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Guideline of the month - NICE guideline on type 2 diabetes

Presenting key points and expert comment regarding the new NICE guidance on type 2 diabetes.

Diabetes test pregnant women 3x2


The guideline

This guideline updates NICE advice on type 2 diabetes. A previous draft proved controversial due to its recommendation that repaglinide should be considered as an alternative first-line therapy to metformin.


Key points for GPs

• GPs should consider ‘relaxing’ HbA1c targets on a case-by-case basis, particularly in older or frail patients who are unlikely to achieve longer-term risk-reduction benefits.

• Under the new guideline, GPs can now prescribe a DPP-4 inhibitor, pioglitazone, a sulfonylurea or SGLT2 inhibitor, as dual therapy if metformin fails to control HbA1c.

• GPs should only offer self-monitoring routinely to patients on insulin, those with evidence of hypoglycaemic episodes or those at risk of hypoglycaemia while driving. Women planning to become pregnant, or who are already pregnant, can also be offered self-monitoring on a routine basis.

• Repaglinide, which was initially recommended as an alternative first-line therapy, has been relegated in the new update to a footnote on the treatment algorithm.


Practical issues

The move away from self-monitoring in the new guideline means some patients currently monitoring their own blood glucose can be advised they no longer need to do so. But it may be a challenge to convince more concerned patients to stop self-monitoring.


Expert comment

Dr Rupal Shah, a GPSI in diabetes in south London, says: ‘The guidelines propose some very sensible changes to HbA1c targets, which take into account the lack of evidence for the benefit of intense glycaemic control in people who are elderly or who have a limited life expectancy.

‘The new recommendations will mean that more people are managed on a single oral hypoglycaemic – usually metformin – as a second glucose-lowering drug is only recommended where the HbA1c is ≥58mmol/mol (7.5%).

‘These are positive changes, which should mean less iatrogenic harm and a more holistic approach.’


The guideline

NICE. NG28: Type 2 diabetes in adults – management. London: NICE; 2015

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Readers' comments (3)

  • As a Podiatrist working in the private sector we regularly see Type 2 Diabetics and it appears that a high percentage have not ever been asked to check their own HbA1c and they are middle aged; those that do, dont appear to know what the readings mean; very few are given a copy of any results so they could monitor for themselves,differences/changes/increases or decreases of levels etc. It seems that when advice is given there is a non uniform approach of care guidelines passed onto patients, whilst considering geographical comparison, from one Gp surgery to another being in the same district!

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  • Under the new guideline, GPs can now prescribe a DPP-4 inhibitor, pioglitazone, a sulfonylurea or SGLT2 inhibitor, as dual therapy if metformin fails to control HbA1c.

    True (& concise - as befits the genre), but maybe not the whole truth. New guideline states that SGLT2 inhibitors are an option in line with relevant technology appraisals. NICE TAs place limits on use. Use in dual therapy with metformin only an option if:
    •a sulfonylurea is contraindicated or not tolerated or
    •the person is at significant risk of hypoglycaemia or its consequences.

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  • Gives explanation as to self testing and keeping hba1c monitoring is useful

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