A member of the NICE guideline development group highlights the key issues from the latest evidence-based guideline for readers of Nursing Times
The new NICE (2009) updated guideline on management of type 2 diabetes updates recommendations on several newer agents for blood glucose control in adults, and replaces guidance issued last year.
The new guideline gives recommendations on the use of several newly licensed drugs, in particular DPP-4 inhibitors and GLP-1 mimetics (exenatide) (liraglutide is excluded as it did not receive marketing authorisation during development of the guideline). It also considers the use of long-acting insulin analogues in relation to NPH insulin. All treatments were assessed for clinical and cost effectiveness, using the best evidence currently available, and the final recommendations clarify whether they represent an effective use of NHS resources.
The management of type 2 diabetes requires a large element of self-care, and therefore it is important that treatment is individualised to maximise concordance. Working in partnership with patients and carers can help to identify which regimens are most suitable for the individual, and this guideline increases the range of options available.
Setting a target HbA1c is a key priority and involves a thorough assessment of the patient’s lifestyle. The risk of hypoglycaemia and ability to promptly and safely recognise and treat hypoglycaemic episodes must be considered. The guideline combines a step-wise approach with flexibility and the facility to individualise treatments considering not only blood glucose control, but lifestyle factors and risk of weight gain and therefore concordance.
Before changing medication a full patient assessment should review:
- Concordance with current medication;
- Diet/alcohol and eating patterns;
- Level and regularity of activity/exercise;
- Work; hobbies and social patterns;
- Motivation and ability to improve diabetes control;
- Hypoglycaemia risk;
- Weight-gain risk.
Lifestyle has an enormous influence on diabetes control and modification of diet and exercise should be considered before changing treatments. Once the decision to change is made, the choice of medications, including potential side-effects should be discussed with the patient, allowing an informed decision.
Adding a DPP-4 inhibitor/thiazolidinedione second-line to metformin instead of a sulphonylurea may be invaluable if risk of hypoglycaemia is affecting a patient’s work or hobby or where weight-gain is undesirable. Its use with both metformin and a suphonylurea may be preferable in patients for whom insulin would affect their work, weight or social life.
The guideline says thiazolinediones should not be prescribed for people who have had heart failure or who are at higher risk of fracture. It recommends referring to advice from the Medicines and Healthcare products Regulatory Agency when selecting these drugs. This stresses the need for thorough assessment before changing treatment. The guideline also suggests pioglitazone may be added to insulin therapy if there has been a previous marked response in control with pioglitazone, or where control is inadequate on high doses of insulin.
NICE now endorses the third-line use of GLP-1 agent exenatide in patients with a BMI over 35 or below 35 if insulin is unacceptable due to work or if comorbidities contraindicate weight loss. Patients can be started on exenatide in primary care by practitioners who initiate insulin therapy, with appropriate education and support by specialist teams.
The guideline advises starting insulin if HbA1c is above 7.5% or a higher level as agreed with the individual. If a patient is on dual therapy and still significantly hyperglycaemic insulin may be considered instead of initiating other drugs. NPH insulin is recommended as first choice, but the guideline allows flexibility with use of long-acting analogues where they would reduce the number of injections required.
Patients should be monitored for the need to introduce short-acting insulin before meals or a pre-mixed preparation. Those using pre-mixed insulin for a mealtime plus basal insulin should also be monitored if control remains inadequate.
In summary, the new guideline provides a clear and concise treatment pathway emphasising the need for informed patient decision-making and allowing flexibility to meet individuals’ needs in order to reach their target HbA1c level.
Author Julie Wood, MSc, BSc, RGN, is diabetes nurse specialist, diabetes and renal programme manager, NHS Kirklees Primary Care Trust
NICE (2009) Type 2 Diabetes: The management of type 2 diabetes. London: NICE.