Update to NG28, Type 2 diabetes guidelines - what's new?

It has been a long time in the waiting, but this week we have an important update to the NICE Type 2 Diabetes in Adults guideline. Much has changed in the world of type 2 diabetes management over the last few years, particularly in light of the cardiovascular and renal outcome trials for the newer agents the SGLT2 inhibitors and GLP1 agonists, so this update is very welcome!

So what is new?

Firstly, NICE are further encouraging the individualisation of glycaemic targets for people with Type 2 Diabetes and have produced a useful patient decision aid to help guide that discussion.  They also specify that relaxation of targets should be considered in frailty as appropriate, good news.

When it comes to prescribing, there are 2 new prescribing flow charts for us to get our heads around, one for first line treatment and the other for ongoing management. 

Firstly, in people newly diagnosed with type 2 diabetes there is a major change to management. They ask us to make a decision as to whether that person has established atherosclerotic CVD, heart failure or is high cardiovascular risk (defined as a Qrisk2 > 10%). In people with established CVD the advice is to offer dual therapy with metformin and an SGLT2i from the outset, starting the metformin initially to establish tolerability and then adding the SGLT2i shortly afterwards. In those at high cardiovascular risk with a Qrisk2> 10% (i.e. the majority of our patients with type 2 diabetes), NICE tell us to consider exactly the same dual therapy approach from the outset so still an option but at a lower evidence level than for those with established CVD. In people who are not high CVD risk the initial treatment will be metformin alone. 

The second flow chart refers to ongoing treatment.  Here the changes are less dramatic, allowing us to choose additional therapies as required if HBA1c is over individualised target and adding an SGLT2i if cardiovascular risk status changes.  In terms of GLP1’s, NICE differ from our international colleagues here.  They conclude that the GLP1 class are not consistently cost effective like the SGLT2i’s, so they remain a choice further down the treatment pathway.

Finally, the guideline reminds us of the renal benefits of SGLT2i’s which was also included in the NICE CKD guideline update at the end of 2021.  In people with type 2 diabetes and CKD with a ACR> 30, we should offer an SGLT2i alongside ACEi/ARB , and indeed consider adding one if the ACR 3-30. This is in light of the evidence they will reduce both renal and cardiovascular events in this group of patients.

We will be covering this important guideline update, looking at its clinical implications for us and our patients on our Hot Topics Update course in forthcoming months starting on March 5^th. As SGLT2i look to be used in a much wider group of patients, we shall also cover recent guidance on how these drugs can be used safely in primary care to mitigate the risk of DKA. We shall explore the guideline update in more detail with a full update on Diabetes management in our Diabetes in Primary Care course, which will next be live on Saturday 11^th June 2022.