When choosing pharmacological treatments for type 2 diabetes (T2DM), it is essential to consider both anticipated benefits and adverse effects (safety and tolerability). The decision to select a particular medication will depend primarily on the balance between these criteria, which will vary on an individual basis. Once treatment has started, side effects can be monitored and necessary adjustments can be made to manage them.
This article reviews approaches to reduce the risk of side effects from medications for T2DM and how to manage these side effects should they occur.
General principles
Before medication
The first step in avoiding medication side effects is to ask whether pharmacological treatment is needed. In the case of T2DM, the starting point of treatment for hyperglycaemia is to tackle lifestyle factors, notably diet, exercise and weight loss (NICE, 2015a; Davies et al, 2022). Addressing these issues can reduce the requirement for medical treatment. There is strong evidence that weight loss through an intensive structured diet and lifestyle support can lead to remission of T2DM (off all medication) (Lean et al, 2018; 2019).
Individual glycaemic targets
Before commencing treatment, it is important to be clear about what HbA1c target you are aiming for. This target needs to take account of personal circumstances – duration of diabetes, risk of hypoglycaemia and hypoglycaemic awareness, co-morbidities, degree of frailty, life-expectancy and occupation and social circumstances, such as if holistic care is needed (Davies et al, 2022; NICE, 2015a). Side effects are more likely to occur with intensive treatment that may be inappropriate for the individual concerned
Starting a treatment
In the majority of cases, medical treatment of T2DM will be required to achieve satisfactory glycaemic control. The choice of medication for T2DM will be directed by scientific evidence and directed by scientific evidence and evidence-based guidelines, as they apple to individual circumstances (Box 1) (NICE, 2015a). For women with T2DM, metformin and insulin are the two safe treatments routinely used during pregnancy and breastfeeding, and during pregnancy with gestational diabetes.
Box 1.Factors affecting the choice of medication for type 2 diabetes
- Effectiveness of glycaemic control
- Risk of hypoglycaemia, hypoglycaemic awareness
- Effect on weight
- Comorbidities, such as cardiovascular disease, heart failure, chronic kidney disease
- Safety (contraindications)
- Tolerability (side effects)
- Interaction with other medications
- Required monitoring
- Individual preference
- Cost.
It is crucial to explain the necessity of medication and the benefits and risks of treatments to the person with T2DM and/or their caregivers. Providing clear instructions on how to take medication correctly can help minimise side effects. Involving the individual in treatment choices, including discussing potential side effects and how to respond to them, can increase adherence and improve the likelihood of achieving glycaemic targets (Davies et al, 2022; NICE, 2015a).
Key adverse effects to be considered when choosing medications for T2DM include risk of hypoglycaemia, propensity for weight gain and the consequences for cardiovascular and renal function.
Who is most at risk of medication side effects?
A drug may need to be avoided or even contraindicated, as they can trigger side effects in sulphonylureasceptible individuals or worsen pre-existing conditions. For instance, metformin is contraindicated in people with T2DM who have chronic kidney disease with an estimated glomerular filtration rate (eGFR) of <30 ml/min/1.73 m2 because of the heightened risk of lactic acidosis. In those with impaired hepatic metabolism or renal clearance, drug accumulation and subsequent adverse reactions are more likely to occur. Therefore, it is advisable to assess hepatic and renal function when starting therapy.
Polypharmacy increases the probability of a medication interaction that may lead either to elevated drug concentrations and increased side effects, or lowered drug concentrations and suboptimal therapeutic effect. Therefore, the choice of treatment must take account of the medication already being taken by the person with T2DM (NICE, 2015a; Davies et al, 2022).
The situations described are not uncommon in T2DM, especially in the elderly, and demand careful consideration. It is important to remember that adverse drug events can have a negative impact on a person's quality of life, lead to poor adherence to treatment and be a significant cause of hospital admission. The risk of drug toxicity is much higher in acute illness situations, such as impaired renal function in dehydrated patients. Although possible side effects from medications are mostly predictable, there is a significant amount of individual variation in drug responses.
