NICE has updated its guidance on the management of type 2 diabetes from 2002, incorporating updates to technology appraisals published since then.
Key points and changes from earlier guidance include:
- Offer structured education to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review (see also our recent blog)
- Provide individualised and ongoing specialist nutritional advice
- Involve the person in decisions about their individual HbA1c target level, which may be above that of 6.5% set for people with type 2 diabetes in general
- Self-monitoring of blood glucose should be offered to a patient newly diagnosed with T2DM only as an integral part of his/her self-management education. Its purpose should be discussed and there should be agreement how the results should be interpreted and acted upon.
- Use aspirin 75 mg in higher-risk patients and those aged 50 and older, whose blood pressure is less than 145/90 mmHg. Clopidogrel is an alternative only in those with clear aspirin intolerance
- Metformin is the first-choice oral hypoglycaemic in overweight patients and may be considered in the non-overweight. Sulphonylureas may be considered in the non-overweight, or if metformin is contraindicated or not tolerated. Glitazones are third-line, as dual therapy or triple therapy with metformin and/or a sulphonylurea if HbA1c targets are not reached, but note the cardiovascular concerns relating to glitazones (see our blog)
- First-choice antihypertensive drug is a once-daily ACE-inhibitor (plus a diuretic and/or calcium channel blocker in people of African-Caribbean descent or in people whose blood pressure is not controlled to target on monotherapy) with other drugs added as needed. A calcium channel blocker is recommended for women who may become pregnant
- Initiate simvastatin 40 mg for most people aged 40 or older (unless their 10-year cardiovascular disease (CVD) risk has been estimated at less than 20%), and younger people if their CV risk factor profile seems particularly poor. Increase the dose to 80 mg if a total cholesterol of less than 4 mmol/L or LDL-cholesterol of less than 2 mmol/L is not attained. Aim for these targets by changing statin or adding ezetimibe if there is new or existing CV disease or increased albumin excretion (but see the blog on the new NICE lipid guidance)
- Screen for eye and kidney damage annually
NICE also includes advice on management of depression, nerve damage, diabetic neuropathic pain, gastropresis, erectile dysfunction and other aspects of autonomic neuropathy.