Médicaments antihyperglycémiants utilisés pour le diabète de type 2

Voir également le document séparé Management of Type 2 Diabetes article.

Oral hypoglycaemic agents are the group of drugs that may be taken singly or in combination to lower the blood glucose in type 2 diabetes. Type 2 diabetes can be due to increased peripheral resistance to insulin or to reduced secretion of insulin. They should be used together with changes in diet and lifestyle to achieve good glycaemic control and it is customary to monitor such changes for three months before considering medication. Oral hypoglycaemic agents are not usually used in type 1 diabetes but metformin may be of use in combination with insulin for overweight people with type 1 diabetes.¹

Blood glucose-lowering therapy²

HbA1c measurement

In adults with type 2 diabetes, measure HbA1c levels at:

• 3- to 6-monthly intervals (tailored to individual needs), until the HbA1c is stable on unchanging therapy

• Intervalles de 6 mois une fois que le niveau d'HbA1c et le traitement hypoglycémiant sont stables.

Si le suivi de l'HbA1c est invalide en raison d'un renouvellement perturbé des érythrocytes ou d'un type d'hémoglobine anormal, estimez les tendances du contrôle de la glycémie en utilisant l'une des options suivantes :

• Quality-controlled plasma glucose profiles.

• Estimation totale de l'hémoglobine glyquée (si hémoglobines anormales).

• Estimation de la fructosamine.

HbA1c targets

For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%).

In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher: reinforce advice about diet, lifestyle and adherence to drug treatment, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment.

Envisagez de relâcher le niveau cible d'HbA1c au cas par cas, en tenant particulièrement compte des personnes âgées ou fragiles, pour les adultes atteints de diabète de type 2 :

• Who are unlikely to achieve longer-term risk-reduction benefits - for example, people with a reduced life expectancy.

• For whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia - for example:

  • People who are at risk of falling.

  • People who have impaired awareness of hypoglycaemia.

  • People who drive or operate machinery as part of their job.

• For whom intensive management would not necessarily be appropriate - for example, people with significant comorbidities.

Si les adultes atteints de diabète de type 2 atteignent un niveau d'HbA1c inférieur à leur objectif et qu'ils ne ressentent pas d'hypoglycémie, encouragez-les à le maintenir. Soyez conscient qu'il existe d'autres raisons possibles pour un faible niveau d'HbA1c - par exemple, une détérioration de la fonction rénale ou une perte de poids soudaine.

Thérapie de secours à n'importe quelle phase du traitement

If an adult with type 2 diabetes is symptomatically hyperglycaemic, consider insulin or a sulfonylurea and review treatment when blood glucose control has been achieved.

First-line drug treatment

Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes. Gradually increase the dose over several weeks to minimise the risk of gastrointestinal side-effects. If an adult with type 2 diabetes experiences gastrointestinal side-effects with standard-release metformin, consider a trial of modified-release metformin.

In adults with type 2 diabetes, review the dose of metformin if the eGFR is below 45 ml/minute/1.73 m². Stop metformin if the eGFR is below 30 ml/minute/1.73 m². Prescribe metformin with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR falling below 45 ml/minute/1.73 m².

In adults with type 2 diabetes, if metformin is contra-indicated or not tolerated, assess the cardiovascular risk using a recognised risk scoring system such as QRISK®3.

Basé sur l'évaluation du risque cardiovasculaire pour la personne atteinte de diabète de type 2 :

• If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin. If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.When starting an adult with type 2 diabetes on dual therapy with metformin and an SGLT2 inhibitor as first-line therapy, introduce the drugs sequentially, starting with metformin and checking tolerability. Start the SGLT2 inhibitor as soon as metformin tolerability is confirmed.

• For first-line drug treatment in adults with type 2 diabetes, if metformin is contra-indicated or not tolerated and if they do not have chronic heart failure, or established atherosclerotic cardiovascular disease or are at high risk for developing cardiovascular disease, consider:

  • A DPP‑4 inhibitor; ou

  • Pioglitazone; ou

  • A sulfonylurea; ou

  • An SGLT2 inhibitor for people who meet the criteria in the National Institute for Health and Care Excellence (NICE's) technology appraisal guidance on canagliflozin, dapagliflozin and empagliflozin as monotherapies or ertugliflozin as monotherapy or with metformin for treating type 2 diabetes.³

• Before starting an SGLT2 inhibitor, check whether the person may be at increased risk of diabetic ketoacidosis (DKA) - for example if:

  • Ils ont eu un épisode antérieur de DKA.

  • Ils sont malades avec une maladie intercurrente.

  • Ils suivent un régime très pauvre en glucides ou cétogène.

Intervention supplémentaire

Introduire les médicaments utilisés en thérapie combinée de manière progressive, en vérifiant la tolérance et l'efficacité de chaque médicament.

For adults with type 2 diabetes, if monotherapy has not continued to control HbA1c to below the person's individually agreed threshold for further intervention, consider adding:

• A DPP‑4 inhibitor; ou

• Pioglitazone; ou

• A sulfonylurea; ou

• Un inhibiteur de SGLT2 pour les personnes répondant aux critères des recommandations d'évaluation technologique du NICE sur le canagliflozine en thérapie combinée, l'ertugliflozine en monothérapie ou avec la metformine, ou le dapagliflozine ou l'empagliflozine en thérapie combinée.³

Pour les adultes atteints de diabète de type 2, si la bithérapie avec la metformine et un autre médicament oral n'a pas permis de maintenir l'HbA1c en dessous du seuil convenu individuellement pour une intervention supplémentaire, envisagez soit :

• Thérapie triple par l'ajout d'un inhibiteur de la DPP‑4, de la pioglitazone ou d'une sulfonylurée ou d'un inhibiteur de SGLT2 pour les personnes répondant aux critères des recommandations d'évaluation technologique du NICE sur le canagliflozine en thérapie combinée, le dapagliflozine en thérapie triple, l'empagliflozine en thérapie combinée, ou l'ertugliflozine avec la metformine et un inhibiteur de la dipeptidyl peptidase-4;³ ou

• Commencer un traitement à base d'insuline (voir la section sur les traitements à base d'insuline).

See the separate article on Schémas d'insuline for further information.

If triple therapy with metformin and two other oral drugs is not effective, is not tolerated or is contra-indicated, consider triple therapy by switching one drug for a GLP‑1 mimetic for adults with type 2 diabetes who:

• Have a body mass index (BMI) of 35 kg/m² or higher (adjust accordingly for people from Black, Asian and other minority ethnic groups) et specific psychological or other medical problems associated with obesity; ou

• Avoir un IMC inférieur à 35 kg/m²; et:

  • For whom insulin therapy would have significant occupational implications; ou

  • La perte de poids bénéficierait à d'autres comorbidités importantes liées à l'obésité.

• Only continue GLP‑1 mimetic therapy if the adult with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and weight loss of at least 3% of initial body weight in sixmonths).

• For adults with type 2 diabetes, only offer combination therapy with a GLP‑1 mimetic and insulin along with specialist care advice and ongoing support from a consultant-led multidisciplinary team.

• Dipeptidylpeptidase-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin and vildagliptin)