Dealing with side effects
The majority of drug side effects are dose-dependent, with allergic reactions being the exception. Therefore, it is good practice to use the lowest effective dose of a medication to achieve glycaemic control. Dose reduction may be necessary to relieve side effects. Even if the ideal medication dose cannot be reached because of side effects, a lower dose of treatment may still produce significant benefits for hyperglycaemia and other indications. Another strategy is to gradually uptitrate a dose of medication to allow tolerance to develop gradually. If a medication is not tolerated at even a low dose, another member of the same class could be tried, or a switch could be made to an alternative treatment for hyperglycaemia (Coleman and Pontefract, 2016).
Medication reviews should take place regularly, screening for side effects at every appointment. It may be appropriate to arrange a review following initiation of a new treatment for T2DM to assess its tolerability and efficacy. In general, it is best to keep drug regimens as simple as possible. Once-daily medications have an obvious advantage here, and modified-release preparations and combination tablets may also improve patient adherence.
Reporting adverse drug reactions
Sulphonylureaspected adverse drug side effects can be reported electronically to the Medicines and Healthcare Products Regulatory Agency (MHRA) by nurses and doctors using the online yellow card system (MHRA, 2022). The black triangle labelling of drugs in the British National Formulary (BNF) and Monthly Index of Medical Specialities (MIMS) identifies newer treatments that are under more intense surveillance. All sulphonylureaspected side effects should be reported through the yellow card system, while only serious side effects need to be reported for established drugs.
Managing side-effects from medications for type 2 diabetes
Metformin
Metformin is the recommended first-line medical treatment for T2DM. Gastrointestinal symptoms such as nausea, abdominal discomfort and diarrhea are common but are generally mild and temporary. To reduce the risk of side-effects, a starting dose of 500 mg once daily is recommended, followed by a weekly increase in dosage until the target dose is reached (Box 2). If side effects persist, the dose should be reduced. Another option is to use a modified-release preparation of metformin, which produces fewer gastrointestinal side-effects, according to NICE.
Box 2.Suggested titration regime for starting metformin
- Commence 500 mg od with breakfast
- After 1-week increase the dose to 500 mg bd with breakfast and evening meal
- After a further week increase to 1.5 g daily in divided doses
- After a further week increase to target dose of 1 g bd.
Vitamin B12 deficiency is associated with the use of metformin (Aroda et al, 2016). This could lead to potentially irreversible peripheral neuropathy and a macrocyctic anaemia. While screening for B12 deficiency is not routinely recommended, however, it would certainly be worth checking B12 levels should either of these conditions arise. B12 deficiency may be corrected with oral B12 supplements or hydroxocobalamin injections, and ongoing B12 supplements would allow metformin to be continued.
A rare but potentially life-threatening complication from the use of metformin is lactic acidosis, which has an estimated incidence of 3–10/100 000 users of metformin per year (Sanchez-Rangel and Inzucci, 2017). Lactic acidosis is most likely to occur when toxic levels of metformin arise through reduced renal clearance that could be in the context of chronic kidney disease or acute kidney injury (DeFronzo et al, 2016). In acute illness where there is dehydration/hypovolaemia and a sudden deterioration of renal function, or risk of tissue hypoxia, metformin should be temporarily withdrawn to reduce the risk of lactic acidosis (Box 3).
Box 3.Clinical situations requiring temporary withdrawal of metformin
- Dehydration, shock
- Severe infection, sepsis
- Acidosis – diabetic ketoacidosis, lactic acidosis
- Acute heart failure
- Post-myocardial infarction
- Acute respiratory failure
- Severe acute renal failure (or worsening of chronic renal failure)
- Acute hepatic impairment (or worsening of chronic liver impairment)
- Acute alcohol intoxication
- Intravenous administration of iodinated contrast agents
- Surgery
- Worsening of chronic renal or chronic liver failure may require the permanent withdrawal of metformin.
NICE recommend reviewing the dose of metformin once eGFR falls below 45 ml/min (the author's practice is to cut the dose to 500 mg bd when eGFR reaches 40 ml/min) and avoiding metformin altogether once eGFR falls below 30 ml/min (NICE, 2015a). Other situations where metformin should be avoided or temporarily discontinued are listed in Box 3 (Electronic Medicines Compendium (EMC), 2022a).
Sulphonylureas and meglitinides (glinides)
The sulphonylureas and meglitinides (repaglinide, nateglinide) function by stimulating insulin secretion from pancreatic beta-cells. As beta-cell function declines with the duration of T2DM, they become less effective agents and their use may accelerate this process (Buse et al, 2020). The activity of these treatments is independent of prevailing glucose levels and they can therefore induce hypoglycaemia, the most limiting side effect in their deployment. The association between the use of sulphonylureas and hypoglycaemia has been established in many studies, although the incidence of severe hypoglycaemia appears to be lower than with insulin (Khunti et al, 2018).
