2022 NICE diabetes treatment flowcharts
14m | Aug 28, 2022My name is Fernando Florido and I am a GP in the United Kingdom. In this video I go through the Visual summary “choosing medicines for first-line and further treatment” corresponding to the 2022 updated NICE Guideline: Type 2 diabetes in adults: management (NG28 guideline), updated on 29th June 2022. The video focuses on the drug treatment recommendations in blood glucose management in adults with Type 2 Diabetes.
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There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:
https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw
This podcast also appears in the Primary Care Guidelines podcast which can be found here:
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NICE Guideline NG28 can be found here:
https://www.nice.org.uk/guidance/ng28
The full NG28 full guideline PDF document can be found here:
· Website:
· If outside the UK, you can download it here: https://1drv.ms/b/s!AiVFJ_Uoigq0lWqK_tYk1rnOolRO
The visual summary “choosing medicines for first-line and further treatment” can be found here:
· Website:
· If outside the UK, you can download it here: https://1drv.ms/b/s!AiVFJ_Uoigq0lWugUmhgaYv1PHyf
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Transcript
Thank you for listening and welcome to a new episode of this podcast bringing medical information and NICE guidance from a primary care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.
Now, imagine that we have Mr. Johnson, who is 78 and has type 2 diabetes. His diabetes control is reasonable or metformin, 500mg BD. With an HbA1c of 7.1% or 54 mmol/mol, but he has just developed stable angina. How should his diabetic treatment change? We have covered the 2022 NICE diabetes management update in previous episodes, but perhaps we need a quick reminder?
And this is what we’re going to do today because in this video I am going to go through the flow charts produced by NICE in respect of the blood glucose management in type 2 diabetes. The full guideline has 59 pages in a PDF format and NICE has produced a 5-page summary on the blood glucose management. This video is going to focus on the two flow charts that will advise how to choose first line medicines and how to choose medicines for further treatment.
I will put in the description below a link to download the full NICE guideline as well as the five-page summary. There is a YouTube version of this episode and other NICE guidance on the NICE GP YouTube Channel and a link to access it can be found in the podcast description. Because of the visual nature of the flow chart, I would highly recommend watching the YouTube video if you can.
Although describing visual aids as audio files can be challenging, I hope that you find the content clear and informative.
Now the first flow chart that we are going to look at is the one about how to choose first line medicines. It is only one page and there is a combination of arrows that will guide us through the treatment pathways and a number of boxes with further information and clarification on the treatments described.
Right at the top of the chart, we find a box that tells us about rescue therapy and it reminds us that for patients with symptomatic hyperglycaemia, we will consider insulin or a sulphonylurea and then review the treatment when their blood glucose control has been achieved.
Then the next step is to assess the HbA1c, the cardiovascular risk and kidney function. Obviously, as you know, to calculate the cardio vascular risk with, for example, the QRISK2 tool, we will need to know the patient’s age, sex, smoking status, blood pressure and the total cholesterol/HDL ratio.
Now, having checked the renal function, before starting to follow the pathway, there is a little box on the left telling us that for information on using SGLT 2 inhibitors for people with type 2 diabetes and CKD, there is specific guidance that is not on this flow chart and we will have to refer to CKD section of the diabetic guideline.
So, after we have done our initial assessment with the HbA1c, cardiovascular risk and kidney function, the flow chart divides into three categories. One, it could be that the patient is not at high cardiovascular risk. Two, that the patient has chronic heart failure or established atherosclerotic cardio vascular disease. Or three, that the patient has a high risk of cardiovascular disease, which is defined as a QRISK 2 of 10% or higher over ten years, or an elevated lifetime risk.
Now, the first pathway would be when the patient is not at high risk of cardio vascular disease and for these patients, we will offer metformin, or, if there are gastrointestinal side effects, we will give Metformin slow release. Now if metformin is contraindicated, we will consider one of the other antidiabetic agents, either a DPP-4 inhibitor, pioglitazone or a sulphonylurea, although it does also tell us that SGLT 2 inhibitors can also be given as monotherapy for some patients. Basically, NICE recommends an SGLT 2 inhibitor as monotherapy in people who can’t take metformin and for whom the diabetic control is poor, and only if a DPP-4 inhibitor would otherwise be prescribed and a sulphonylurea or pioglitazone is not appropriate. So, it is fairly restrictive.
We also see a small note saying that using your ertugliflozin to reduce cardiovascular risk when the blood glucose is well controlled was an off-label use.
So, if no cardiovascular risk, we give metformin first and if contraindicated one of the other agents, sulphonylurea, pioglitazone, DPPG4 inhibitors of an SGLT2 inhibitor, although the latter with a few restrictions.
