Guideline of the month - SIGN update on glycaemic control in type 2 diabetes

The guideline

The Scottish Intercollegiate Guideline Network has published updated guidance on the pharmacological management of glycaemic control in type 2 diabetes, including new advice on the use of GLP-1 receptor agonists.

Key points for GPs

An HbA1C of 7% (53mmol/mol) should be the aim in most patients, to reduce the risk of micro- and macrovascular disease but 6.5% (48mmol/mol) may be more appropriate for some patients.
Metformin should be the first-line oral treatment; sulphonylureas should be first-line if metformin is contraindicated.
SGLT2 inhibitors should be considered as an add-on to metformin. Those with proven cardiovascular benefit (empagliflozin and canagliflozin) should be considered in established CVD.
GLP-1 receptor agonist therapy should be considered as a third- or fourth-line add-on in patients with a BMI ≥30 in whom control has not been achieved. Liraglutide, which has proven cardiovascular benefit, should be considered in established CVD.
Pioglitazone should be considered as a dual or triple therapy to lower HbA1C.

Practical issues

SIGN guidance differs from NICE in some areas, so GPs will need to use clinical judgment to determine the best course of treatment. For example, NICE suggests adding a GLP-1 receptor agonist in those with a BMI of ≥35 and psychological or medical problems associated with obesity; SIGN only stipulates a BMI ≥30.

Expert comment

Dr Alan Begg, a GPSI in cardiology in Dundee, commented: ‘SIGN 154 gives an up-to-date, evidence-based overview of the therapeutic groups of glucose-lowering drugs. There is a management algorithm that is excellent, if a little daunting initially.

‘Of particular interest is the use of specific SGLT2 drugs that have proven cardiovascular benefit. However, the use of these drugs may be out of line with current formularies and procurement schemes, and side-effects may be higher than in some of the other drug groups.’