GPs have been told to consider not treating elderly or very ill patients with type 2 diabetes to such strict HbA1c targets, under new NICE guidelines published today.
The long-awaited guideline suggests a more individual approach to patients who may not have so much to gain from very low blood glucose levels and that targets must be applied on a ‘case-by-case’ basis.
It also gives the green light to make more use of a wider range of glucose-lowering drugs, recommending gliptins and gliflozins are offered second-line alongside metformin.
NICE advisors said the updates marked a major step in helping GPs to tailor treatment to their individual patients.
However, some critics, including GP diabetes experts, said NICE should have pushed some of the newly available therapies harder in light of latest evidence, although they welcomed NICE’s pledge to set up a dedicated committee to help keep the guidelines more up to date in future.
The final guidelines publication – the first time NICE has updated the recommendations in six years – come after an extraordinary second round of consultations that was triggered by a number of fierce criticisms of earlier drafts, when GP experts expressed dismay at ‘bonkers’ and ‘truly retrograde’ recommendations on glucose-lowering treatment.
NICE advisors have now bowed to some of these pressures, notably to update the glucose-lowering treatment algorithm to include the dipeptidyl peptidase-4 (DPP-4) inhibitors (gliptins) and sodium-glucose cotransporter 2 (SGLT2) inhibitors – also known as gliflozins – in order to intensify treatment.
GPs can now choose a gliptin, pioglitazone, sulfonylurea or a gliflozin, depending on the patients’ individual profile and preferences, as an add-on to metformin if patients are struggling to get their blood glucose controlled.
The guidelines advise patients should still aim for an HbA1c level of 48 mmol/mol (6.5%) in the first instance, or 53 mmol/mol (7.0%) if the patient is taking a drug that risks hypoglycaemia, with treatment intensified if they go up to 58 mmol/mol (7.5%) or above.
What do the guidelines say?
’Consider relaxing the target HbA1c level on case by case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes: who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy; for whom tight bood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job; [and] for whom intensive management would not be appropriate, for example, people with significant comorbidities.’
Professor Andrew Farmer, professor of primary care at the University of Oxford and a member of the guidelines development group, told Pulse the changes were a ‘huge step forward’, and would give ‘GPs have the opportunity to individualise care, taking into account individual patients’ preferences, requirements and indications for the drugs’.
Professor Farmer said there was ‘still a perception the management of diabetes is metformin, sulfonylurea and insulin with a few others if there are problems’ but that there were now ’a range of new treatments that NICE has found are clinically and cost effective’.
He added that the guidelines committee had not demoted sulfonylurea below these newer treatments, despite previous objections, because some patients, for example, with contraindications to other drugs, would still benefit from them.
Professor Farmer said: ‘They are not there as this is what everyone should use because they are cheap, but because they are an option.’
Dr Paul Newman, a GP diabetes expert advisor to Diabetes UK, said he welcomed the majority of changes NICE had brought in but was ‘disappointed on several levels’ about some of the glucose lowering recommendations.
In particular, he highlighted the lower prominence relative to other second-line alternatives of gliflozins, which he said had been put in ’as a “bolt-on”, obviously not giving [them] the same weight – and also maybe not really taking into account the latest evidence on empagliflozin, which has now been shown to reduce cardiovascular risk.’
NICE insisted the guidelines would ensure patients received more individualised packages of care, but that it was looking at setting up a new diabetes group to help keep pace with new evidence.
Sir Andrew Dillon, NICE chief executive, said: ’To ensure the guideline keeps pace with new developments in diabetes care, NICE has plans in place to establish a standing committee on diabetes within its guideline updates programme.’