This site is intended for healthcare professionals only
DiabetesontheNet Logo

Diabetes &
Primary Care


Share this article

Reassessing the goals in type 2 diabetes management: A time for change?

David Haslam

Type 2 diabetes is associated with a significant risk of micro- and macrovascular complications, with the risk of cardiovascular disease (CVD), in particular, two- to five-times higher for people with type 2 diabetes compared with healthy individuals. This article considers the steps that can be taken in primary care to minimise these risks, in particular by screening asymptomatic individuals for type 2 diabetes, establishing and maintaining both metabolic and CVD treatment targets, and implementing appropriate and intensive treatment early in the disease process. The article also considers whether incretin-based therapies, a relatively new treatment option for type 2 diabetes, have a role in the management of the condition early in the disease process.

Individuals with type 2 diabetes may remain asymptomatic for many years, resulting in delayed diagnosis and treatment. A report states that 2.1 million people of at least 17 years of age with a diagnosis of diabetes were registered at GP practices in England in 2008 (NHS Information Centre for Health and Social Care et al, 2008). The discrepancy between this figure and the estimated prevalence from modelling suggests that approximately 350 000 adults with diabetes were undiagnosed (NHS Information Centre for Health and Social Care et al, 2008).

The importance of effective screening
Earlier and more extensive screening is necessary to reduce the number of people with undiagnosed type 2 diabetes. The importance of such screening is apparent from a Canadian study in which 21–39% of individuals at the time of type 2 diabetes diagnosis already had some sight-threatening retinopathy (International Diabetes Federation Clinical Guidelines Taskforce, 2005).

Particular attention should be paid to screening individuals at a higher risk of type 2 diabetes, including obese people, those presenting with other metabolic syndrome criteria, a history of gestational diabetes or a strong family history of diabetes. As people with cardiovascular disease (CVD) often have undiagnosed type 2 diabetes or glucose intolerance (Norhammar et al, 2002; Matz et al, 2006), there is a clear rationale for incorporating CVD risk scores, such as the Systematic Coronary Risk Evaluation (SCORE) (Conroy et al, 2003), UK Prospective Diabetes Study (UKPDS) Risk Engine (Stevens et al, 2001), Framingham (Wilson et al, 1998), and QRISK-2 (Hippisley-Cox et al, 2008), into screening methodologies.

The NHS “Health Check” programme – which assesses vascular risk in adults aged 40–74 years with no existing diagnosed vascular disease – is an important step in this direction (Department of Health, 2009). This programme should identify individuals with type 2 diabetes early in the course of the condition so they can gain prompt access to lifestyle counselling, monitoring and treatment intervention.

Ensuring individuals achieve treatment goals
Current type 2 diabetes management fails to reach treatment goals

Management guidelines from NICE (2009), the European Society of Cardiology/European Association for the Study of Diabetes (EASD) (Rydén et al, 2007), the American Diabetes Association (ADA)/EASD (Nathan et al, 2009) and the Joint British Societies (JBS-2) (British Cardiac Society et al, 2005) detail recommended goals for levels of HbA1c, fasting and postprandial glucose, blood pressure and lipids (Table 1). While two of the guidelines also include BMI or weight (Table 1), abdominal obesity (as measured by waist circumference) is more accurate than BMI for predicting cardiometabolic risk (Balkau et al, 2007; Smith and Haslam, 2007). Of the recommended goals, HbA1c is generally considered the standard measure for assessing blood glucose control.

Despite the many guidelines for the management of type 2 diabetes, target blood glucose and CVD risk factor goals are currently poorly attained. The National Diabetes Audit analysis for general practice for 2007–2008 reported that 63% of people with diabetes in England reached HbA1c levels of ≤7.5% (≤58 mmol/mol) (NHS Information Centre for Health and Social Care, 2009). The NICE cholesterol target (<5 mmol/L) and diastolic and systolic blood pressure targets (≤75 and ≤135 mmHg, respectively) were attained by 78 and 30% of people, respectively. Similarly, an evaluation of cholesterol goal achievement in UK clinical practice determined that most people (~73%) did not achieve the stringent JBS-2 cholesterol target (<4.0 mmol/L; British Cardiac Society et al, 2005), even with prescribed therapy (Rajagopalan et al, 2007).

