1 of the 7-steps medicine review process) when determining individual glycaemic control.  

People with T2DM should consider their options for controlling their blood glucose in order to reduce the long-term risks of diabetes.

The decision cycle for person-centred glycaemic management in T2DM³ is summarised in the figure below. This is based on a full version produced by the American Diabetes Association and European Association for the Study of Diabetes.  

Each section should be viewed with the person at the centre of decision making. 

Focusing on the whole person alongside their medication during the review will ensure the person remains central in the decision-making process and is not a passive recipient of care.

This in turn encourages self-care and an understanding of how their condition/s impacts on their life.

This multi-faceted approach is in line with Scottish Government’s Realistic Medicine Approach to care.

The medication algorithm allows individualised choice and firmly focuses on the evidence from long-term outcome trials and the benefits seen with newer agents (see section on cardiovascular and renal risk), asking clinicians to decide at an early stage whether a person will gain from these benefits independent of HbA1c. 

The person centred 7-step medication review process can be used at initiation and review of medication to support shared decision making throughout the process.

Hyperglycaemia is central to development and progression of microvascular disease.

The epidemiological analysis of the UKPDS³⁰ demonstrated a strong relationship between diabetes complications including mortality and blood glucose levels (see table below). 

HbA1c reduction by 11mmol/mol (1%)

When creating and reviewing individual care plans, the following factors should be considered that may lead to loss of adequate glycaemic control:

• lifestyle and diet
• raised BMI
• medication non-adherence
• depression
• musculoskeletal injury or worsening arthritis
• competing illnesses perceived as more important by the individual
• social stress at home or at work
• substance abuse
• infections
• use of medications (such as corticosteroids, certain depression medications [paroxetine], mood stabilisers, or atypical antipsychotics) that elevate weight or glucose
• other endocrinopathies such as Cushing's disease.

The table below illustrates an alternative individualised approach to diabetes care should be adopted that is tailored to the needs and circumstances of people with T2DM, accounting for personal preferences.

*See summary of the benefits and cautions for anti-diabetic therapies

Reassess the person’s needs and circumstances at each review and consider discontinuing any medicines that are not effective in line with polypharmacy guidance.