Interventions and support for people with type 2 diabetes

The latest NICE guidance on type 2 diabetes signals a major shift, particularly with the earlier use of SGLT-2 inhibitors. As uptake increases, pharmacists can play a central role in safe initiation, counselling and ongoing monitoring. Key considerations include diet, sick day management and recognition of adverse effects such as diabetic ketoacidosis (DKA).

People currently taking standard-release metformin without problems do not need to switch to metformin modified-release (MR). However, those intolerant of standard-release metformin, or who prefer metformin MR, should be supported to change where appropriate.

SGLT-2s

NICE has highlighted the current underutilisation of SGLT-2 inhibitors and the potential to reduce health inequalities through increased uptake. As noted in our accompanying CPD module, SGLT-2 inhibitors reduce glucose levels, and provide cardiovascular and renal protection. Pharmacy teams should actively identify people who could benefit from adding a SGLT-2 inhibitor to their treatment.

The move to make SGLT-2 inhibitors first-line therapy alongside metformin MR for almost all newly diagnosed adults with diabetes will substantially increase their use in primary care. Pharmacist NMS consultations will now frequently involve two medicines from week one. People should be provided with clear advice explaining the benefits of earlier dual therapy and what to expect from treatment.

According to NICE, achieving a 90% uptake of joint first-line treatment with SGLT-2 inhibitors and metformin MR could prevent up to 22,000 deaths each year.

Overall, the cardiovascular and renal benefits from using SGLT-2 inhibitors (and GLP-1 agonists where applicable) should reduce both long-term morbidity and the costs associated with diabetes complications.

Pharmacists should liaise with local GP practices to understand how new diagnoses and medicines initiation are being managed for people with type 2 diabetes – and how NMS consultations could fit within local pathways.

They therefore need to stay hydrated and eat little and often to avoid hyperglycaemia. Community pharmacy teams can check that people understand how to manage their diabetes medicines when unwell or during periods of increased stress.

Clear sick day rules should form part of individualised treatment plans. People taking SGLT-2 inhibitors, metformin or GLP-1 agonists should be advised to stop these medicines if they are vomiting or have diarrhoea to reduce the risk of dehydration. There should also be given clear instructions on restarting their medicines.

Sick day rules

Clear guidance should be given to people to help them manage their diabetes during periods of illness. Stressful situations such as illness and infection elevate insulin resistance and raise blood glucose levels through increased hepatic production. This is the body’s normal response to stress.

People with diabetes are either less responsive to insulin or unable to produce sufficient insulin to reduce glucose levels when unwell.

They therefore need to stay hydrated and eat little and often to avoid hyperglycaemia. Community pharmacy teams can check that people understand how to manage their diabetes medicines when unwell or during periods of increased stress.

Clear sick day rules should form part of individualised treatment plans. People taking SGLT-2 inhibitors, metformin or GLP-1 agonists should be advised to stop these medicines if they are vomiting or have diarrhoea to reduce the risk of dehydration. There should also be given clear instructions on restarting their medicines.

Diabetic ketoacidosis

DKA is more common in type 1 diabetes but can also occur in people taking SGLT-2 inhibitors. Individuals should be advised about the signs and symptoms so they can take action.

Symptoms include nausea, vomiting, abdominal pain, unusual sleepiness or fatigue, fruity-smelling breath (like pear drop sweets or nail varnish), and breathing that is deeper or faster than normal.

Symptoms usually develop over 24 hours but may occur more rapidly. Guidance should be given on monitoring ketones and blood glucose levels when unwell. People should seek urgent medical advice and stop taking SGLT-2 inhibitors if DKA is suspected.

Hypoglycaemia

People should be counselled on the risks, signs and symptoms of hypoglycaemia, usually defined as blood glucose levels below 4mmol/L, and advised what to do if their levels fall. They should also be informed of driving-related safety requirements.

The phrase “five to drive” is a useful reminder that blood glucose levels should be 5mmol/L or above before driving.

Structured education

Pharmacy teams should be involved in delivering structured patient education programmes or signposting accordingly. This should be done soon after diagnosis, with key messages reinforced regularly around healthy living and diabetes self-management.

Patients should be supported to make informed treatment decisions, including discussion of benefits, potential side-effects and adherence.

SGLT-2 inhibitors should generally be maintained for their renal and cardiovascular benefits even if HbA1c targets are not met. GLP-1 agonists or tirzepatide should be discontinued if a person becomes underweight (BMI <18.5kg/m²).

Table 1 below, outlines some areas of clinical responsibility, priorities and opportunities for pharmacy teams to help improve patient care. You may like to consider adding some additional information relevant to your pharmacy. 

Making a difference

The emphasis on cardiometabolic risk reduction offers opportunities for proactive health promotion, including BP checks, lipid optimisation and healthy living advice for people with type 2 diabetes.

Pharmacy teams should use every opportunity to provide clear information on treatments, confirm understanding of dosing and highlight potential risks. Regular review is important, including consideration of escalation or deprescribing where appropriate.