Barriers to reaching treatment goals
A multitude of factors underlie the failure to reach treatment goals. Treatment goals may not be achieved because appropriate or intensified treatment is given too late in the disease process, resulting from delays in diagnosis and/or in the current stepwise treatment protocols. Patients’ adherence to the treatment plan may also be poor, perhaps due to fears regarding hypoglycaemia and weight gain, but particularly with dosing regimens that are complex. A treatment adherence study of people with type 2 diabetes in Scotland, for example, demonstrated that only one in three people had adequate adherence (defined as ≥90%) when prescribed one tablet per day, and adherence decreased linearly with increases in the number of prescribed medications to be taken daily (Donnan et al, 2002).

Type 2 diabetes management may also be hindered by the failure of treatments to arrest the decline in beta-cell function and/or the tendency of some treatments to increase CVD risk factors, such as abdominal obesity. In the UKPDS 49, effective diabetes control progressively deteriorated over time (Turner et al, 1999). For people receiving insulin monotherapy, the proportion attaining the HbA1c goal (<7.0% [<53 mmol/mol]) declined from 47% at 3 years to 37 and 28% at 6 and 9 years, respectively; corresponding values of 50, 34 and 24% were reported for people treated with a sulphonylurea.

Weight gain is associated with many commonly used type 2 diabetes treatments, such as insulin, sulphonylureas and meglitinides (Nathan et al, 2009). Weight gain is also apparent with thiazolidinedione treatment, however there is some evidence that although the overall fat mass is increased, a redistribution of fat from visceral to lower-risk subcutaneous areas occurs (Kushner and Sujak, 2009). This is exemplified by data from UKPDS 33, in which people receiving insulin or sulphonylureas had increased weight gains of 4.0 and 1.7–2.6 kg, respectively, compared with the conventional therapy group receiving dietary advice (UKPDS Group, 1998). In contrast, metformin is considered to be weight-neutral (Nathan et al, 2009).

Targeting all risk factors and initiating early intensive therapy
Micro- and macrovascular disease

Several studies have demonstrated that intensively managing hyperglycaemia decreases diabetes-related microvascular disease. UKPDS 35, for example, showed that the risk of microvascular complications was reduced by 37% when HbA1c was reduced by 1% (Stratton et al, 2000). However, both the incidence of, and mortality due to, macrovascular disease are more significant than those due to microvascular disease. In UKPDS 17, diabetic microvascular disease was experienced by 9% of people with type 2 diabetes, while 20% experienced macrovascular complications; additionally, a fatal outcome occurred 70 times more frequently with macrovascular disease compared with microvascular disease (Turner et al, 1996).

Current evidence suggests that macrovascular outcomes can be improved by managing all metabolic and CVD risk factors. In the Steno-2 study, which targeted several risk factors with intensive treatment (including lifestyle modification, CVD primary prevention with aspirin and maintenance of an HbA1c level ≤6.5% [≤48 mmol/mol] using a stepped treatment algorithm) over an average of 7.8 years, the risk of both macro- and microvascular events was reduced by approximately 50% when hyperglycaemia, hypertension, dyslipidaemia and microalbuminuria were targeted in combination (Gaede et al, 2003). This CVD risk reduction is higher than that observed in most studies using single-factor intervention therapies. In addition, a decrease in the ratio of saturated and unsaturated fatty acids, and total fat intake in the daily diet of people, in the intensive treatment arm was significantly lower than those for the people in the standard treatment arm (Gaede et al, 2001).

In a 5.5-year follow-up to the Steno-2 study, the beneficial effects on CVD events were sustained, demonstrating the effectiveness of multifactorial treatment for people with type 2 diabetes (Gaede et al, 2008). The benefits of tailoring this multifaceted approach to the individual’s needs with personalised education and surveillance were demonstrated in a 6-year Danish study in primary care, as metabolic and CVD risk factors (HbA1c, fasting plasma glucose, systolic blood pressure and cholesterol levels) were reduced, compared with routine, non-individualised type 2 diabetes management (Olivarius et al, 2001).

The literature regarding the effects of intensive glycaemic control alone on macrovascular outcomes appears conflicting. However, it is possible that discrepancies arise in part because of differences in the timings of interventions relative to the disease process, with early intervention associated with more positive outcomes. For example, analyses of data from the General Practice Research Database (GPRD), involving more than 47000 people over a 12-year period, revealed that the likelihood of both all-cause mortality and progression to first large-vessel event was reduced for those taking a combination of metformin with sulphonylurea compared with people whose regimens included insulin (Currie et al, 2010). Of relevance here is the fact that the group receiving metformin with sulphonylurea had a shorter duration of diabetes and fewer people with comorbidities at baseline compared with the group receiving insulin regimens.

