Type 2 diabetes in adults latest NICE guidelines
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Type 2 diabetes is a condition that causes too much sugar in your blood. It can cause serious health problems if not treated.
Symptoms of type 2 diabetes include needing to pee a lot, feeling thirsty all the time and feeling very tired.Treatment for type 2 diabetes includes medicines and changes to your diet and activity levels to help control your blood sugar levels.
Patient education
NICE recommends structured diabetes education at diagnosis, with annual reinforcement and review much as previously. The only change is the recommendation that the outcomes be audited regularly. Advice on diet is unchanged and can really be summarised by the statement ‘a healthy diet for someone with type 2 diabetes is the same as a healthy diet for anyone else’.
Eye screening for retinopathy
Hypertension
NICE hypertension guidance, published in August 2019, updates the 2015 type 2 diabetes guidance and puts more emphasis on taking into account frailty and comorbidity. The 2019 QOF targets for general practice also take into account moderate and severe frailty.
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So for those with existing hypertension:
- reduce clinic blood pressure to <140/90mmHg and use clinical judgment for those with comorbidity or frailty
- if >80 years old, aim for BP <150/90mmHg and again maintain clinical judgment.
Take into account patients’ wishes and preferences after a shared decision-making discussion regarding the pros and cons of antihypertensive treatment.
There is more focus on ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). Be guided by your local services/CCG as to which approach you wish to adopt. There are a number of ways of dong this now and patients may well have their own appropriate machines. Be cautious about white coat hypertension and mindful to the dangers of diagnosis on clinic readings alone.
Be alert to those in AF and the pitfalls of electronic monitoring in patients with an irregular pulse.
For those without known hypertension:
- Make a diagnosis of hypertension in those with BP >140/90mmHg and ABPM or HBPM of BP >135/85mmHg
Consider antihypertensive therapy in addition to lifestyle support for those adults:
- aged under 60 with stage 1 hypertension and an estimated 10 years CV risk <10%, maintaining clinical judgement for those with morbidity and frailty
- aged 80 and over with clinic BP of >150/90mmHg again maintaining judgment for those with frailty and morbidity
- with persistent stage 2 hypertension
Refer for same day assessment for severe hypertension (>180/120mmHg) and those with
- retinal changes on fundoscopy (consider optician)
- suspected phaeochromocytoma
- concerning symptoms such as confusion or chest pain
Pharmacological management of hypertension includes ACEi or AR2 in those of African or Caribbean origin. Consider additional treatment if needed using calcium channel blockers, beta blockers or diuretics.
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Always consider drug interactions, previous intolerances, co morbidities and patients wishes. Be conscious of when referral to specialist services maybe required.
Antiplatelets
Whereas in previous guidelines, NICE recommended the routine use of antiplatelet medication (aspirin or clopidogrel) in most people with diabetes, antiplatelets are now not recommended for use in people with type diabetes without cardiovascular disease. In other words, we should use antiplatelets for secondary prevention, exactly as would be the case in a person without diabetes, but not for primary cardiovascular prevention.
HbA1c targets
The recommendations for HbA1c measurement and targets have changed substantially since 2009. These include the recommendations to measure at least six-monthly, use of the newer IFCC units (mmol/mol) rather than the older percentages, the use of alternative measurements of glucose in those with disturbed erythrocyte turnover (eg moderate/severe iron-deficiency anaemia, stages 4 and 5 chronic kidney disease) or abnormal haemoglobin types (eg sickle cell disease) and some of the targets for treatment.
HbA1c targets should generally be 48mmol/mol for those on diet treatment, or any monotherapy with a drug not associated with hypoglycaemia, and 53mmol/mol for those on monotherapy with a drug associated with hypoglycaemia or any combination therapies. Existing drug treatment should generally be intensified if HbA1c rises to ≥58mmol/mol.
