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In summary: NICE’s updated T2D guidelines

NICE has said that GPs can relax treatment targets in some patients with diabetes. Read a summary of key new glucose management recommendations here

NICE type 2 diabetes guidelines - key updates

Glucose measurement/targets

Measure patients’ HbA1c levels at 3-6 monthly intervals (formerly 2-6 monthly) until stable on unchanging therapy; continue to check HbA1c every 6 months thereafter

GPs should still encourage patients to aim for a target of 48 mmol/mol (6.5%), unless this involves taking a drug that risks hypoglycaemia, in which case they should aim for 53 mmol/mol (7.0%)

They should now consider intensifying treatment if HbA1c is still not adequately controlled and goes up to 58 mmol/mol (7.5%) or higher

And they should consider relaxing the targets on a case by case basis, particularly in elderly or frail people – for example:

  • if the patient is unlikely to achieve long-term risk benefits because they have reduced life expectancy;
  • if tight blood glucose control poses a high risk from hypoglycaemia – such as for those at risk of falls, or who drive or operate machinery in their job
  • in patients with significant comorbidities

Glucose-lowering medication

Offer standard-release metformin as initial drug treatment; consider modified-release metformin if patient experiences gastrointestinal side effects

For first intensification of treatment, consider adding the following to metformin:

  • a DPP-4 inhibitor
  • pioglitazone (unless patient has heart failure, hepatic impairment, diabetic ketoacidosis, current or history of bladder cancer, or uninvestigated macroscopic haematuria)
  • a sulfonylurea

GPs are also advised an SGLT-2 inhibitor ‘may be appropriate’ in combination with other drugs for first or second treatment intensifications

For a second treatment intensification, consider:

  • triple therapy with: metformin, a DPP-4 inhibitor and a sulfonylurea; or metformin, pioglitazone and a sulfonylurea
  • starting insulin-based treatment

If above triple therapy is not effective or not tolerated/contraindicated then GPs can also consider triple therapy with metformin, a sulfonylurea and glucagon-like peptide (GLP)-1 mimetic in the following groups:

  • patients with a BMI of 35 kg/m2 (or equivalent in black, Asian and other ethnic minority groups) or higher
  • those under a BMI of 35 kg/m2 if insulin would have significant occupational implications, or if weight loss would benefit other obesity-related comorbidities

However, GPs are advised to continue GLP-1 therapy only if the patient achieves at least an 11mmol/mol (1%) drop in HbA1c AND loses at least 3% of weight in the first six months on treatment

NICE: NG28 The management of type 2 diabetes 

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Readers' comments (3)

  • Yikes. Spot guidelines driven by partialist priorities when population studies show mortality higher with HbA1c at 6.5%. Good rule of thumb in the elderly - don't stress unless HbA1c [expressed in mmol/mol ] is above their age and they are symptomatic.

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  • 25 years ago my old professor of endocrinology was saying that GP's were over controlling the elderly diabetics, overlooking the effect of transient hypoglycaemia on the ageing brain, and reminded us all we treat PATIENTS not BLOOD RESULTS. He is now long dead but seems to have put in an appearance at the last NICE seance, which is how I have always assumed these guidelines are produced. Right, I'm off to look up the drug tariffs on SGLT-2's. (has anyone done this already?).

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  • Almost looks usable!

    Where is the comedy value guidance they put in to see if all the sheep jump off the cliff they have set up?

    Where is the drug that is obsolete and never became fashionable, but will be 'Cost effective'?

    Did all the idiots from their ivory towers on the committee get shipped off on some drug company booze 5 star cruise (No Conflict of interest - honest Guv), leaving only some normal GPs to knock out the guidance during their lunch break, in their absence?

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