Therefore, it is essential to discuss the risk of hypoglycaemia from sulphonylureas and meglitinides with individuals, including how to recognise the symptoms and respond to them. The availability of glucose monitoring should be considered in all those who use sulphonylureas and meglitinides and this assumes greater importance with those who drive. Practitioners should aim to use antidiabetic drugs other than sulphonylureas or meglitinides with those who drive group 2 vehicles (bus and lorry). Group 2 drivers who do take sulphonylureas (or meglitinides) must notify the DVLA and test blood glucose readings at least twice daily and at times relevant to driving, whilst retaining full awareness of hypoglycaemia and being free of episodes of severe hypoglycaemia in the last 12 months (DVLA, 2020).
The risk of hypoglycaemia is increased in those with renal impairment so consider smaller (initial) doses in this situation. Also, in this context, gliclazide may be the safest choice of SU because it is largely metabolised in the liver (BNF, 2022). Those with impaired awareness of hypoglycaemia and the elderly as a group are ideally better directed towards alternative antidiabetic agents.
Gliclazide, glipizide and glimepiride may be preferred sulphonylureas because they are less likely to cause persistent hypoglycaemia (leading to hospital admission) than a longer-acting SU such as glibenclamide (Davies et al, 2018). Compared to sulphonylureas, meglinitides are faster acting and have a shorter duration of action (BNF, 2022). When further medication for diabetes is added to a regime containing sulphonylureas or meglitinides then it is wise to reduce the dose of these latter agents (at least initially) to decrease the risk of hypoglycaemia.
Generally, Sulphonylureas and meglinitides should be avoided in pregnancy and breastfeeding as they may induce neonatal hypoglycaemia. One exception is glibenclamide, which can be used (unlicensed) in the second and third trimesters if metformin is insufficiently effective, poorly tolerated or contraindicated and insulin is declined (BNF, 2022).
Weight gain with Sulphonylureas and meglitinides is a further significant disadvantage of these agents and thought should be given to preferentially selecting a weight-losing or at least weight-neutral antidiabetic drug in an overweight/obese person with T2DM.
While there have been concerns over adverse cardiovascular outcomes with Sulphonylureas, this has not been supported in recent systematic reviews (Khunti et al, 2018; Buse et al, 2020).
Pioglitazone
Pioglitazone is the sole remaining thiazolinedione (glitazone) available in the UK, and it is typically considered a second-line option after metformin. Before commencing treatment, it is crucial to conduct a thorough analysis of the potential benefits and risks, particularly for elderly patients (NICE, 2015a). To minimise the risk of side effects, it is recommended to begin with a low dose of pioglitazone, such as 15 mg for the elderly, and closely monitor the patient as the dosage is increased. A summary of the safety concerns associated with pioglitazone can be found in Table 1.
Table 1. Problems associated with use of pioglitazone
| Problem | Action required |
|---|---|
| Heart failure, left ventricular dysfunction (Dormandy et al, 2005) | Contraindicated |
| Fluid retention, ankle swelling, weight gain (more likely in combination with insulin) | Reduce dose or consider alternative agent |
| Risk of bladder cancer (Lewis et al, 2015) | Avoid if history of bladder cancer or risk factors for this, or uninvestigated haematuria |
| Risk of fracture (notably post-menopausal women) | Use alternative agent if high risk of fracture (osteoporosis, previous fragility fracture) |
Hepatic impairment is listed as a contraindication but it is noteworthy that there is evidence that pioglitazone can benefit non-alcoholic steatohepatitis in T2DM (Vilar-Gomez and Adams, 2016).
DPP-4 inhibitors (gliptins)
The DPP-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin) are a well-tolerated class of medication and discontinuation because of side effects is unusual. The use of DPP-4 inhibitors has been associated with acute pancreatitis (Tkac and Raz, 2017). Therefore, people should be warned that if severe upper abdominal pain occurs, treatment should be stopped and medical advice should be sought. If acute pancreatitis is confirmed, DPP-4 inhibitors should not be restarted (EMC, 2022b). If there is a past history of pancreatitis, then an alternative class of medication for hyperglycaemia should be considered.
