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NICE reveals long-awaited guideline update on treating type 2 diabetes

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Updated guidelines on treating type 2 diabetes, which focus on an individualised approach to care, have been published by the National Institute for Health and Care Excellence.

However, updating its guidance has been a drawn-out process for NICE, with challenges made by charities, specialists and pharmaceutical companies.

NICE said the final guidance published today promoted tailoring advice and treatments to the patient’s circumstances, including co-existing illnesses and reassessing needs at each review.

“NICE has plans in place to establish a standing subcommittee on diabetes within its guideline updates programme”

Andrew Dillon

It also underlines the importance of structured education for adults with type 2 diabetes and their family members or carers to help them “develop the knowledge and skills to self-manage diabetes”.

In addition, NICE highlighted new recommendations on blood glucose management designed to give “clarity on the sequence of drug treatments to offer” and when to consider adding further drugs, to achieve and maintain target blood glucose levels.

An algorithm to help clinicians make decisions on drug treatments is a “key feature” of the guideline, it said.

Announcing the guidance, NICE chief executive Sir Andrew Dillon said: “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,” he said.

He added: “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.”

NICE’s proposals on drug treatment had been a source of criticism in earlier versions of the guidance, as reported by Nursing Times.

Stakeholders argued that the draft guidance focused too much on cost, advocating a limited number of treatments and, as a result, ignoring the most up-to-date drugs and risked moving away from the patient-centred approach in the 2009 version of the guideline.

There was particular concern that sodium-glucose co-transporter-2 (SGLT-2) inhibitors were being overlooked.

“Diabetes experts had expressed concerns about the previous guidelines due to their focus on cost over clinical care”

Jacintha Sivarajah

They claimed that, while specialist nurses and other experts would use their judgement and knowledge of available treatments to go beyond the guidance, practice nurses and other generalists would most likely follow the NICE recommendations and risked the NHS falling behind on best clinical practice.

Most of the concerns appear to have been addressed in the final version of the guidance, which calls for a focus on treatment decisions based on the needs of individual patients and does highlight that SGLT-2s can be considered where appropriate.

Dr Jacintha Sivarajah, head of medical affairs at the Association of the British Pharmaceutical Industry, described the final guidance update as “great news for patients”.

“Diabetes experts had expressed concerns about the previous guidelines due to their focus on cost over clinical care,” she said. “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.”

Diabetes UK said it was “broadly” happy the guidance had been published after “long delays”, noting that it had argued further changes needed to be made to earlier drafts to make the final version “more practical in-line with other international guidelines”.

“Diabetes treatment is an ever-changing field so it is important for recommendations to be updated regularly”

Chris Askew

However, the charity claimed NICE may still be “putting unnecessary obstacles in the way of people with type 2 diabetes getting best care”. It said it remained concerned that NICE was still continuing to wait “far too long” before making guideline changes that could benefit patients.

Diabetes UK called on clinicians to use information from the guidelines but also to apply their clinical judgement in discussing all appropriate options for medication regimes.

It also called on NICE to confirm that it would definitely put in place a regular review process that looked at emerging evidence and fully incorporated it into existing guidelines on an ongoing basis, so patients were “not left waiting five years or more for an update”.

Chris Askew, chief executive of Diabetes UK, said: “We urge NICE to go ahead and set up the proposed standing committee to enable a far more rapid update of reputable diabetes guidance.”

NICE’s updated type 2 diabetes guideline recommendations include:

  • Adopt an individualised approach to diabetes care that is 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 140/80mmHg (below 130/80mmHg 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 58mmol/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 53mmol/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; six-monthly intervals once the HbA1c level and blood glucose lowering therapy are stable

The full guidance upate can be viewed and downloaded from the NICE website 

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