The National Institute for Health and Clinical Excellence (NICE) has issued a new guidance on the use of several newer agents for blood glucose control in adults with type 2 diabetes.
These include long-acting insulin analogues, DPP-4 inhibitors, glucagon-like peptide-1 (GLP-1) mimetics and thiazolidinediones.
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 needs help to inject the insulin 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 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. A DPP-4 inhibitor can also be considered in patients who have contraindications to 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 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. 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)
A thiazolidinedione can be considered in patients taking metformin and/or a sulfonylurea in whom treatment with insulin is inappropriate because of the potential for hypoglycaemia and its consequences. But thiazolidinedione therapy should not be started or continued in any individual who has heart failure or is at high risk of bone fracture.
In a NICE press release, Philip Home (Professor of Diabetes Medicine at Newcastle Primary Care Trust) who was part of the guideline development group, 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”.