Treatment options
Standard-release metformin is still the recommended initial therapy if a brief trial of lifestyle measures fail to achieve an HbA1c of ≤48mmol/mol. New recommendations are to slowly increase the dose over several weeks to minimise the risks of gastrointestinal side-effects (starting with 500mg a day with the main meal, increasing in steps of an extra 500mg every one or two weeks, aiming for 1g twice daily), and to consider a trial of modified-release metformin should these occur. Also new is the recommendation to consider any of a DPP4 inhibitor, pioglitazone or a sulfonylurea if metformin is not tolerated or contraindicated (for example if eGFR<30). An update to NG28 in May 2017 recommends an SGLT2 inhibitor as another option as monotherapy for treating some adults with type 2 diabetes instead of a DPP4 inhibitor when metformin is not tolerated or contraindicated and if a sulfonylurea or pioglitazone is not appropriate.
Additionally, whereas previous guidelines recommended this intensification take place if monotherapy failed to achieve an HbA1c of <48mmol/mol, a second drug should now generally only be recommended if HbA1c rises to 58mmol/mol.
Standard-release metformin is still the recommended initial therapy if a brief trial of lifestyle measures fail to achieve an HbA1c of ≤48mmol/mol. New recommendations are to slowly increase the dose over several weeks to minimise the risks of gastrointestinal side-effects (starting with 500mg a day with the main meal, increasing in steps of an extra 500mg every one or two weeks, aiming for 1g twice daily), and to consider a trial of modified-release metformin should these occur. Also new is the recommendation to consider any of a DPP4 inhibitor, pioglitazone or a sulfonylurea if metformin is not tolerated or contraindicated (for example if eGFR<30). An update to NG28 in May 2017 recommends an SGLT2 inhibitor as another option as monotherapy for treating some adults with type 2 diabetes instead of a DPP4 inhibitor when metformin is not tolerated or contraindicated and if a sulfonylurea or pioglitazone is not appropriate.
Substantial changes from 2009 are seen in the algorithm after monotherapy with metformin. Whereas previously there was a strong steer to add a sulfonylurea, clinicians can now choose from DPP4 inhibitors, pioglitazone, sulfonylureas or SGLT2 inhibitors. This choice should be based on the following criteria:
- Effectiveness: remember to evaluate this after three to six months and be prepared to change medication should HbA1c not fall by a reasonable level (>5mmol/mol in the author’s opinion)
- Safety
- The person’s individual circumstances (comorbidities, risk of polypharmacy, weight)
- The person’s individual preferences and needs
- Licensed indications or combinations available
- Cost (if two drugs in the same class are appropriate, choose the option with the lowest cost)
Additionally, whereas previous guidelines recommended this intensification take place if monotherapy failed to achieve an HbA1c of <48mmol/mol, a second drug should now generally only be recommended if HbA1c rises to 58mmol/mol.
Previously, when a combination of two oral therapies failed to achieve an HbA1c <58mmol/mol, insulin initiation was the preferred option. Now the use of triple oral therapy is recommended as an equally valid option. Use of a GLP1 agonist is an alternative if either strategy is ineffective, not tolerated or contraindicated, and the BMI is >35 or weight loss would benefit other comorbidities or insulin would have significant impact on the person’s job. While all therapies should be reviewed for effectiveness, NICE specifies that GLP1 agonists should only be continued if by six months HbA1c has fallen by ≥11mmol/mol and weight by 3% from baseline.
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To transform your dreams into reality, the next revolution is never far away. This is a place where education is a force for positive change. Mission We are here because you have a dream: to advance or change your career, to immerse yourself in a subject you love, to meet future mentors, colleagues and friends. At The RIST EDUCATION LIMITED UK you’ll find an incredible range of opportunities to take these next steps. You’ll see your dreams take shape and become real. Our aim is to produce graduates of high Caliber distinguished for their depth of knowledge, professional competence, knack and energy to put their knowledge to practical applications, the best human being and the best professional.
