UK drugs regulator NICE has published updated guidelines on type 2 diabetes, saying that taking an individualised approach to care is at the heart of effective management of the condition.
The guideline – which has changed substantially after companies and clinicians criticised an over-reliance of older, cheaper anti-diabetes drugs in the draft document – now “focuses on tailoring advice and treatments to the individual person’s circumstances. This includes considering co-existing illnesses, and reassessing their needs at each review.
The new recommendations on blood glucose management give clarity on the sequence of drug treatments to offer, and when to consider adding further drugs to achieve and maintain target blood glucose (sugar) levels.
Healthcare professionals should offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes. The guidelines recommend treatment with a single non‑insulin blood glucose lowering therapy (monotherapy), then intensification treatment with two non‑insulin blood glucose lowering therapies in combination, followed by treatment with either three non‑insulin blood glucose lowering therapies in combination (triple therapy) or any treatment combination containing insulin.
The new guideline also underlines the importance of structured education for adults with type 2 diabetes and/or their family members or carers to help them develop the knowledge and skills to manage their own diabetes.
In addition to making recommendations on managing blood pressure and dietary advice, the guideline also covers managing complications including eye disease and erectile dysfunction, and related NICE guidance on diabetic foot problems.
Sir Andrew Dillon, NICE chief executive, says: “Around 2.7 million people in the UK have type 2 diabetes. This long-term condition has a serious impact on people who live with it – but it can be managed successfully with advice, support and treatments that are tailored for the individual. This updated guideline focuses on the importance of putting each person’s needs and preferences at the heart of joint discussions and decision-making.
“Following these evidence-based recommendations will enable health professionals to create individual packages of care to prevent serious illnesses linked to diabetes. And to ensure the guideline keeps pace with new developments in diabetes care, NICE has plans in place to establish a standing subcommittee on diabetes within its guideline updates programme.”
Type 2 diabetes occurs when a person has too much glucose in their blood, either because their body doesn’t produce enough insulin – the hormone which controls the amount of glucose in blood – or their body doesn’t use insulin effectively.
Around 90% of all adults currently diagnosed with diabetes have the type 2 form, which can lead to complications including tissue damage which can result in blindness, kidney failure, foot ulcers which can lead to amputation, and also premature heart disease, stroke and death, if blood glucose levels are not managed effectively.
NICE’s type 2 diabetes guideline recommendations include:
• Adopt an individualised approach to diabetes care, tailored to the needs and circumstances of adults with type 2 diabetes, taking into account their personal preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long-term interventions because of reduced life expectancy
• Monitor blood pressure every 1–2 months, and intensify therapy if the person is already on antihypertensive drug treatment, until the blood pressure is consistently below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage)
• Integrate dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification, such as increasing physical activity and losing weight
• Offer standard-release metformin as the initial drug treatment for adults with type 2 diabetes
• 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 and support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment
• In adults with type 2 diabetes, measure HbA1c levels at: 3–6-monthly intervals (tailored to individual needs), until the HbA1c is stable on unchanging therapy; 6-monthly intervals once the HbA1c level and blood glucose lowering therapy are stable.
Commenting on the updated guidelines, Dr Amanda Adler, consultant diabetologist and NICE guideline developer, says: “[It] is good news for people with type 2 diabetes and for health professionals given the many therapies now available. The guideline comprehensively covers the best care for patients with type 2 diabetes, taking into account effectiveness of medications, enhancing quality of life, and wisely using NHS resources.
“The guideline encourages all patients to eat well and be physically active. For the many adults with type 2 diabetes who do require drugs to help manage their diabetes, the guideline details treatments and includes an algorithm which summarises the range of treatment options at a glance.”
Dr Ian Lewin, NICE guideline developer and retired consultant endocrinologist, comments: “The guideline highlights that putting people with type 2 diabetes at the centre of their care package is essential. For example the guideline recommends that adults with type 2 diabetes should be involved in decisions about their individual HbA1c target – the average amount of glucose in their blood over two to three months.
“Health professionals are also advised to individualise recommendations for carbohydrate intake and alcohol intake, and meal patterns. All of these steps should result in improved outcomes for adults with type 2 diabetes – reduced complications and better health.”
Responsing to the new guidance, the ABPI’s head of medical afairs, Dr Jacintha Sivarajah welcomed NICE’s move away from the recommendations in the draft, which had a “focus on cost over clinical care”.
“NICE has addressed these concerns, and today’s announcement should encourage clinicians to adopt an individualised approach to treatment, tailored to meet the needs of each patient. This will result in greater long-term health benefits for patients. We are pleased to have had the opportunity to work with NICE and to contribute to this important guidance.
“We believe these guidelines now represent ‘one voice’ from the diabetes community – doctors, patient groups, science leaders and the pharmaceutical industry – and this can only be positive.
“New medicines will continue to play a vital role in the management of patients with type 2 diabetes over the coming years. The pharmaceutical industry has committed to providing hundreds of millions of pounds to the NHS in order to help fund new, innovative medicines. We hope this provides clinicians with more flexibility to prescribe the medicines best suited to meet the needs of their individual patients.”
The updated type 2 diabetes guideline is available here.