This interpretation of the GPRD data, with macrovascular benefits perhaps dependent on early intervention, resonates with findings from other studies (Holman et al, 2008; ACCORD [Action to Control Cardiovascular Risk in Diabetes] Study Group et al, 2011; ADVANCE [Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation] Collaborative Group et al, 2008; Reaven et al, 2009). In the UKPDS, people newly diagnosed with type 2 diabetes at baseline were randomly allocated to either intensive treatment (sulphonylurea or insulin or metformin) or conventional treatment (a change in diet) (Holman et al, 2008).

While there were no differences between groups for the risk of myocardial infarction at the end of the intervention period, participants were followed-up for a further 10 years after the cessation of randomised treatment, and a significant reduction in the risk of myocardial infarction was apparent in the group formerly assigned to intensive treatment. Similarly, in a sub-study analysis of the VADT (Veteran’s Affairs Diabetes Trial) data, participants with less advanced atherosclerosis had a greater improvement in CVD outcomes with intensive therapy compared with people with more advanced atherosclerosis (Reaven et al, 2009). In the ACCORD and ADVANCE studies, participants with diabetes and micro- or macrovascular disease achieved good glycaemic control without a reduction in cardiovascular risk (ACCORD Study Group et al, 2011; ADVANCE Collaborative Group et al, 2008).

The GPRD study also showed increased all-cause mortality and progression to a first large-vessel disease event at high HbA1c levels compared with HbA1c levels of approximately 7.5% (58 mmol/mol), and an increased risk of all-cause mortality at low HbA1c levels compared with levels of approximately 7.5% (58 mmol/mol) (Currie et al, 2010). The authors suggest that one explanation for the increased risk of all-cause mortality at lower HbA1c levels may be the increased risk of hypoglycaemia associated with intensive glycaemic control, potentiating glucose variability and contributing to oxidative stress and vascular inflammation.

If hypoglycaemia is responsible for increased mortality risk it could be postulated that intensive glycaemic control should be implemented with antidiabetes agents associated with a particularly low risk of hypoglycaemia. However, the authors of a recent 5-year follow-up of the ACCORD trial concluded that although the intensively treated group experienced an increased rate of overall mortality compared with the less intensively treated group, severe hypoglycaemia was not implicated (ACCORD Study Group et al, 2011).

Cost considerations
As health costs increase significantly with the prevalence of long-term diabetes complications (Clarke et al, 2003), one might expect that improved type 2 diabetes management early in the disease process would yield some cost benefits. ADDITION (Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care) will soon provide further data regarding the benefit and costs of intensive multifactorial treatment early in the disease process (Sandbaek et al, 2008).

Implementing good management strategies for type 2 diabetes in primary care

In the UK, QOF provides treatment indicators for use in primary care. The lowest HbA1c levels for QOF indicators were tightened from ≤7.5 to ≤7.0% (≤58 to ≤53 mmol/mol) in 2009. Although there is clinical research evidence indicative of significant benefits with tight glycaemic control early in the disease process (Holman et al, 2008), setting indicators in this manner was not without problems.

By rewarding physicians to attain HbA1c levels of ≤7.0% (≤53 mmol/mol), there was a natural temptation to drive the levels of people at 7.1% (54 mmol/mol) down further by intensifying treatment, even if their diabetes was well controlled. In addition, those people with HbA1c levels of ≥10% (≥86 mmol/mol) may have been neglected because, for example, people who improve from 12 to 10% had a negative impact on incentive payments despite a marked improvement in glycaemic control. Debate over the QOF indicators has resulted in a change in the lowest HbA1c levels back to ≥7.5% (≥58 mmol/mol) (NHS Employers, 2011).

Another limitation of the QOF indicators is the lack of incentives for screening obese or high-risk people, which is necessary for early treatment intervention. To achieve sufficient numbers of people with HbA1c levels ≤7.0%, those with manageable levels should be treated earlier.

A key consideration in the safe delivery of intensive type 2 diabetes treatment remains the risk of hypoglycaemia. In the ACCORD and VADT trials, hypoglycaemia was significantly more common in the intensive therapy group compared with the standard therapy group (ACCORD Study Group et al, 2008; Duckworth et al, 2009).

