Diabetes Learning Event
7th October 2016
New NICE Guidelines for
Managing blood glucose in adults
with type 2 diabetes
Mark Chamley
Clinical Lead
Lambeth Diabetes Intermediate Care Team
NICE T2DM Guideline December 2015
• What’s new – drugs and targets
• South East London Blood
Glucose Control Management
Pathway for Adults with Type 2
Diabetes Mellitus
• Local recommendations in drug
choices
• Case studies
Cost of diabetes prescribing in UK
• 123,610 prescriptions for
diabetes every day
• £800 million/ year
• £213 – £369/ patient with
diabetes
• Large regional variation
reflecting local prescribing
practice but no clear association
between expenditure and
outcomes
• Source: HSCIC 2014
Effects of diabetes control on complications - UKPDS
% risk reduction
40
P=0.000054
35
30
P=0.0099
P=0.046
25
20
15
P=0.015
P=0.052
P=0.029
10
5
0
extraction
UKPDS 33. Lancet 1998;352:837–853
HbA1c targets and intensification levels in NICE T2DM
• New NICE guidance defines blood glucose targets as
<48 mmol/mol (< 6.5%) for patients on lifestyle or monotherapy
with a medication with a low risk of hypoglycemia (metformin)
• <53 mmol/mol (<7.0%) for patients on a monotherapy associated
with the risk of hypo glycaemia (gliclazide)
• Recommends intensification of treatment if HbA1c > 58
mmol/mol (>7.5%)
Reminder - medications for type 2 diabetes
Drugs that stimulate insulin
secretion:
Sulphonylureas eg. gliclazide
Meglitinides eg. replaglinide
Drugs that mimic/ increase GLP-1:
GLP-1 analogues – “tides”
DPP4 inhibitors – “gliptins”
Drugs that influence insulin
Drugs that promote glycosuria
action
SGLT-2 inhibitors – “gliflozins”
Biguanides - metformin
Thiazolinediones - pioglitazone Insulins
Important principles!
• Refer to structured education
(Desmond) or give information
about HELP website
• Reinforce lifestyle (diet and
exercise) at every treatment
intensification
• Check HbA1c 2-3/12 after an
new tablet started and review
effectiveness of treatment
NICE T2DM 1st line therapy
Metformin:
Renal function:
Don’t start if adjusted eGFR less than 45
and stop if eGFR falls below 30
Caution in those at risk of a sudden
change in renal function
If BMI < 22 use gliclazide 1st line
Consider the need for insulin in a
patient with BMI < 22 particularly with
symptoms of diabetes
Consider an alternative to SU if group 2
driver (hypo risk), frail/elderly or BMI >
35
Titration:
Start at 500mg OD and increase by
500mg every 2 weeks to a dose of 1g BD
GI side-effects try MR preparation
Alternatives to metformin or SU:
DPP4 or pioglitazone
SGLT-2 – only if SU or pioglitazone are
not appropriate and DPP4 would be
used otherwise
NICE T2DM 1st Intensification of treatment
The LOCAL RECOMMENDED CHOICE
is to add an SU (gliclazide) to
metformin
NICE provides other options:
metformin + pioglitazone
metformin + DPP4
An SGLT-2 should only be added to
metformin if SU cannot be used or
patient has a significant risk of
hypoglycaemia
In patients in whom metformin
cannot be used:
Gliclazide + pioglitazone
Gliclazide + DPP4
DPP4 + pioglitazone
Pros and cons and rationale for local
recommendation to use gliclazide
Cost of oral hypoglycaemic agents
per month:
Metformin 1g BD = £1.33p
Gliclazide 80mg BD = £1.61p
Pioglitazone 30mg OD = £1.42p
Alogliptin 25mg OD = £26.60p
Dapagliflozin = £36.59p
HbA1c reduction (efficacy):
Metformin 1-2%
Gliclazide 1-2 %
Pioglitazone 1-2%
Gliptin 0.5 – 1%
SGLT-2 0.5 – 1%
The newer agents have a lower
efficacy – consider baseline HbA1c
Pros and cons and rationale for local
recommendation to use gliclazide
Effect on a patients weight:
Metformin – weight neutral
Gliclazide – weight gain
Pioglitazone – weight gain
Gliptin – weight neutral
SGLT-2 – weight loss
Hypoglycaemia risk:
Metformin – none/low
Gliclazide – high
Pioglitazone – low
Gliptin – low
SGLT-2 - moderate
The incidence of non-severe
hypoglycaemia in T2DM is around 15%
and is most associated with SU or
insulin tx and longer duration of
diabetes
T2DM is a progressive disease
NICE T2DM 2nd Intensification of treatment
The LOCAL RECOMMENDED CHOICE is
insulin if HbA1c > 1% over individualised
target
NICE provides other options:
metformin + SU + DPP4
metformin + SU + pioglitazone
metformin + pioglitazone + SGLT-2
metformin + SU + SGLT-2
Pioglitazone contra-indications:
Heart failure or h/o heart failure
(fluid retention)
Bladder cancer or h/o bladder ca
Uninvestigated haematuria
Liver impairment
Pioglitazone cautions:
Known CV disease
Risk of bladder cancer (smokers)
Elderly
Risk of fractures (osteoporosis)
GLP1 - analogues
NICE recommendation:
If patient fails to meet target HbA1c
on three oral agents AND:
BMI > 35
BMI < 35 with medical reasons why
weight gain with insulin would be an
issue or occupation
Review at 6/12
1% reduction in HbA1c and 3%
reduction in weight
Local guideline pending