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NICE issues national guidelines for the management of blood pressure and lipids in people with type 2 diabetes

NICE 2002/055
Issued: 31 October 2002


PRESS RELEASE

NICE issues national guidelines for the management of blood pressure and lipids in people with type 2 diabetes

 

The National Institute for Clinical Excellence (NICE or "the Institute") has today issued the fourth in its series of clinical guidelines to support the care of people with diabetes. The guideline covers the management of blood pressure and blood lipid levels of people with type 2 diabetes and looks at their role in limiting or preventing complications of the disease.

Raised blood pressure and higher than normal levels of certain lipids (fats) in the blood are known to increase the risk of having cardiovascular disease, one of the main complications of diabetes. The guideline recommends that:

  • People with type 2 diabetes who do not have manifest evidence of cardiovascular disease should have their heart disease risk estimated annually. This risk level should then be used, in conjunction with measurements of blood pressure and blood lipid levels, to inform subsequent treatment options.

  • People with type 2 diabetes should have their blood pressure taken at least once a year. Those whose blood pressure is found to be 140/80mmHg or higher should initially be offered advice on lifestyle changes - such as diet and exercise - to help prevent further rises in blood pressure.

  • People with type 2 diabetes should have their blood lipid levels checked once a year. Those whose blood lipid levels are found to be high should initially be offered advice on lifestyle changes - such as diet and exercise - to help reduce these levels.

The guideline also recommends the circumstances under which certain blood pressure and blood lipid-lowering medicines (such as ACE inhibitors and statins) should be used.

Peter Littlejohns, Clinical Director and executive lead for the guideline said: "This guideline is designed to be used in conjunction with the other NICE guidelines in this series to inform a comprehensive approach to evaluating and then effectively managing the risks of people with type 2 diabetes."

Ends

Notes to Editors

About NICE

1. 1. NICE is part of the NHS. It is the independent organisation responsible for providing national guidance on treatments and care for those using the NHS in England and Wales. Its guidance is for healthcare professionals and patients and their carers to help them make decisions about treatment and healthcare. For further information about NICE you can visit www.nice.org.uk.
   
2.

NICE produces guidance in three areas of health:

  • the use of new and existing medicines and treatments within the NHS in England and Wales - technology appraisals
  • the appropriate treatment and care of patients with specific diseases and conditions within the NHS in England and Wales - clinical guidelines.
  • the safety and usefulness of an interventional procedure, for example a new type of surgery -interventional procedures.

NICE also funds four enquiries that undertake research into the way patients are treated to identify ways of improving the quality of care (the investigations are known as confidential enquiries).

3.

NICE guidance and recommendations are prepared by independent groups that include professionals working in the NHS and people who are familiar with the issues affecting patients and carers.

   
About clinical guidelines
   
4. Clinical guidelines are recommendations on the appropriate treatment and care of patients with specific diseases and conditions within the NHS in England and Wales. They sit alongside, but do not replace, the knowledge and skills of experienced health professionals.
   
5. NICE clinical guidelines are developed by independent groups that include healthcare professionals working in the NHS, patients and people who are familiar with the issues affecting patients and carers. Professional and patient/carer groups whose members are likely to be affected by the guideline are able to submit information and comment on the recommendations before they are finalised.
   
About diabetes
   
6. The guidelines in the type 2 diabetes series were commissioned by the Department of Health before NICE was formed in April 1999. The developers have followed closely the development brief that was agreed at the time of commissioning. The developers have worked with the Institute to ensure, in the time available, that the guideline has been the subject of validation and consultation with stakeholders. However, it has not been possible to subject it to the full guideline development process that the Institute has now adopted.
   
7.

Copies of the full guideline and the NICE short form guidelines are available on the NICE website and on the National Electronic Library for Health's website, . Copies of the NICE guideline are also available from the NHS Response line by telephoning 0870 155 455 and quoting ref. N0167.

   
8.

Diabetes is a common condition in which the amount of glucose (sugar) in the blood is too high because the body is unable to use it properly. Normally, the pancreas produces insulin, which controls the levels of glucose in the blood. Diabetes occurs when the body does not produce enough insulin, or produces insulin but cannot use it properly.

   
9.

Type 2 diabetes (also called non-insulin-dependent diabetes) develops when the body can still make some insulin, but not enough for its needs, or when the insulin that is produced does not work properly (known as insulin resistance). This type of diabetes usually appears in people over the age of 40, though it can appear in younger people.

   
10.

One of the effects of diabetes is that small blood vessels in the body may become damaged. This can cause a number of problems, which may affect:

  • blood glucose (sugar) levels
  • blood pressure levels
  • the feet
  • the eyes (diabetic retinopathy)
  • the levels of certain substances in the blood (for example, lipids such as cholesterol)
  • the kidneys (nephropathy or renal disease).

What does the guideline say?

   
11.

Because cardiovascular disease (disorders of the heart, blood vessels or blood circulation) is a particular risk for people with diabetes, NICE has made recommendations about:

  • how doctors should estimate how much at risk those people with type 2 diabetes are from cardiovascular disease (that is, what are the chances of developing cardiovascular disease, or of existing cardiovascular problems getting worse)
  • ways in which doctors can help to reduce risk from cardiovascular disease of patients with type 2 diabetes.
12.