There is an inherent risk of hypoglycaemia with therapies that increase insulin concentrations in the blood independently of blood glucose levels (such as insulin secretagogues and insulins). Over the first 10 years of the UKPDS, 36.5% of people treated with insulin reported hypoglycaemia, with 1.8% experiencing severe hypoglycaemic episodes (UKPDS Group, 1998). Other UK community-based studies have observed higher incidences of severe hypoglycaemic events (2–15%) in people treated with insulin (Leese et al, 2003; Henderson et al, 2003; Donnelly et al, 2005). In addition, in a study of people with type 2 diabetes treated with sulphonylureas or insulin for <2 years, there were no significant differences between the two treatments in the proportion of people experiencing mild (39 versus 51%) or severe hypoglycaemia (7% in both cases) (UK Hypoglycaemia Study Group, 2007).

It is important to appreciate that severe hypoglycaemic events may be more common than is recognised by primary care clinicians as there is no obligation for severe hypoglycaemic events requiring assistance from a paramedic to be reported to primary care (Leese et al, 2003). The choice of antidiabetes agent can do much to mitigate the risk of hypoglycaemia, while also achieving good glycaemic control.

Management strategies
Good type 2 diabetes management requires treatments that provide good glycaemic control with low rates of hypoglycaemia, but that can also improve CVD risk factors and have the potential to preserve beta-cell function.

Currently, when lifestyle and dietary advice are no longer sufficient to maintain glycaemic control, metformin is the most commonly recommended first-line pharmacological intervention (Nathan et al, 2009; NICE, 2009; Rodbard et al, 2009). Other well-established agents commonly recommended for use early in the disease process include sulphonylureas and thiazolidinediones. The recent development of incretin-based therapies – namely the dipeptidyl peptidase-4 (DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists – offer newer options for the management of type 2 diabetes.

Incretin-based therapies: approved uses and efficacy
DPP-4 inhibitors are orally administered agents that block the inactivation of GLP-1 and gastric inhibitory peptide, incretin hormones that are secreted from the gastrointestinal tract (Drucker and Nauck, 2006). DPP-4 inhibitors approved for use in the UK comprise sitagliptin, vildagliptin and saxagliptin. There are variations in the licenced indications of these drugs, which are listed in full in the relevant summary of product characteristics (Electronic Medicines Compendium [EMC] 2011a; b; c) and national guidance on their use is available from NICE (2009) and SIGN (2010).

These agents offer clinically important improvements in glycaemic control, generally in the range 0.5–1.1%, as monotherapy and in combination with a range of other oral antidiabetes drugs (Ahrén, 2008; Nathan et al, 2009). DPP-4 inhibitors are normally considered to be weight neutral (Ahrén, 2008; Nathan et al, 2009), although a mean weight loss of 0.96 kg has been reported with sitagliptin in a head-to-head study with liraglutide (Pratley et al, 2010).

Improved beta-cell function, assessed using the homeostasis assessment model of beta-cell function (HOMA-B) and proinsulin:insulin ratio, has been demonstrated in clinical trials with DPP-4 inhibitors (Pratley et al, 2008; Riche et al, 2009; DeFronzo et al, 2009). The limited data available also suggest that DPP-4 inhibitors may mediate reductions in blood pressure (Bosi et al, 2007; Pratley et al, 2010).

There are two injectable GLP-1 receptor agonists available in the UK – exenatide, administered twice-daily and liraglutide, administered once-daily. These agents stimulate glucose-dependent endogenous insulin secretion, decrease glucagon secretion and inhibit gastric emptying (Drucker and Nauck, 2006). There are variations in the specific licenced indications for exenatide and liraglutide in people with type 2 diabetes and full details can be found in the respective summary of product characteristics (EMC 2010; 2011d). National guidance on their use is available from NICE (2009; 2010) and SIGN (2010).

GLP-1 receptor agonists have demonstrated improvements in glycaemic control. Exenatide 10 μg reduced HbA1c levels by 0.78–1.5% over 26–30 weeks, and 30–40% of people reached HbA1c levels of ≤7.0% (≤53 mmol/mol) (Buse et al, 2004; DeFronzo et al, 2005; Kendall et al, 2005; Drucker et al, 2008; Buse et al, 2009). In those completing up to 3 years of treatment, glycaemic control was sustained and approximately half achieved HbA1c levels ≤7.0% (≤53 mmol/mol) (Buse et al, 2007; Klonoff et al, 2008).