Now the second pathway would be when the patient has got chronic heart failure or established atherosclerotic cardiovascular disease. And the flow chart tells us in a box what they actually mean by established atherosclerotic cardiovascular disease, and this is fairly intuitive. It includes CHD, acute coronary syndrome, previous MI, stable angina, prior coronary or other revascularisation, cerebrovascular disease, which includes both ischemic stroke and TIAs and finally, peripheral arterial disease. So, for those patients, we will do very similar. We will start with metformin or if there are gastrointestinal side effects, we will give Metformin slow release and then, as soon as metformin tolerability is confirmed, we will offer an SGLT 2 inhibitor with proven cardiovascular benefit. And this is because SGLT 2 inhibitors have now been found to reduce cardio vascular events. However, if metformin is contraindicated, then we will give an SGLT 2 inhibitor alone. So, this is fairly straight forward.
Finally, the third option after the initial assessment is that the patient has not got cardiovascular disease but is at high risk of it. In this case, the flow chart is basically fairly similar. We will give metformin or, if there are side effects, metformin slow release and then as soon as metformin tolerability is confirmed we will consider an SGLT 2 inhibitor with proven cardiovascular benefit. And also, if metformin is contraindicated, we will consider an SGLT 2 inhibitor alone.
So, you may ask what is the difference between those two, having cardiovascular disease and being at high risk of CVD? And the difference is basically that, if the patient has got cardiovascular disease or heart failure, we will definitely offer an SGLT 2 inhibitor, whereas if a patient is only at high risk of cardiovascular disease, we will consider it. But in practice you will probably find that pathways are exactly the same, because you’re going to consider it seriously and you're going to give it unless a contraindication or other major consideration.
In the middle of the flow chart there’s a little box that reminds us that we always have to start metformin alone to assess tolerability before adding an SGLT 2 inhibitor. So, metformin is always the start.
So, this is really the flowchart on how to choose first line medicines. After this, if the person’s HbA1c is not controlled below the target or a person develops cardio vascular disease or a high risk of cardiovascular disease, then we will move to the second flow chart, which is the one about treatment options if further interventions are needed.
So, there we go. The second flow chart which is on how to choose medicines for further treatment.
Here, at the beginning, there’s another box telling us again about rescue therapy and using insulin, or a sulphonylurea for symptomatic hyperglycaemia until the levels are controlled.
Now, if further treatment options are needed, it will be because either at any point the HbA1c is not well controlled, or at any point, the cardio vascular risk or cardiovascular status change.
Right, we’re going to start with the cardiovascular risk of cardiovascular status change and we’ve got two options. The first one is that the person has or develops chronic heart failure or established atherosclerotic cardiovascular disease, and the second one is that the person develops a high risk of cardiovascular disease.
If the person has or develops chronic heart failure or established atherosclerotic cardiovascular disease, we will basically switch or add treatments to make sure that we offer an SGLT 2 inhibitor if this is not already prescribed. So, if the person develops the condition, we will either add an SGLT 2 inhibitor if the HbA1c could do with lowering further or, if the HBA 1C, is fairly low and we don’t want to lower it any more then we will switch one of the existing drugs for an SGLT 2 inhibitor.
On the other hand, if the person has or develops a high risk of cardio vascular disease, then we will consider an SGLT 2 inhibitor when switching or adding treatments. So, like before in the previous flow chart, giving an SGLT2 is slightly more imperative when the person has developed cardiovascular disease, whereas, if the person is just at a high risk, we will only consider it. But again, in practice it may not make much difference.
Now, if at any point the HbA1c is not well controlled, there is a box that tells us that we will switch or add treatments from different drug classes up to triple therapy or dual therapy if metformin is contraindicated. So basically, we will consider any combination to dual or triple therapy of the antidiabetic agents, that is, either a DPP 4 inhibitor, pioglitazone or a sulphonylurea, although it also tells us that SGLT 2 inhibitors may also be an option both in dual therapy or triple therapy.
Now you may ask when should we start insulin? Well at the bottom left corner we find a box that tells us that, when dual therapy is not enough to control the HbA1c, we can consider insulin-based therapy, with or without other drugs and there is additional guidance on how to use insulin with SGLT 2 inhibitors. So basically, if a patient goes up to dual therapy and is not well controlled, you may consider triple therapy if the patient is on metformin or just consider insulin as the next step.
And finally, what is happening to GLP 1 mimetics? Well, this is where NICE has been quite restrictive in their approach because it tells us that if triple therapy with metformin and two other oral drugs is not enough, we will consider triple therapy by switching one drug for a GLP 1 mimetic, but only for people:
· who have a BMI of 35 or higher and specific psychological or other medical problems associated with obesity, although it does say that you can adjust the BMI to lower for people from Black, Asian and other minority ethnic groups, because these groups are at higher risk of cardiovascular disease and GLP mimetics have also been shown to reduce cardiovascular events, or
· we can give it to patients who have a BMI lower than 35 and for whom:
o insulin therapy would have a significant occupational implication or
o weight loss would benefit other significant obesity related comorbidities.
Right, so this is it, we have finished our second flow chart and therefore we have come to the end of this episode, I hope that you have found it useful. There is also a YouTube version in the NICE GP YouTube Channel and I will leave a link in the podcast description. Thank you for listening and I hope that you will join me in the next one. Goodbye.