Because raised blood pressure and higher than normal levels of certain lipids (fats) in the blood are known to increase the risk of having cardiovascular disease, NICE has also made recommendations about monitoring and managing blood pressure and blood lipid levels.

.

 

13.

The NICE recommendations about estimating the level of risk of cardiovascular disease are as follows.

  • When the diagnosis of type 2 diabetes is made, doctors should find out about any problems patients have had with their health in the past. This will include checking whether they have had cardiovascular problems and whether patients have symptoms of cardiovascular disease now.

  • At least once a year people with type 2 diabetes should have a review of their level of risk of cardiovascular problems; this means that the doctor will carry out a number of tests and measurements, including weight, measuring blood pressure and taking a sample of blood so that the level of blood glucose (sugar) and lipids (fats) in it can be measured in a laboratory; the review should also include questions about lifestyle, including diet, exercise and smoking.

  • For people with type 2 diabetes who do not have obvious symptoms of cardiovascular disease, the guideline recommends that at least once a year their doctor should estimate how much at risk they are of having a coronary event, which means the chance of having a heart attack or a first attack of angina some time in the next 10 years. The risk should be estimated using standard charts that combine information about blood pressure, levels of certain blood lipids (fats) age and smoking.

  • People with type 2 diabetes who do have obvious symptoms of cardiovascular disease should be considered to be at higher risk of having a 'coronary event'.
14.

The NICE recommendations for managing high blood pressure (140/80 mmHg or higher) for people with type 2 diabetes are:

  • Health professionals should offer advice on lifestyle changes to help prevent further rises in blood pressure

  • three blood pressure readings should be taken so that the average can be used as a baseline against which later measurements can be compared

  • blood pressure is checked at least once every 6 months.
15.

NICE recommendations about when medicines should be used to help lower blood pressure are:

 

Table 1 NICE recommendations about when to use medicines to help lower blood pressure
1. If someone has:
blood pressure equal to or greater than 140/80 mmHg and less than 160/100 mmHg		 and
a lower 10-year coronary event risk

Medicine is not recommended unless:

  • coronary event risk increases to the higher level, or
  • several measurements show blood pressure increases to 160 mmHg or above.

    (If either of these occurs, the treatment should be according to recommendations 2 or 3 below.)
2. If someone has:
blood pressure equal to or greater than 140/80 mmHg and less than 160/100 mmHg		 and
a higher 10-year coronary event risk

NICE recommends that the doctor should:

  • offer treatment with medicine* to help to reduce blood pressure
  • aim for treatment to reduce blood pressure to below 140/80 mmHg.
3. If someone has:
blood pressure of 160/100 mmHg or higher

 

NICE recommends that the doctor should:

  • offer treatment with medicine* to help to reduce blood pressure
  • aim for treatment to reduce blood pressure to below 140/80 mmHg.
4. If someone has:
blood pressure of 140/80 mmHg or higher		 and
has albumin or protein in their urine (these are signs of kidney problems)

NICE recommends that the doctor should:

  • offer treatment with medicine* with the aim of lowering blood pressure to 135/75 mmHg or lower.

 

16.

The NICE guideline also makes recommendations on the choice of medicine to reduce blood pressure, including ACE inhibitors, angiotensin II receptor antagonists, beta blockers, thiazide diuretics and long-acting calcium channel blockers.

 

 

17.

NICE has made the following recommendations about aspirin treatment for people with type 2 diabetes.

  • For people who have obvious signs of or a history of cardiovascular disease: 75 mg aspirin each day.
  • For people with a more than 15% risk of heart problems in the next 10 years: 75 mg aspirin each day, with treatment starting after systolic blood pressure has been reduced to 145 mmHg or lower; blood pressure should be kept at 145 mmHg or lower while aspirin is being taken as anti-platelet therapy.
18.

NICE recommendations about measuring blood lipid levels are:

  • When someone is diagnosed with type 2 diabetes, their levels of total cholesterol, low-density lipoprotein carrying cholesterol (LDL-C), high-density lipoprotein carrying cholesterol (HDL-C) and triglycerides (simple fats) should be measured

  • The measurements should be made in fasting blood samples if possible.

  • People with type 2 diabetes should expect to have their blood lipid levels checked on diagnosis and then at least once a year.
19.

The NICE recommendations for people with type 2 diabetes who have a total cholesterol level of 5.0 mmol/litre or more (or a LDL-C reading of 3.0 mmol/litre or more) or a triglyceride level of 2.3 mmol/litre or more are that health professionals should:

  • Carry out checks to ascertain whether the high lipid level is related to a disease other than diabetes
  • Ensure blood glucose levels are being controlled as well as possible
  • Offer lifestyle advice on how to help reduce blood lipid levels, for example by losing weight, changing diet, or increasing the amount of exercise taken
  • Measure blood lipid levels again before considering whether using a medicine would be an appropriate way to help to lower blood lipid levels - any treatment with a medicine should only start if the new measurements show that lipid levels are still high
  • Continue to measure blood lipid levels (preferably using fasting blood samples) during any treatment with medicines.
20.

The guideline also recommends the circumstances in which drugs (statins and fibrates) should be used to help lower blood lipid levels, and sets minimum targets to be achieved by the treatments:

  • to reduce total cholesterol to below 5.0 mmol/litre or to 75-80% of the level before treatment, whichever is lower, or
  • to reduce LDL-C to below 3.0 mmol/litre or to 70% of the level before treatment, whichever is lower.