Mean reductions in HbA1c levels for liraglutide 1.2 and 1.8 mg after 26 weeks in combination therapy ranged from 1.0–1.5% for both doses, allowing 35–58% of people receiving 1.2 mg and 42–55% receiving 1.8 mg to achieve HbA1c levels of <7.0% (<53 mmol/mol) Marre et al, 2009; Nauck et al, 2009; Zinman et al, 2009; Russell-Jones et al, 2009; Buse et al, 2009; Pratley et al, 2010).

In addition to their antihyperglycaemic effects, GLP-1 receptor agonists provide other benefits for the management of people with type 2 diabetes. Weight loss has been demonstrated with both exenatide and liraglutide. Progressive weight reductions were associated with exenatide treatment, with a mean loss of 1.6–3.6 kg in 26- to 30-week studies (Buse et al, 2004; DeFronzo et al, 2005; Kendall et al, 2005; Drucker et al, 2008; Buse et al, 2009) and, among completers, 5.3 kg after a 3-year treatment period (Klonoff et al, 2008). In combination with metformin, liraglutide treatment was associated with clinically meaningful weight loss after 26 weeks (1.2 mg: 2.6–2.9 kg; 1.8 mg: 2.8–3.4 kg) (Nauck et al, 2009; Pratley et al, 2010). As expected, in combinations including oral agents associated with weight gain (sulphonylureas or thiazolidinediones), weight benefits were more variable (Buse et al, 2009; Marre et al, 2009; Russell-Jones et al, 2009; Zinman et al, 2009).

GLP-1 receptor agonists also have the potential to maintain or improve beta-cell function. HOMA-B and proinsulin:insulin ratios indicate improvements in beta-cell function after exenatide treatment (Buse et al, 2004; DeFronzo et al, 2005; Buse et al, 2007). Improvements in first- and second-phase insulin secretion have been observed with liraglutide treatment, in addition to improvements in arginine-stimulated insulin secretion during hyperglycaemia (Vilsbøll et al, 2008).

Beneficial effects on blood pressure have also been reported with GLP-1 receptor agonists (Buse et al, 2009; Pratley et al, 2010).

Safety of incretin-based therapies
Incretin-based therapies are generally well tolerated and rates of hypoglycaemia are low, although rates may increase in combination with sulphonylureas (Ahrén, 2008; Buse et al, 2009).

Increased rates of infections with sitagliptin have been noted as being of possible concern (Richter et al, 2008; Nathan et al, 2009), but an association with sitagliptin or other DPP-4 inhibitors has not been established.

Concerns have also been raised over a potential relationship between incretin-based therapies and acute pancreatitis (US Food and Drug Administration, 2009a; b). In light of the uncertainty regarding such a relationship, the discontinuation of exenatide and liraglutide is recommended if pancreatitis is suspected (EMC, 2010; 2011d). The most common adverse event with GLP-1 receptor agonists is nausea, although this is generally transient (DeFronzo et al, 2005; Buse et al, 2009).

Given the data for both glycaemic and extraglycaemic benefits, the low rates of hypoglycaemia and good general tolerability, the author suggests that it may be appropriate to consider using incretin therapies earlier in the treatment pathway for selected people with type 2 diabetes.

Traditional blood glucose-lowering therapies for type 2 diabetes often result in inadequate management, providing insufficient glycaemic control over time and being limited by side-effects, such as weight gain and an increased risk of hypoglycaemia. In addition, improvements in beta-cell function are, at best, modest. A number of practical changes in type 2 diabetes management are thus required, particularly in primary care, where most of the early treatment decisions are made. Effective screening to facilitate early diagnosis of type 2 diabetes is critical, and should be followed by a complete metabolic and CVD risk assessment. Early intensive multifactorial treatment intervention based on the individual’s risk assessment is recommended, provided treatment goals can be achieved safely and responsibly. The effects of blood glucose-lowering drugs on all risk factors and on beta-cell function should also be considered when making these treatment decisions.

Conflicts of interest
Professor David Haslam receives occasional honoraria for speaking or consultancy from GlaxoSmithKline, Merck Sharp & Dohme, Bristol-Myers Squibb, Novo Nordisk and sanofi-aventis, and has participated in advisory board meetings for them.

The author is grateful for writing support provided principally by Medi Cine International and also by Watermeadow Medical, supported by Novo Nordisk UK.


