Updated guidelines published for management of type 2 diabetes

NICE document focuses on patient information with revised guidance on reviewing drug treatments.

Newly updated guidelines have been published covering care and management for adults (aged 18 and over) with type 2 diabetes. 

The NICE (National Institute for Health and Care Excellence) document focuses on patient education, dietary advice, managing cardiovascular risk, managing blood glucose levels, and identifying and managing long-term complications of type 2 diabetes. 

The guidelines include recently reviewed evidence on drug treatment in order to make new recommendations. 

This updated guideline includes new recommendations on first-line drug treatment based on the cardiovascular risk assessment for the person with type 2 diabetes and if they have chronic heart failure or are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin. 

Additional recommendations include reviewing drug treatments and introducing drugs used in combination therapy in a stepwise manner, checking for tolerability and effectiveness of each drug. 

For example, in adults with type 2 diabetes, if monotherapy has not continued to control HbA1c (blood glucose levels) to below the person's individually agreed threshold for further intervention, consider adding treatment options including a DPP-4 inhibitor, pioglitazone, sulfonylurea, or an SGLT2 inhibitor for people who meet the criteria. 

The guidelines state: “When reviewing or considering changing drug treatments for adults with type 2 diabetes, think about and discuss the following with the person: how to optimise their current treatment regimen before thinking about changing treatments, taking into account factors such as: adverse effects, adherence to existing medicines, the need to revisit advice about diet and lifestyle and prescribed doses and formulations.” 

Additionally, to consider when reviewing drug treatment options, the report adds to stop medicines that have had no impact on glycaemic control or weight, unless there is an additional clinical benefit, such as cardiovascular or renal protection, from continued treatment (see the note below on off-label use) and whether switching rather than adding drugs could be effective. 

Bethany Kelly, Diabetes Specialist Nurse at Wiltshire Health and Care and member of the DRWF Editorial Advisory Board, said: “It is great to finally see the NICE type 2 diabetes guidance reviewed and published. This has been long overdue. The stand-out change for many, is that there is now an option to prescribe dual therapy at diagnosis if healthcare professionals can detect risk for heart disease in a patient. These changes should mean that long-term complications such as heart attacks and strokes are reduced.” 

Type 2 diabetes in adults: choosing medicines 

This is a summary of the advice in the NICE guideline on type 2 diabetes in adults: management. 

Factors to take into account when choosing, reviewing and changing medicines: 

• Prescribing guidance 
• Rescue therapy
• For symptomatic hyperglycaemia, consider insulin or a sulfonylurea and review when blood glucose control has been achieved. Diet and lifestyle advice
• At each point reinforce advice about diet and lifestyle. 

Choosing treatments 

Base the choice of medicine on: 

• The person’s individual clinical circumstances, for example comorbidities, contraindications, weight, and risks from polypharmacy
• The person’s individual preferences and needs
• The effectiveness of the drug treatments in terms of metabolic response and cardiovascular and renal protection
• Safety 

Reviewing and changing treatments 

At each point, think about and discuss the following with the person: 

• Stopping medicines that are not tolerated
• Stopping medicines that have had no impact on glycaemic control or weight, unless there is an additional clinical benefit, such as cardiovascular or renal protection, from continued treatment
• How to optimise their current treatment regimen before thinking about changing treatments 

The guidelines are designed for use by healthcare professionals that care for adults with diabetes; commissioners and providers of diabetes services and adults with type 2 diabetes, and their families and carers. 

Read the NICE report Type 2 diabetes in adults: management 

Read more about type 2 diabetes 

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