02 December 2015

Ensure people with type 2 diabetes are involved in decisions about their care

Healthcare professionals should involve people with type 2 diabetes in decisions about their care such as managing blood glucose levels, NICE says.

Updated guidelines stress the need for individualising care for people with type 2 diabetes, and include new recommendations on managing blood glucose, effective drug treatments and lifestyle interventions.

The vast majority of people who have diabetes have type 2 diabetes, a form of the condition that tends to appear in people over 40, but that is increasingly being seen in younger people due to rising obesity levels.

The condition is also common among people from people from African, African Caribbean and South Asian family origins. It can result in blindness, kidney failure, premature heart disease stroke and death if not effectively managed.

In an update to existing guidelines, NICE has developed new recommendations on which provide clarity on the sequence of drug treatments that can be offered. The guideline also includes an algorithm to help healthcare professionals make decisions on the most appropriate pathway of care.

Tailor diabetes care to the needs and circumstances of the individual

The new guideline is underpinned by a recommendation which says healthcare professionals should adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of adults with the condition.

Healthcare professionals should take into account a person’s:

  • personal preferences
  • comorbidities
  • risks from polypharmacy
  •  ability to benefit from long-term interventions because of reduced life expectancy

NICE says that such an approach is especially important in the context of multimorbidity.

A person’s needs and circumstances should be reassessed at each review, and healthcare professional and patient should both think about whether to stop any medicines that are not effective.

The guideline also recommends offering structure education to adults with type 2 diabetes and their family or carers around the time of diagnosis. A full list of recommended components is included.

Managing HbA1c levels – importance of lifestyle changes

The treatment and management of diabetes relies on blood sugar control, which is measured through a HbA1c test.

NICE says adults with type 2 diabetes should be involved  in decisions about their individual HbA1c target, and it has produced a patient decision aid to help  with this.

They should be encouraged to achieve the target and maintain it unless any resulting adverse effects - including hypoglycaemia - or their efforts to achieve their target, impair their quality of life.

Changes to lifestyle such as increasing physical activity and losing weight to achieve a health body mass index are known to be effective at reducing the risk of type 2 diabetes.

As a result, NICE recommends offering lifestyle advice and drug treatment to support adults with type 2 diabetes to achieve and maintain their HbA1c target.

If HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher, healthcare professionals should:

  • reinforce advice about diet, lifestyle and adherence to drug treatment and
  • support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and
  • intensify drug treatment.

In adults with type 2 diabetes, HbA1c levels should be measured at:

  • 3–6-monthly intervals (tailored to individual needs), until the HbA1c is stable on unchanging therapy
  • 6-monthly intervals once the HbA1c level and blood glucose lowering therapy are stable.

New advice on drug treatment

NICE says that standard-release metformin should be offered as the initial drug treatment for adults with type 2 diabetes.

The dose should be gradually increased over several weeks to minimise the risk of gastrointestinal side effects in adults with type 2 diabetes.

If the person experiences gastrointestinal side effects with standard-release metformin, then a trial of modified-release metformin should be considered.

The guideline also includes an algorithm to help with this most effect guideline includes an algorithm for blood glucose lowering therapy in adults with type 2 diabetes.

Dr Amanda Adler, consultant diabetologist and member of the NICE guideline development group, said: “This update to the guideline for type 2 diabetes is good news for people with type 2 diabetes and for health professionals given the many therapies now available. The guideline comprehensively covers the best care for patients with type 2 diabetes taking into account effectiveness of medications, enhancing quality of life, and wisely using NHS resources.  

Dr Ian Lewin, NICE guideline developer and retired consultant endocrinologist, commented: “The guideline highlights that putting people with type 2 diabetes at the centre of their care package is essential. For example the guideline recommends that adults with type 2 diabetes should be involved in decisions about their individual HbA1c target – the average amount of glucose in their blood over 2 to 3 months. 

“Health professionals are also advised to individualise recommendations for carbohydrate intake and alcohol intake, and meal patterns. All of these steps should result in improved outcomes for adults with type 2 diabetes – reduced complications and better health.”

Dr Jacintha Sivarajah, Head of Medical Affairs at the Association of the British Pharmaceutical Industry, said:  “The updated NICE guidance for treating type 2 diabetes is great news for patients.  Diabetes experts had expressed concerns about the previous guidelines due to their focus on cost over clinical care.  NIC has addressed these concerns and today’s announcement should encourage clinicians to adopt an individualised approach to treatment, tailored to meet the needs of each patient.   This will result in greater long-term health benefits for patients.  We are pleased to have had the opportunity to work with NICE and to contribute to this important guidance."   
 
"We believe these guidelines now represent ‘one voice’ from the diabetes community - doctors, patient groups, science leaders and the pharmaceutical industry - and this can only be positive."

The guideline comprehensively covers the best care for patients with type 2 diabetes taking into account effectiveness of medications, enhancing quality of life, and wisely using NHS resources.

Dr Amanda Adler, consultant diabetologist and member of the NICE guideline development group

We believe these guidelines now represent ‘one voice’ from the diabetes community - doctors, patient groups, science leaders and the pharmaceutical industry - and this can only be positive.

Dr Jacintha Sivarajah, Head of Medical Affairs at the Association of the British Pharmaceutical Industry