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2022 NICE guidance: type 2 diabetes
Question clinique
How should patients with type 2 diabetes be treated?
L’Essentiel
These NICE treatment guidelines continue the move toward modifying cardiovascular risk over glycemic control when making treatment decisions for type 2 diabetes. Although metformin treatment is still the cornerstone, these updated guidelines make way for routine treatment with SGLT2 inhibitors. For patients with chronic heart failure, patients at high risk of or with established atherosclerotic cardiovascular disease, or patients with chronic kidney disease, consider adding an SGLT2 inhibitor. The guidance makes no specific recommendation for an HbA1c treatment goal, other than to suggest switching or adding treatments if an "individually agreed threshold" is not met. A useful decision tree is available here. (LOE = 5)
Overuse alert: This POEM aligns with the following Choosing Wisely Canada recommendations:
1. The Canadian Geriatrics Society’s recommendation: Avoid using medications known to cause hypoglycemia to achieve hemoglobin A1c < 7.5% in many adults aged 65 and older; moderate control is generally better.
2. The Canadian Society of Endocrinology and Metabolism’s recommendation: Don’t recommend routine or multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.
Référence
Plan de l'etude: Practice guideline
Financement: Government
Cadre: Various (guideline)
Sommaire
These National Institute of Health and Care Excellence (NICE) guidelines are based on a review of the best evidence on the treatment of type 2 diabetes along with explicit consideration of cost effectiveness. The complete guideline can be found here. These guidelines continue to evolve our thinking away from glycemic control treatment goals and toward goals that consider cardiovascular risk and kidney function. Metformin should be the first medicine used in patients with type 2 diabetes; the modified-release version (Glumetza) should be considered for patients with continued gastrointestinal symptoms. Assess kidney function via albumin to creatinine ratio and cardiovascular disease status and risk via the QRISK2 calculator. As in previous guidelines, chronic kidney disease should be treated, and a sodium glucose co-transporter 2 (SGLT2) inhibitor should be considered. Patients with chronic heart failure (strong recommendation) or established cardiovascular disease (weak recommendation) should be treated with an SGLT2 inhibitor, as well. The guidelines hint that empagliflozin (Jardiance), canagliflozin (Invokana), or dapagliflozin (Farxiga, Forxiga), which have stronger evidence of cardiovascular disease protection, should be used. The guidance does not specify a specific level of glycemic control as a goal.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Commentaires
Excellent information
Good review of this topic