An increased risk of heart failure (compared to placebo) was identified in the saxagliptin cardiovascular outcome trial (CVOT) (Scirica et al, 2013), while in the alogliptin CVOT, a non-significant increased risk of heart failure was noted (White et al, 2013). It would be prudent to avoid these treatments in a person with a history of heart failure or with risk factors for heart failure, and to use other DPP-4 inhibitors with caution in these situations (signals for heart failure were not identified in the sitagliptin and linagliptin CVOTs). A recent statement from the ADA consensulphonylureas group did not recommend using DPP-4 inhibitors in heart failure (Pop-Busui, 2022).
The DPP-4 inhibitors can be used safely in renal failure but dose adjustment is necessary (BNF, 2022) except in the case of linagliptin, which is minimally renally excreted (EMC, 2022c).
GLP-1 receptor agonists
The GLP-1 receptor agonists (GLP-1 RAs) may be classified as short-acting (the exendin-4 derivatives: exenatide bd, lixisenatide) or long-acting (the human GLP-1 analogues: liraglutide, dulaglutide, semaglutide). Exenatide is now available as a modified-release once-weekly formulation. All these agents are administered by subcutaneous injection but in addition, an oral formulation of semaglutide has been developed.
The most troublesome side effects from GLP-1 RAs are gastrointestinal, although these do tend to settle with time and can be mitigated by starting at a lower dose with subsequent upward dose titration (Raccah, 2017). The incidence of nausea and vomiting appears to be higher with shorter-acting GLP-1 RAs while the frequency of diarrhea is higher for longer-acting GLP-1RAs (Nauck and Meier, 2019). It is important to warn individuals about these side effects and, if they do persist, then dose reduction or switching to an alternative class member can be instituted.
As with DPP-4 inhibitors, the GLP-1 RA product licenses contain a warning to advise people about symptoms of pancreatitis and to withdraw and not restart treatment should this occur (EMC, 2022d). A recent analysis of data on GLP-1 RAs has been reassuring in respect of the possible increased risk of pancreatitis and pancreatic cancer (Storgaard et al, 2017). However, an increased incidence of gallbladder events has been identified (Monami et al, 2017).
While injection site reactions are rare with GLP-1 RAs, the appearance of small subcutaneous nodules can appear at injection sites with the use of the microsphere formulation of once-weekly exenatide (usually self-resolving over weeks) (EMC, 2022e).
In the semaglutide CVOT (SUSTAIN 6), there was a significantly increased risk of pre-specified retinopathy outcomes, principally in those with pre-existing retinopathy who were using insulin (Marso et al, 2016). This has been attributed to a rapid improvement in glycaemic control. Until this is further investigated, caution should be exercised in initiating semaglutide in people with diabetic retinopathy.
When adding a GLP-1 RA to Sulphonylureas or insulin then it is appropriate to reduce the dose of these latter agents to reduce the risk of hypoglycaemia. The dosing arrangements for oral semaglutide are crucial to ensure absorption: it should be taken once daily after an overnight fast with a small sip of water 30 minutes before breakfast or any other medication (EMC, 2022f).
SGLT2 inhibitors
The SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) induce glycosuria, which predisposes the patient to genital fungal infection and to a much lesser extent urinary tract infection (UTI) (Li et al, 2017). The symptoms of candidal vulvovaginitis and balanitis and how to respond to these should be explained to people starting SGLT2 inhibitors. Female sex and previous history of genital thrush are the strongest predictors of genital fungal infection (Thong et al, 2018).
Topical antifungal creams and pessaries (or alternatively oral fluconazole) are usually effective in settling genital candidiasis and treatment with the SGLT2 inhibitor can be continued. Good genital hygiene should be encouraged. Persistent/recurrent infection may necessitate discontinuation of the SGLT2 inhibitor, although there is the option of using fluconazole prophylactically (Pappas et al, 2016).
Conventional antibiotic treatment together with a good fluid intake should be used to manage UTIs, but again, SGLT2 inhibitors may need to be avoided in the case of recurrent infection. A pre-existing history of recurrent UTI would be a relative contraindication to SGLT2 inhibitor use.
