Patients with type 2 diabetes - also known as non-insulin dependent diabetes - may be controlled by diet alone, or may require medication as well.

Oral hypoglycaemic agents are usually tried first, and there are many types: sulphonylureas (chlorpropamide, glibenclamide, gliclazide, glimeprimide, glipizide, tolbutamide), biguanides (metformin), alpha glucosidase inhibitors (acarbose), meglitinides (nateglinide, repaglinide) thiazolidinediones (pioglitazone, rosiglitazone), and dipeptidylpeptidase-4 inhibitors (sitagliptin, vildagliptin). The incretin mimetic exatinide is given by subcutaneous injection.

These agents may be used alone or in combination, some are only licensed for concurrent use with other antidiabetic medication. Insulin may also be used.

Dosage regimen

* Sulphonylureas are usually taken twice a day.

* Biguanides are usually taken twice a day.

* Alpha glucosidase inhibitors are taken three times a day.

* Meglitinides such as repaglinide are taken once a day.

* Thiazolidinediones are usually taken once a day.

* Dipeptidylpeptidase-4 inhibitors are taken once or twice daily.

* Incretin mimetics are injected twice daily, within one hour of the two main meals, and with at least six hours between doses.

Patient's knowledge of the medicine's use

* Sulphonylureas are used for patients who are not overweight or who cannot take metformin. Sulphonylureas can be used as monotherapy, or in combination with other agents.

* A biguanide is the first choice for patients who are overweight, but may also be considered for patients whose weight is within the normal range. Metformin may be used alone, or in combination with other agents.

* Alpha glucosidase inhibitors may be used alone or with other antidiabetic drugs.

* Meglitinides: repaglinide may be as monotherapy, or with metformin, nateglinide is only licensed for use with metformin.

* Thiazolidinediones are used as monotherapy when other drugs do not work, or they are used in combination with metformin or a sulphonylurea.

* Dipeptidylpeptidase-4 inhibitors are used in combination therapy only.

* Incretin mimetics are only used in combination therapy.

Is the medicine working?

* Is the patient aware of the need to perform regular blood glucose checks, and what the normal range is?

* If the patient has been taking medication correctly but still has high blood sugar levels, refer to his or her GP.

Side-effects

* Sulphonylureas can cause hypoglycaemia, and weight gain.

* Metformin can cause anorexia, diarrhea, vomiting and nausea. If lactic acidosis occurs the patient should contact his doctor.

* Acarbose can cause soft stools, diarrhoea and flatulence.

* Meglitinides can cause hypoglycaemia and a rash.

* Thiazolidinediones can cause weight gain, and fluid retention.

* Dipeptidylpeptidase-4 inhibitors can cause GI disturbances and peripheral oedema

* Incretin mimetics can cause GI disturbances and reduced appetite.

Monitoring

* Ensure that annual renal and hepatic function tests are carried out on patients taking metformin.

* Regular liver function tests should be conducted on patients taking thiazolidinediones.

* Ensure the patient knows the signs of hypoglycaemia, which include sweating, blurred vision, paleness, confusion, tingling lips, mood changes, trembling and anxiety. Advise patients to eat glucose and not sugar in an attack.

Lifestyle

* Diet is an important aspect in the control of diabetes. Patients should be encouraged to eat more fruit, vegetables, fish, and fibre. They should reduce their consumption of sugar, salt, fat and alcohol.

* Patient should be encouraged to lose weight if needed.

* Patients who smoke should be given advice on smoking cessation.

* Encourage patients to be more physically active. Ideally patients should aim to exercise for 30 minutes at least five times a week.

* Patients should be advised to see a chiropodist and optician regularly, to ensure signs of peripheral or retinal neuropathy are picked up early.

* Patients with diabetes should be advised to have an influenza vaccination each year and a one-off pneumococcal vaccine.

* Patients with diabetes are at higher than normal risk of heart disease, stroke and renal disease, and may be on medication such a statin, aspirin, and antihypertensives. Emphasise the need to comply with these medicines.

Uzma Chaudhry, relief pharmacist, Lloydspharmacy, Oxfordshire

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