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NICE endorses new drugs for type 2 diabetes

By Lilian Anekwe

GPs should consider a new drug class, the gliptins, as a second-line option for treating patients with type 2 diabetes, NICE has recommended.

The institute's new guidance positions two new drugs, sitagliptin and vildagliptin as alternatives to sulfonylurea and glitazones.

The latest advice has been released as an update to NICE guidelines on diabetes released last year, and specifically addresses the role of the newer drugs for diabetes – the gliptins, or DPP-4 inhibitors, and exenatide.

NICE recommends GPs consider the gliptins or a glitazone as alternatives to a sulfonylurea ‘if there is a significant risk of hypoglycaemia', or if a patient is intolerant of sulfonylurea or has a contraindication.

Sitagliptin is also recommended, along with a glitazone, as a third-line option instead of insulin. Exenatide can be used as a third-line option too, but only for patients with a BMI more than 35 kg/m2.

Tough new QOF indicators announced in October last year require GPs to treat patients with diabetes to HbA1c targets of 7, 8 and 9%, prompting concern over the aggressive levels of drug treatment required to hit them.

But some GP experts said the new advice could make the targets easier to hit, by providing new options that might avoid the side-effects associated with sulfonylureas and glitazones, including hypoglycaemia and weight gain.

Professor Jonathan Mant, professor of primary care research at the University of Cambridge and chair of the original guideline development group, said: ‘Hypoglycaemia is a concern and these new drugs are another tool in the armoury for GPs. They may also be important given the lingering concerns around glitazones.'

Dr Pam Brown, a GP in Swansea said the guidance on when to use gliptins and exenatide was ‘very positive news'.

She said: ‘Hypoglycaemia is a significant problem with sulfonylurea. If we ask patients if they feel sweaty or have the shakes, it becomes obvious there is a lot of it out there. I'm certainly going to be more likely to use the oral DPP-4 drugs, and I'm sure this new recommendation will be practice-changing.'

But Dr Alan Hayes, secretary of the Primary Care Diabetes Society and a GP in Brighstone on the Isle of Wight, said he was unsure about the NICE recommendation: ‘To place the newer drugs so blatantly as second line – I'm not sure what to make of that.

‘I don't think there's any reason to switch patients from sulfonylurea onto the newer ones because there's a substantial evidence base for the traditional drugs.'

NICE has approved new drugs to fight diabetes NICE has approved new drugs to fight diabetes ONLINE POLL: Diabetes in your practice

What impact do you expect the new NICE type 2 diabetes guidelines to have on the management of your diabetes patients? How will patient care and current outcomes be affected?

Click here to complete our quick survey of GPs' views.

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