Cookie policy notice

By continuing to use this site you agree to our cookies policy below:
Since 26 May 2011, the law now states that cookies on websites can ony be used with your specific consent. Cookies allow us to ensure that you enjoy the best browsing experience.

This site is intended for health professionals only

At the heart of general practice since 1960

Warning issued against intensive glucose lowering

By Lilian Anekwe

GPs have been warned against intensively lowering blood glucose in patients with type 2 diabetes after NICE reviewed trial evidence suggesting the strategy could be dangerous.

GPs have been warned against intensively lowering blood glucose in patients with type 2 diabetes after NICE reviewed trial evidence suggesting the strategy could be dangerous.

But NICE has toughened up its recommendations on cholesterol lowering in diabetes by instructing GPs to aim for lipid levels of 4mmol/l and 2mmol/l.

The institute's final guidance on type 2 diabetes, issued this week, recommends GPs reduce HbA1c levels below 7.5%, but specifically warns them to ‘avoid pursuing highly intensive management to levels of less than 6.5%'.

The move was forced on NICE by the results of the ACCORD trial, which was abandoned after finding patients treated to below 6.0% HbA1c had a 27% increased risk of death.

The decision not to recommend aggressive lowering of blood sugar is expected to reduce the cost of diabetes management, by avoiding the use of expensive glucose-monitoring strips.

Cost was also a key factor in the institute's decision to recommend new drug exenatide only in patients who would otherwise be started on insulin, or with a BMI over 35.

But while intensive management of blood glucose is out, intensive management of cholesterol is in. The institute re- commends GPs use lipid-lowering drugs even in patients with no evidence of CVD.

The new recommendations – a total cholesterol of 4mmol/l and an LDL cholesterol level of 2mmol/l – are substantially tougher than those set out in NICE's draft guidance.

The draft had recommended GPs use simvastatin 40mg to treat all patients to 5mmol/l and 3mmol/l, except those with chronic kidney disease, microalbuminuria or proteinuria, in whom higher-dose or potency statins could be used, and the tougher targets applied.

Professor Philip Home, professor of diabetes medicine at the University of Newcastle and a member of the NICE guideline development group, told Pulse: ‘There is no evidence on the safety of treating to below 6.0%. The decision to recommend lowering lipids to 4mmol/l and 2mmol/l came in light of new economic data suggesting the gains of intensive treatment were greatest when targets were lower.'

What the guidance recommends

• Initiate patients with simvastatin 40mg, assess lipid profile every 1-3 months, increase the dose to 80mg daily, until cholesterol is lowered to 4 and 2 mmol/l
• Consider a more effective statin or ezetimibe in patients
• All newly diagnosed patients should be offered self-monitoring and followed-up, structured education should be offered to every patients, and ongoing nutritional and lifestyle advice should be provided
• Target of 5-10% weight loss
• Avoid pursuing highly intensive management to levels of less than 6.5% HbA1c
• Target blood pressure levels of 140/80 mm Hg, or 130/80 mm Hg if patients have kidney, eye or cerebrovascular damage
Source: NICE guidelines on type 2 diabetes www.nice.org.uk

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say