The osmotic diuresis induced by SGLT2 inhibitors leads to increased micturition that can be troublesome, especially for those with detrusor instability or prostatism. Volume depletion side effects including dehydration and postural hypotension may result, meaning SGLT2 inhibitors should be used cautiously in the elderly and particularly in those using diuretics (notably, loop diuretics).
The use of SGLT2 inhibitors has been associated with a small increased risk of diabetic ketoacidosis (DKA) (Liu et al, 2020) and predisposing situations are listed in Box 4 (Morris, 2022). A characteristic feature is that DKA may occur with only modestly elevated glucose levels (<14 mmol/l) (Wilding et al, 2018). It is important to warn people using SGLT2 inhibitors of the warning symptoms of DKA (nausea, vomiting, abdominal pain, shortness of breath, thirst, increased micturition, fatigue, fruity smell on breath) and the need to stop the treatment and seek immediate medical advice (MHRA, 2016).
Box 4.Situations predisposing to diabetic ketoacidosis with SGLT-2 inhibitor use
- Type 1 diabetes, latent autoimmune disease in adults, pancreatogenic diabetes
- Sudden reduction in insulin dose
- Acute illness/infection
- Dehydration
- Surgery
- Alcohol excess
- Fasting (carbohydrate restriction, ketogenic diet)
- Corticosteroid therapy.
If DKA is suspected, the key test is for ketones (preferably fingerprick blood ketones) – Table 2 explains how to interpret these results (Morris, 2022). The provision of information to reduce the risk of DKA should be given to all individuals commencing SGLT-2 inhibitors (Box 5) (MHRA, 2016; Morris, 2022).
Table 2. Blood and urine ketone test results and interpretation
| Blood ketone concentration | Urine ketones dipstick | Interpretation |
|---|---|---|
| <0.6 mmol/L | Negative | Normal range |
| 0.6–1.5 mmol/L | Trace or + | Potential problem. Keep monitoring. Seek medical advice if unwell. |
| 1.5–3.0 mmol/L | ++ | High risk of DKA, seek medical advice urgently. |
| >3 mmol/L | +++/++++ | Likely DKA. Immediate medical review needed |
Box 5.Advice to reduce the risk of DKA when taking SGLT-2 inhibitors
- Maintain good fluid intake
- Avoid very low carbohydrate (or ketogenic) diet
- Temporarily stop SGLT-2 inhibitor in situation of acute illness, vomiting and diarrhoea, inability to eat and drink, 48 hrs prior to planned major surgery (to reduce risk of DKA and acute kidney injury)
- Awareness of DKA symptoms
- If DKA suspected, stop SGLT-2 inhibitor, seek medical advice (even if blood glucose levels not unduly raised).
SGLT2 inhibitors have been implicated in causing Fournier's gangrene. This is a rare but potentially life-threatening necrotic soft tissue infection of the perineum, external genitalia and perianal region. If this condition is suspected, stop the SGLT2 inhibitor immediately and urgently refer the patient to urologists for surgical debridement and treatment with broad-spectrum antibiotics (Bersoff-Matcha et al, 2019).
An increased risk of lower limb amputation (mainly toe or metatarsal) and increased risk of fracture were identified in the canagliflozin CVOT (Neal et al, 2017), although these findings have not been replicated with other SGLT-2 inhibitors. The EMA (2017) advised that a warning regarding lower limb amputation be included in the product information of all SGLT2 inhibitors. Box 6 (Morris, 2022) details good foot care practices and precautions for clinicians to reduce the risk of lower limb amputation when using SGLT-2 inhibitors as advised by MHRA and NICE (MHRA, 2017; NICE, 2015b).
Box 6.Reducing the risk of lower limb amputation when using SGLT2 inhibitors in T2DMPeople taking SGLT2 inhibitors should:
- Check feet regularly and practice preventative foot care (remove calluses, apply emollient etc)
- Report any foot infection or ulceration
- Maintain adequate hydration.
Clinicians should:
- Provide education
- Emphasise the importance of good foot care when taking SGLT-2 inhibitors
- Avoid initiation of SGLT2 inhibitors if the patient has active foot ulceration
- Be cautious about initiating SGLT2 inhibitors in a person with peripheral vascular disease or previous limb amputation.
- Consider stopping SGLT2 inhibitors in cases of foot ulceration, osteomyelitis or gangrene.