ACCORD Study Group, Gerstein HC, Miller ME et al (2008) Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 358: 2545–59
ACCORD Study Group, Gerstein HC, Miller ME et al (2011) Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med 364: 818–28
ADVANCE Collaborative Group, Patel A, MacMahon S et al (2008) Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 358: 2560–72
Ahrén B (2008) Emerging dipeptidyl peptidase-4 inhibitors for the treatment of diabetes. Expert Opin Emerg Drugs 13: 593–607
Balkau B, Deanfield JE, Després JP et al (2007) International Day for the Evaluation of Abdominal Obesity (IDEA): a study of waist circumference, cardiovascular disease, and diabetes mellitus in 168,000 primary care patients in 63 countries. Circulation 116: 1942–51
Bosi E, Camisasca RP, Collober C et al (2007) Effects of vildagliptin on glucose control over 24 weeks in patients with type 2 diabetes inadequately controlled with metformin. Diabetes Care 30: 890–5
Buse JB, Henry RR, Han J et al (2004) Effects of exenatide (exendin-4) on glycemic control over 30 weeks in sulfonylurea-treated patients with type 2 diabetes. Diabetes Care 27: 2628–35
Buse JB, Klonoff DC, Nielsen LL et al (2007) Metabolic effects of two years of exenatide treatment on diabetes, obesity, and hepatic biomarkers in patients with type 2 diabetes: an interim analysis of data from the open-label, uncontrolled extension of three double-blind, placebo-controlled trials. Clin Ther 29: 139–53
Buse JB, Rosenstock J, Sesti G et al (2009) Liraglutide once a day versus exenatide twice a day for type 2 diabetes: a 26-week randomised, parallel-group, multinational, open-label trial (LEAD-6). Lancet 374: 39–47
British Cardiac Society, British Hypertension Society, Diabetes UK et al (2005) JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 91(Suppl 5): v1–52
Clarke P, Gray A, Legood R et al (2003) The impact of diabetes-related complications on healthcare costs: results from the United Kingdom Prospective Diabetes Study (UKPDS Study No. 65). Diabet Med 20: 442–50
Conroy RM, Pyörälä K, Fitzgerald AP et al (2003) Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 24: 987–1003
Currie CJ, Peters JR, Tynan A et al (2010) Survival as a function of HbA(1c) in people with type 2 diabetes: a retrospective cohort study. Lancet 375: 481–9
DeFronzo RA, Ratner RE, Han J et al (2005) Effects of exenatide (exendin-4) on glycemic control and weight over 30 weeks in metformin-treated patients with type 2 diabetes. Diabetes Care 28: 1092–100
DeFronzo RA, Hissa MN, Garber AJ et al (2009) The efficacy and safety of saxagliptin when added to metformin therapy in patients with inadequately controlled type 2 diabetes with metformin alone. Diabetes Care 32: 1649–55
Department of Health (2009) Putting Prevention First. NHS Health Check: Vascular Risk Assessment and Management. Best Practice Guidance. DH, London. Available at (accessed 21.03.11)
Donnan PT, MacDonald TM, Morris AD (2002) Adherence to prescribed oral hypoglycaemic medication in a population of patients with type 2 diabetes: a retrospective cohort study. Diabet Med 19: 279–84
Donnelly LA, Morris AD, Frier BM et al (2005) Frequency and predictors of hypoglycaemia in type 1 and insulin-treated type 2 diabetes: a population-based study. Diabet Med 22: 749–55
Drucker DJ, Nauck MA (2006) The incretin system: glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes. Lancet 368: 1696–705
Drucker DJ, Buse JB, Taylor K et al (2008) Exenatide once weekly versus twice daily for the treatment of type 2 diabetes: a randomised, open-label, non-inferiority study. Lancet 372: 1240–50
Duckworth W, Abraira C, Moritz T et al (2009) Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 360: 129–39
Electronic Medicines Compendium (2010) Byetta 5 micrograms solution for injection, prefilled pen. Byetta 10 micrograms solution for injection, prefilled pen. Available at: (accessed 21.03.11)
Electronic Medicines Compendium (2011a) Galvus 50 mg Tablets. Available at: (accessed 08.04.11)
Electronic Medicines Compendium (2011b) JANUVIA 100 mg film-coated tablets. Available at: (accessed 08.04.11)
Electronic Medicines Compendium (2011c) Onglyza 2.5 mg & 5 mg film-coated tablets. Available at: (accessed 08.04.11)
Electronic Medicines Compendium (2011d) Victoza 6 mg/ml solution for injection in pre-filled pen. Available at: (accessed 08.04.11)
