Type 2 Diabetes

Diagnosis & Management

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
  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

See: EASD/ADA Guidelines

  1. Metformin may worsen lipoatrophy. Consider lower dose in PLWH with mild to moderate CKD or in individuals receiving DTG
  2. Established atherosclerotic cardiovascular disease (ASCVD) or indicators of high ASCVD (age ≥ 55 years + left ventriciular hypertrophy or coroanary, carotid, lower extermity artery stenosis > 50%)
  3. No data for any oral anti-diabetic agents in terms of CVD prevention in PLWH. 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. Always consider individualised HbA1c targets, which depend on e.g. disease duration, life expectancy, risk for hypoglycemia, individual preference
  4. Heart failure (HF) defined as reduced ejection fraction < 45%, chronic kidney disease (CKD): eGFR > 30 - < 60 mL/min or UA/C > 30 mg/mmoL, particularly UA/C > 300 mg/mmoL
  5. Proven CVD benefit means it has label indication of reducing CVD events
  6. Empagliflozin, canagliflozin and dapagliflozin have shown reduction in HF and to reduce CKD progression
  7. Compelling need to minimise weight gain or promote weight loss use GLP-1RA or SGLT2i. GLP-1RA with good efficacy for weight loss: semaglutide > liraglitide > dulaglutide > exenatide > lixisenatide