While a study on fracture risk with SGLT2 inhibitors has been reassuring (Li et al, 2019), longer-term studies will be required to define whether or not osteoporotic bone fracture is a significant issue (Wilding et al, 2018). In situations of significant acute illness where dehydration is a risk (eg vomiting, diarrhea), SGLT2 inhibitors should be temporarily discontinued to reduce the risk of acute kidney injury and DKA (Fralick et al, 2017; Wilding et al, 2018). Maintenance of a good fluid intake (aiming for 3 litres a day) and an intake of carbohydrates (to reduce ketone production) should be encouraged (Down, 2020).
Insulin
The disadvantages of insulin treatment include the need to inject, the requirement for regular fingerprick glucose monitoring, the complexity of dose titration, the risk of hypoglycemia, and the likelihood of weight gain. An intensive education package from an appropriately trained healthcare professional should accompany insulin initiation (Box 7).
Box 7.Essential education when commencing insulin
- Injection technique, site rotation, managing lipohypertrophy
- Sharps disposal
- Self-monitoring of blood glucose
- Self-adjustment of insulin dose
- Recognition and response to hypoglycaemia
- Sick day rules
- Insurance and driving implications
- Point of contact if problems.
Individuals should be advised on how to recognise impending hypoglycaemia, interpret glucose readings and how to manage episodes of hypoglycaemia, including the necessity to always carry a supply of fast-acting carbohydrates with them. Intrinsic to avoiding hypoglycaemia is an understanding of when and how to correctly administer insulin.
Longer-acting basal insulin analogues and rapid-acting insulin analogues have less propensity to cause hypoglycaemia than the corresponding human insulins, but are more expensive (Davies et al, 2018). In people with hypoglycaemia, insulins and target glucose ranges will need to be carefully chosen.
People may seek to avoid insulin therapy because of fear of hypoglycaemia and weight gain, an unwillingness to monitor or needle phobia. For some, starting insulin might result in loss, or at least disruption, of employment, notably drivers of large goods vehicles and passenger-carrying vehicles; in such cases, the individual may choose to delay insulin initiation and accept suboptimal glycaemic control.
Innovations in glucose monitoring have now been recommended for use in T2DM under certain circumstances (NICE, 2015a). Real-time and intermittently scanned (flash) continuous glucose monitoring help overcome the burden of regular fingerprick glucose monitoring and the alarm systems accompanying these devices may reduce concerns over insulin-induced hypoglycaemia.
Conclusion
When considering a treatment to improve glycaemic control, it is important to involve the individual in the decision-making process and to consider their specific circumstances and potential vulnerability to adverse events associated with the treatment. It is also essential to provide clear information about possible medication side-effects and how to manage them.
The benefits of improved glycaemic control and other potential gains from treatment should be balanced against the risk of side effects. Regular medication reviews are an important part of this dynamic process, as they allow for ongoing assessment of efficacy and tolerability and adjustment of treatment as needed.
Key points
- Before commencing a medication for diabetes, be clear on the target for glycaemic control and ensure lifestyle issues have been addressed
- Explain the need for treatment, its possible side effects, and how to manage them
- Be aware of those who may be most vulnerable to adverse medication events, including the elderly, those with reduced renal or hepatic function, and in situations of polypharmacy
- Use the lowest effective dose of medication and consider slow dose increases to minimise side effects
- If side effects occur, consider reducing the dose, discontinuing the drug, or switching to an alternative treatment
- Metformin's gastrointestinal side effects can be minimised by slow dose titration and/or use of the modified-release formulation.
- Hypoglycaemia and weight gain are problematic side effects of sulfonylureas and insulins
- Pioglitazone is contraindicated in heart failure and should be avoided in those at risk of bladder cancer or fracture
- DPP-4 inhibitors are generally well-tolerated, while gastrointestinal issues can limit the use of GLP-1 receptor agonists. Longer-acting human GLP-1 analogues may carry a lower risk of side-effects
- SGLT2 inhibitors can cause genital fungal infections, and diabetic ketoacidosis is a rare but serious side-effect.
CPD reflective questions
- When considering the escalation of therapy in type 2 diabetes do you routinely reinforce the importance of lifestyle measures?
- Do you review renal function when prescribing medication for type 2 diabetes?
- Do you individualise HbA1C targets according to personal circumstances?
- How do you decide which medication side effects to counsel individuals about?