Gaede P, Beck M, Vedel P, Pedersen O (2001) Limited impact of lifestyle education in patients with type 2 diabetes mellitus and microalbuminuria: results from a randomized intervention study. Diabet Med 18: 104–8
Gaede P, Vedel P, Larsen N et al (2003) Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 348: 383–93
Gaede P, Lund-Andersen H, Parving HH, Pedersen O (2008) Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 358: 580–91
Henderson JN, Allen KV, Deary IJ, Frier BM (2003) Hypoglycaemia in insulin-treated type 2 diabetes: frequency, symptoms and impaired awareness. Diabet Med 20: 1016–21
Hippisley-Cox J, Coupland C, Vinogradova Y et al (2008) Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ 336: 1475–82
Holman RR, Paul SK, Bethel MA et al (2008) 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 359: 1577–89
International Diabetes Federation Clinical Guidelines Task Force (2005) Global Guideline for Type 2 Diabetes. International Diabetes Federation, Brussels. Available at: (accessed 21.03.11)
Kendall DM, Riddle MC, Rosenstock J et al (2005) Effects of exenatide (exendin-4) on glycemic control over 30 weeks in patients with type 2 diabetes treated with metformin and a sulfonylurea. Diabetes Care 28: 1083–91
Klonoff DC, Buse JB, Nielsen LL et al (2008) Exenatide effects on diabetes, obesity, cardiovascular risk factors and hepatic biomarkers in patients with type 2 diabetes treated for at least 3 years. Curr Med Res Opin 24: 275–86
Kushner RF, Sujak M (2009) Prevention of weight gain in adult patients with type 2 diabetes treated with pioglitazone. Obesity (Silver Spring) 17: 1017–22
Leese GP, Wang J, Broomhall J et al (2003) Frequency of severe hypoglycemia requiring emergency treatment in type 1 and type 2 diabetes: a population-based study of health service resource use. Diabetes Care 26: 1176–80
Marre M, Shaw J, Brändle M et al (2009) Liraglutide, a once-daily human GLP-1 analogue, added to a sulphonylurea over 26 weeks produces greater improvements in glycaemic and weight control compared with adding rosiglitazone or placebo in subjects with type 2 diabetes (LEAD-1 SU). Diabet Med 26: 268–78
Matz K, Keresztes K, Tatschl C et al (2006) Disorders of glucose metabolism in acute stroke patients: an underrecognized problem. Diabetes Care 29: 792–7
Nathan DM, Buse JB, Davidson MB et al (2009) Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 32: 193–203
Nauck M, Frid A, Hermansen K et al (2009) Efficacy and safety comparison of liraglutide, glimepiride, and placebo, all in combination with metformin, in type 2 diabetes: the LEAD (liraglutide effect and action in diabetes)-2 study. Diabetes Care 32: 84–90
NHS Employers (2011) Changes to QOF 2011/12. Available at: (accessed 14.03.11)
NHS Information Centre for Health and Social Care, Prescribing Support Unit, Yorkshire and Humber Public Health Observatory (2008) Prescribing for Diabetes in England: An Update 2002–2008. Available at: (accessed 21.03.11)
NHS Information Centre for Health and Social Care (2009) National clinical audit support programme (diabetes). Available at: (accessed 21.03.11)
NICE (2009) Type 2 Diabetes. The Management of Type 2 Diabetes. NICE Clinical Guideline 87. NICE, London
NICE (2010) Liraglutide for the Treatment of Type 2 Diabetes Mellitus. NICE, London
Norhammar A, Tenerz A, Nilsson G et al (2002) Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet 359: 2140–4
Olivarius NF, Beck-Nielsen H, Andreasen AH et al (2001) Randomised controlled trial of structured personal care of type 2 diabetes mellitus. BMJ 323: 970–5
Pratley RE, Schweizer A, Rosenstock J et al (2008) Robust improvements in fasting and prandial measures of beta-cell function with vildagliptin in drug-naïve patients: analysis of pooled vildagliptin monotherapy database. Diabetes Obes Metab 10: 931–8
Pratley RE, Nauck M, Bailey T et al (2010) Liraglutide versus sitagliptin for patients with type 2 diabetes who did not have adequate glycaemic control with metformin: a 26-week, randomised, parallel-group, open-label trial. Lancet 375: 1447–56
Rajagopalan S, Alemao E, Finch L, Yin D (2007) Impact of new Joint British Societies’ (JBS 2) guidelines on prevention of cardiovascular disease: evaluation of serum total cholesterol goal achievement in UK clinical practice. Curr Med Res Opin 23: 2027–34
