Due to be published in August, the latest NICE guidelines for the management of type 2 diabetes have been available for consultation since January.
Recommendations for lifestyle, patient education, monitoring and glycaemic targets are reasonable.
However, in my opinion, ‘drug treatment’ recommendations are not patient centered.
Repaglinide is recommended as the first line therapy where metformin is unsuitable. This raises several issues. Repaglinide is usually prescribed three times daily which is likely to affect adherence rates.
“In my opinion, ‘drug treatment’ recommendations are not patient centered”
Like all oral antihyperglycaemic agents (OHAs) that secrete insulin independent of blood glucose concentration, repaglinide is associated with increased hypoglycaemia risk and weight gain. It has a limited evidence-base for its efficacy.
Guideline developers appear to accept the consensus amongst clinicians that sulphonylureas (SUs) should not be the preferred second-line therapy to metformin. This acknowledges their negative side effects including hypoglycaemia.
Pioglitazone is recommended as the ‘first choice’ second line agent to metformin where repaglinide is unsuitable.
“Pioglitazone is associated with considerable side effects including weight gain and increased cardiovascular risk”
Yet pioglitazone is associated with considerable side effects including weight gain and increased cardiovascular risk. This recommendation appears to be based on cost rather than clinical effectiveness and is counterintuitive to patient-centered care.
Newer therapies such as DPP-4 inhibitors and GLP-1 analogues are at least weight neutral and are associated with lower hypoglycaemia rates relative to alternative OHAs. The evidence base for their efficacy is growing. However, they are considerably more expensive.
Recent NICE technology appraisals state that SGLT2 inhibitors are cost-effective. But this is not reflected in the new guidelines. They also confer a much lower risk of hypoglycaemia relative to traditional OHAs.
“Recommendations are presented too rigidly, limiting individually tailored treatment”
Recommendations are presented too rigidly, limiting individually tailored treatment. The associated treatment algorithms are not ‘user friendly’.
Implemented in their present state, these guidelines will undermine the faith that healthcare professionals have in NICE and the willingness to apply them.
In my opinion, their implementation will reduce quality of life and pose a greater longer-term economic burden. They appear to be contrary to the ethical maxim ‘do no harm’.
I would hope that the consultation period is extended so that we can get these guidelines right for our patients.
Sam Matthews is a final year student nurse and aspiring Diabetes Specialist Nurse