This is an update of the last Nice guideline on type 2 diabetes in adults, which was published in 2009. I am just summarising things that have changed since the last update. If you don't want to read anything else, just be aware that Nice has produced an excellent single A4 summary of what drugs to use when.
HbA1C targets for Type 2 diabetes
Nice advise that these targets can be tailored to the patient. They also advise that the targets can be relaxed if the side-effects from medications, or if the effort to reach that target impairs their quality of life.
- 48 mmol/mol (6.5%) = target for people just managed with lifestyle or on a single drug which doesn't cause hypoglycaemia.
- 53 mm0l/mol (7%) = target for people on drugs which cause hypoglycaemia.
- 58 mmol/mol (7.5%) or above:
- Offer encouragement
- Lifestyle advice
- Intensify drug treatment
This is largely the same and the differences are subtle. Nice no longer advising doing BMs routinely twice a week. They also no longer advise monitoring with illness, though they do acknowledge that you need to be aware of the risk of hyperglycaemia with illness. Previously they advised monitoring if on oral medication that could cause hypos, but now they only advise testing if they are also driving or operating machinery.[Tweet "Nice no longer advising doing BMs routinely twice a week."]
They also advise monitoring if the patient is on steroids, or if you need to confirm that hypos are happening.
As mentioned above, there is an excellent A4 sheet produced by NICE that I have saved to my Google Drive for easy reference.
Uploading a whole year's worth of evidence into your appraisal toolkit is depressing enough, so having to do it in a consulting room just adds insult to injury. Whilst practices are usually the best places to collect the evidence, your home is usually the most comfortable to work up ideas and reflect. Think warm fire, fresh coffee, chocolate hobnob.
But your learning isn’t just to be locked away for your appraisal. How would it be if next time you see a patient with Bell’s palsy, you don’t have to spend 30 minutes researching the prednisolone dosing regime, but you could look up your case review from 18 months ago to remind yourself? A portable, easy-to-search record of your learning can be a powerful tool during consultations.
Don't even think of using a USB stick between home and work. Too easy too loose, fragile and a great way to transfer viruses. The only way nowadays is through secure online storage accessible from any device.
Enter cloud storage, the peripatetic GP's best friend. The main players are Microsoft's OneDrive, Google Drive and Dropbox, with plenty of websites giving a rundown of these and more.
But our favourite here at NASGP is Google Drive; not only do we run all our email and calendars using Google, but all our documents, including every downloadable Microsoft Word document - were originally created in Google Drive (we simply 'save as' Microsoft Word). Best of all, its enormous sweet suite of products is free, or for £30 a year you can go for the Google for Business package – no adverts, customise your email address, and has the same ISO 27001 security standards that Clarity adheres too.
In a nutshell, so long as you have a modern secure browser in the surgery (sadly not IE8) anything and everything you create in the surgery is instantly saved and available later at home.
Security wise, whatever option you plump for, make sure is supports ISO 27001 security standard. Even though you'll be using a system that is more secure than the "little black book approach", it is still important to remember not to use patient identifiable data.
Double therapy needed
The biggest difference to the 2009 guidance is that after metformin, you can add on either a sulphonylurea, pioglitazone, a DDP-4i or (if indicated) an SGLT-2.
NB - DDP-4i drugs are the gliptins and the SGLT-2 are the gliflozins.
Triple therapy needed
If you need to add on a third drug, you can choose from:
- DDP-4i + sulphonylurea
- Pioglitazone+ sulphonylurea
- Sulphonylurea + SGLT-2 inhibitor (not ertugliflozin)
Thiazolidinedione + canagliflozin OR empagliflozin
DDP-4i + ertuglflozin (if a sulphonylurea or pioglitazone can't be used)
e.g. exenetide = Byetta and liraglutide = Victoza
Can be used alongside metformin and a sulphonylurea if triple therapy is not effective, not suitable or not tolerated and if:
- BMI > 35 AND specific psychological or health problems associated with obesity OR
- BMI < 35 AND insulin would have occupational consequences OR weight loss would benefit other obesity related conditions.
Useful notes on drugs (not all of this is new, but I'd forgotten it...):
- Metformin - they are not specifying a creatinine level to be careful about now, just a GFR level (ie review use if GFR < 45 and stop if GFR < 30).
- Pioglitazone - there are lots of contraindications. Review use after 3-6m and only continue it if the patient is getting benefit.
- Gliflozins - can cause ketoacidosis even with a normal BM and can continue to do this even for a 'short while' after stopping them. If you want a reminder of these drugs and what their indications are, there is a link to my blog on them here.
Nice have lowered the target a little for those with no other complications. It is now 140/80. They do specify that it is OK to trial lifestyle treatment first to get the blood pressure down.
Do not use aspirin for primary prevention.
Lipid Lowering Treatment
There is nothing new in this guideline. NICE produced previous advice which covers type 2 diabetics. Basically for primary prevention, use QRISK-2 and if the risk is 10% or more, start atorvastatin 20mg.
Again there is nothing new here. NICE produced previous guidance which covers type 2 diabetics. The main difference is that an ACR ≥ 3 is felt to be abnormal in both men and women.
Again, nothing new here. NICE produced previous guidance which covers type 2 diabetics. Basically you can use any of a TCA, duloxetine, gabapentin or pregabalin as first line, then try any of the others if needed.
Diabetic foot problems
See my blog covering this, which was released in a separate recent Nice guideline.
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