Reaven PD, Moritz TE, Schwenke DC et al (2009) Intensive glucose-lowering therapy reduces cardiovascular disease events in veterans affairs diabetes trial participants with lower calcified coronary atherosclerosis. Diabetes 58: 2642–8
Riche DM, East HE, Riche KD (2009) Impact of sitagliptin on markers of beta-cell function: a meta-analysis. Am J Med Sci 337: 321–8
Richter B, Bandeira-Echtler E, Bergerhoff K, Lerch C (2008) Emerging role of dipeptidyl peptidase-4 inhibitors in the management of type 2 diabetes. Vasc Health Risk Manag 4: 753–68
Rodbard HW, Jellinger PS, Davidson JA et al (2009) Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology consensus panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocr Pract 15: 540–59
Russell-Jones D, Vaag A, Schmitz O et al (2009) Liraglutide vs insulin glargine and placebo in combination with metformin and sulfonylurea therapy in type 2 diabetes mellitus (LEAD-5 met+SU): a randomised controlled trial. Diabetologia 52: 2046–55
Rydén L, Standl E, Bartnik M et al (2007) Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J 28: 88–136
Sandbaek A, Griffin SJ, Rutten G et al (2008) Stepwise screening for diabetes identifies people with high but modifiable coronary heart disease risk. The ADDITION study. Diabetologia 51: 1127–34
SIGN (2010) 116: Management of Diabetes. A National Clinical Guideline. SIGN, Edinburgh
Smith SC Jr, Haslam D (2007) Abdominal obesity, waist circumference and cardio-metabolic risk: awareness among primary care physicians, the general population and patients at risk – the Shape of the Nations survey. Curr Med Res Opin 23: 29–47
Stevens RJ, Kothari V, Adler AI et al (2001) The UKPDS risk engine: a model for the risk of coronary heart disease in type 2 diabetes (UKPDS 56). Clin Sci (Lond) 101: 671–9
Stratton IM, Adler AI, Neil HA et al (2000) Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 321: 405–12
Turner R, Cull C, Holman R (1996) United Kingdom Prospective Diabetes Study 17: a 9-year update of a randomized, controlled trial on the effect of improved metabolic control on complications in non-insulin-dependent diabetes mellitus. Ann Intern Med 124(1 Pt 2): 136–45
Turner RC, Cull CA, Frighi V, Holman RR (1999) Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA 281: 2005–12
UK Hypoglycaemia Study Group (2007) Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia 50: 1140–7
UK Prospective Diabetes Study Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 352: 837–53
US Food and Drug Administration (2009a) Information for Healthcare Professionals – Acute pancreatitis and sitagliptin (marketed as Januvia and Janumet). Food and Drug Administration, Siver Spring, USA. Available at: (accessed 21.03.11)
US Food and Drug Administration (2009b) Byetta Safety Update for Healthcare Professionals. Food and Drug Administration, Siver Spring, USA. Available at (accessed 21. 03.11)
Vilsbøll T, Brock B, Perrild H et al (2008) Liraglutide, a once-daily human GLP-1 analogue, improves pancreatic B-cell function and arginine-stimulated insulin secretion during hyperglycaemia in patients with Type 2 diabetes mellitus. Diabet Med 25: 152–6
Wilson PW, D’Agostino RB, Levy D et al (1998) Prediction of coronary heart disease using risk factor categories. Circulation 97: 1837–47
Zinman B, Gerich J, Buse JB et al (2009) Efficacy and safety of the human glucagon-like peptide-1 analog liraglutide in combination with metformin and thiazolidinedione in patients with type 2 diabetes (LEAD-4 Met+TZD). Diabetes Care 32: 1224–30

Related content
Free for all UK & Ireland healthcare professionals

Sign up to all DiabetesontheNet journals


By clicking ‘Subscribe’, you are agreeing that are able to email you periodic newsletters. You may unsubscribe from these at any time. Your info is safe with us and we will never sell or trade your details. For information please review our Privacy Policy.

DiabetesontheNet Logo

Are you a healthcare professional? This website is for healthcare professionals only. To continue, please confirm that you are a healthcare professional below.

We use cookies responsibly to ensure that we give you the best experience on our website. If you continue without changing your browser settings, we’ll assume that you are happy to receive all cookies on this website. Read about how we use cookies.