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NICE increases type 2 diabetes options

Guidance on the use of newer agents for blood glucose control in adults with type 2 diabetes has been issued by NICE

Guidance on the use of newer agents for blood glucose control in adults with type 2 diabetes has been issued by the UK's National Institute for Health and Clinical Excellence (NICE). The new short clinical guideline examines several new and existing treatments.

The management of blood glucose levels is a central part of diabetes treatment. The NICE guidance recommends a number of new treatments and positions them among existing therapies for type 2 diabetes. They 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.

When the decision to begin insulin therapy is made, NICE states that human NPH insulin should be started. NPH insulin is a synthetic version of the body's own insulin mixed with a substance that slows down the speed of absorption into the body. 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 needs help to inject, and for whom switching to a long-acting insulin analogue would reduce the number of daily injections.

Healthcare professionals should consider adding a DPP-4 inhibitor (sitagliptin) in patients taking metformin and a sulfonylurea in those for whom treatment with insulin is inappropriate because of employment, social, or recreational problems related to hypoglycaemia.

They should consider 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) 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 and requires twice-daily injection. It should be considered for adding 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 problems associated with high body weight. It may also be added to metformin and a sulfonylurea if the patient has a lower body mass index and a medical problem resulting from being overweight, or for whom insulin is not an option.

They should consider adding a thiazolidinedione in patients taking metformin and/or a sulfonylurea for 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, said: "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 wellbeing, and whether these newer drugs reflect the best use of NHS resources."

27th May 2009

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