NICE guidelines for Type 2 diabetes: revised but still not fit for purpose

Abstract

Revised Type 2 diabetes guidelines (June 2015) have been released for further consultation after pressure from healthcare professionals and other stakeholders [1][2][3][4]. What NICE proposesThe National Institute for Health and Care Excellence (NICE) sets out a structure for the management of Type 2 diabetes. Advice is provided on appropriate lifestyle changes, including diet, exercise and patient education. It is proposed that oral monotherapy (metformin) be introduced when HbA 1c increases beyond 48 mmol/mol (6.5%). Failure to achieve that target should lead to the introduction of combination therapy at HbA 1c ≥ 58 mmol/mol (≥ 7.5%). Glucose monitoring should be limited to those on drugs that cause hypoglycaemia and be supported by regular auditing. The sequence of therapy proposed in the first draft ran: metformin, repaglinide, pioglitazone and then alternative fourth-line choices. In the revised proposal, the sequence runs, at least in the body of the text, as metformin then a choice of repaglinide, pioglitazone, sulfonylureas and dipeptidyl peptidase-4 (DPP-4) inhibitors (gliptins). These are followed by glucagon-like peptide 1 (GLP-1) receptor agonists and insulin. GLP-1 receptor agonists are to be considered only when the BMI is greater than prescribed levels (35 kg/m 2 ) or at lower BMI depending on ethnicity and risk assessment regarding weight loss benefit. Insulin is to be given as regular human insulin (isophane) for patients with Type 2 diabetes. Sodium/ glucose co-transporter 2 (SGLT-2) inhibitors are not formally included in the algorithm because HTA guidance is awaited later in the year.

ATP‐Sensitive Potassium Channels and Their Physiological and Pathophysiological Roles

“…Sulphonylureas are still used in the treatment of type II diabetes however they can lead to counterproductive weight gain and also a risk of hypoglycaemia particularly in the elderly (393). In addition, it is recommended that the newer classes of sulphonylurea and related agents are used because of the potential for drugs such as glibenclamide to inhibit K ATP channels in cardiac cells.…”

“…In addition, it is recommended that the newer classes of sulphonylurea and related agents are used because of the potential for drugs such as glibenclamide to inhibit K ATP channels in cardiac cells. The more modern trend is to use metformin instead though suphonylureas still have a place in those intolerant of metformin and in combination therapy (393). In addition to fewer problems with weight gain there is also evidence that metformin is associated with a lower risk of dementia (399).…”

NICE: type 2 diabetes in adults, 2015

“…Unusually, there was a second consultation. More comments . NICE's guideline NG28, containing much useful guidance, was finally published on 1 December 2015.…”

“…More comments. 1 NICE's guideline NG28, 2 containing much useful guidance, was finally published on 1 December 2015. The delay was frustrating but shows that NICE was listening.…”

NICE guidelines must reflect consensus and be up‐to‐date

“…Currently, the NICE guidelines for the management of Type 2 diabetes are in consultation. In this month's issue of Diabetic Medicine , an esteemed group of diabetes practitioners have come together to write a commentary based on evidenced‐based medicine criticizing the obvious gaps in the suggested guidance ; we hope NICE will listen and that this will lead to changes in their current draft.…”