NICE type 2 diabetes guidelines – key updates
Glucose measurement/targets
Measure patients’ HbA1c levels at 3-6 monthly intervals (formerly 2-6 monthly) until stable on unchanging therapy; continue to check HbA1c every 6 months thereafter
GPs should still encourage patients to aim for a target of 48 mmol/mol (6.5%), unless this involves taking a drug that risks hypoglycaemia, in which case they should aim for 53 mmol/mol (7.0%)
They should now consider intensifying treatment if HbA1c is still not adequately controlled and goes up to 58 mmol/mol (7.5%) or higher
And they should consider relaxing the targets on a case by case basis, particularly in elderly or frail people – for example:
- if the patient is unlikely to achieve long-term risk benefits because they have reduced life expectancy;
- if tight blood glucose control poses a high risk from hypoglycaemia – such as for those at risk of falls, or who drive or operate machinery in their job
- in patients with significant comorbidities
Glucose-lowering medication
Offer standard-release metformin as initial drug treatment; consider modified-release metformin if patient experiences gastrointestinal side effects
For first intensification of treatment, consider adding the following to metformin:
- a DPP-4 inhibitor
- pioglitazone (unless patient has heart failure, hepatic impairment, diabetic ketoacidosis, current or history of bladder cancer, or uninvestigated macroscopic haematuria)
- a sulfonylurea
GPs are also advised an SGLT-2 inhibitor ‘may be appropriate’ in combination with other drugs for first or second treatment intensifications
For a second treatment intensification, consider:
- triple therapy with: metformin, a DPP-4 inhibitor and a sulfonylurea; or metformin, pioglitazone and a sulfonylurea
- starting insulin-based treatment
If above triple therapy is not effective or not tolerated/contraindicated then GPs can also consider triple therapy with metformin, a sulfonylurea and glucagon-like peptide (GLP)-1 mimetic in the following groups:
- patients with a BMI of 35 kg/m2 (or equivalent in black, Asian and other ethnic minority groups) or higher
- those under a BMI of 35 kg/m2 if insulin would have significant occupational implications, or if weight loss would benefit other obesity-related comorbidities
However, GPs are advised to continue GLP-1 therapy only if the patient achieves at least an 11mmol/mol (1%) drop in HbA1c AND loses at least 3% of weight in the first six months on treatment
NICE: NG28 The management of type 2 diabetes
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