The National Institute for Health and Clinical Excellence (NICE) have issued guidance on the use of newer agents for blood glucose control in adults with type 2 diabetes. The new short clinical guideline is a partial update of last year’s clinical guideline “Type 2 Diabetes (Update)” and examines several new and existing treatments for the management of blood glucose levels in individuals with type 2 diabetes.

The management of blood glucose levels, reflected in a patient’s value of haemoglobin HbA1c , is a central part of diabetes treatment. The NICE guidance recommends a number of new treatments to help manage levels of blood glucose, positioning these treatments among existing therapies for type 2 diabetes.  These include recommendations on the use of long-acting insulin analogues, inhibitors of dipeptidylpeptidase-4 (DPP-4 inhibitors), glucagon-like peptide-1 (GLP-1) mimetics and thiazolidinediones within their licensed recommendations.

Summary of therapies and key recommendations are:

Insulin therapy (including the long-acting insulin analogues, insulin detemir, insulin glargine)

·      Insulin detemir and insulin glargine, like NPH insulin, provide slowly-released insulin to meet basal requirements.  When the decision to start insulin is made, human NPH insulin should be started; healthcare professionals should consider switching to a long-acting insulin analogue if the patient experiences significant hypoglycaemia, is unable to use the device needed to inject NPH insulin, or who needs help to inject from a carer or healthcare professional, and for whom switching to a long-acting insulin analogue would reduce the number of daily injections.

DPP-4 Inhibitors (sitagliptin, vildagliptin)

• Healthcare professionals should consider the option of adding a DPP-4 inhibitor (sitagliptin) in patients taking metformin and a sulfonylurea in whom treatment with insulin is inappropriate, including because of employment, social, or recreational problems related to hypoglycaemia (low values of blood glucose, which may result from therapy with insulin).
• Healthcare professionals should consider the option of adding a DPP-4 inhibitor in patients taking either metformin or a sulfonylurea, if contraindications exist for adding either metformin or a sulfonylurea.

GLP-1 Mimetic (exenatide)

• Exenatide lowers blood glucose and may lead to weight loss; it is licensed for the treatment of elevated blood glucose (but not elevated body weight) in type 2 diabetes.  The drug requires twice-daily injection.  Healthcare professionals should consider the option of adding the GLP-1 mimetic (exenatide) to metformin and a sulfonylurea in a patient who requires improved control of glucose, has a high body mass index (35 kg/m² or higher) and experiences problems associated with high body weight.
• GLP-1 (exenatide) may also be added to metformin and a sulfonylurea if the patient has a body mass index below 35 kg/m² who has a medical problem resulting from being overweight, or for whom insulin is not an option.

Thiazolidinediones (pioglitazone, rosiglitazone)

• Healthcare professionals should consider the option of adding a thiazolidinedione in patients taking metformin and/or a sulfonylurea in whom treatment with insulin is inappropriate because of the potential for hypoglycaemia and its consequences.
• Thiazolidinedione therapy should not be started or continued in any individual who has heart failure or is at high risk of bone fracture.

Amanda Adler, Consultant Physician at Addenbrooke’s Hospital in Cambridge with an interest in diabetes and guideline development group chair says: “These guidelines acknowledge that the treatment of type 2 diabetes may require many drugs, often used simultaneously.  These guidelines weigh up the effectiveness of these newer agents against older, standard therapies, but also consider side-effects, patient well-being, and whether these newer drugs reflect the best use of NHS resources.”

Philip Home, Professor of Diabetes Medicine and Consultant Physician in Diabetes and Metabolic Medicine at Newcastle Primary Care Trust and guideline development group member says: "The expansion in new glucose-lowering therapies in diabetes is both exciting and has led to confusion.  It is good then to see an evidence- and cost-based approach to these therapies, and to see them accommodated with positive recommendations within the therapeutic pathway."

Dr Andrew Farmer, University Lecturer in General Practice at the University of Oxford and guideline development group member says: “"These guidelines provide welcome clarification about the best use of new glucose lowering treatments for people with type 2 diabetes and where they should be used in the patient’s treatment pathway. This guideline will help patient’s with type 2 diabetes, their carers and healthcare professionals make the best decisions on the treatments currently available and lower the potential risks of complications such as hypoglycaemia "

Yvonne Jones, service user representative and guideline development group member says: “These recommendations suggest a more positive and cost effective means of treating type 2 diabetes. In particular, they take account of the safe use and side effects associated with existing treatment options, such as excessive weight gain, whilst focussing on the well being of the patient.”

The guidance is available at:http://www.nice.org.uk/CG87