Podcast - 2024 Diabetes Update: NICE Guideline with Self-Test MCQs

The video version of this episode can be found here:

·      https://youtu.be/2gDK6E85diU

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In the first part of this episode, I go through the NICE guideline [NG28] on Type 2 diabetes in adults, always focusing on what is relevant in Primary Care only. In the second part I go through a thorough review of the guideline with a series of multiple-choice questions. Each question is paired with quotation, aiming to clarify key concepts and enhance understanding. This informative segment is created to support continuous learning in Primary Care.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The full NICE guideline can be found here:

·      https://www.nice.org.uk/guidance/ng28

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Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do an up to date revision of the NICE guideline on type 2 diabetes. This episode is longer because it has two parts. In the first part, which lasts or about 20 minutes, I go through the NICE guideline itself, always focusing on what is relevant in Primary Care only. In the second part, I will present you with a series of multiple-choice questions so that you can test yourself. After each question, you are given the right answer, which is paired with a guiding quotation. This pairing is designed to clarify key concepts and enhance your continuous learning and retention.

I have created time stamps throughout the video so that you can skip to the section that you wish whenever you want.

Right, let’s jump into it.

Firstly, I will just state that this episode does not cover the management of pregnant women with type 2 diabetes. 

We will offer structured education to patients at the time of diagnosis, with annual reinforcement and, if possible, this should be in the form of group education programmes.

The dietary advice should be the same healthy eating advice as the general population, which includes:

·      high-fibre, low-glycaemic-index sources of carbohydrates

·      low-fat foods and

·      oily fish

And we will discourage foods marketed specifically for people with diabetes. 

If the person is overweight, we should aim for an initial body weight loss target of 5% to 10%, remembering that even a small amount of weight loss may still be beneficial. 

The guideline on type 2 diabetes makes reference to the bariatric surgery guideline which says that we should refer people with type 2 diabetes for consideration of bariatric surgery if they have a BMI of 35 or more. If they have Asian or African-Caribbean family background, we will do so if the BMI is 32.5 or more.

The recommendations on hypertension are broadly the same as for other people so we will simply follow the NICE guideline on hypertension because, when a different approach is needed for people with type 2 diabetes, this is specified in the hypertension guideline.

Additionally, we will not offer antiplatelet therapy (aspirin or clopidogrel) without cardiovascular disease. 

In respect of blood glucose management, broadly speaking we will measure HbA1c:

·      every 3 to 6 months until HbA1c is stable or

·      every 6 months once both HbA1c and therapy are stable. 

If HbA1c is not valid because of disturbed erythrocyte turnover or abnormal haemoglobin type, we will use:

·      plasma glucose levels

·      fructosamine or

·      in cases of abnormal haemoglobins, we will use total glycated haemoglobin

In terms of HbA1c targets, if the diabetes is managed either by diet, or a single drug not associated with hypoglycaemia, we will aim for an HbA1c of 48 mmol/mol or 6.5%. If it’s treated with a drug associated with hypoglycaemia, we will aim for an HbA1c level of 53 mmol/mol or 7.0%. 

If HbA1c on a single drug rises to 58 mmol/mol or 7.5% or higher, we will intensify drug treatment. aiming for an HbA1c of 53 mmol/mol or 7.0%. 

However, we will consider relaxing the HbA1c target, particularly for older or frailer people if:

·      they are unlikely to achieve benefits, for example, because of a reduced life expectancy or if

·      intensive treatment would not be appropriate, for example because of comorbidities or risks of hypoglycaemia. 

If the HbA1c drops below the target, we should consider other possibilities, for example deteriorating renal function or sudden weight loss. 

When considering self-monitoring of blood glucose, we will take into account the DVLA recommendations. But otherwise, we will not routinely offer self-monitoring of capillary blood glucose levels unless:

·      the person is on insulin or oral medication that may increase their risk of hypoglycaemia or

·      there is evidence of hypoglycaemia or

·      they are pregnant or planning to become pregnant

We will consider short-term self-monitoring of blood glucose:

·      when starting oral or intravenous corticosteroids 

·      to confirm suspected hypoglycaemia or

·      if concerned during acute intercurrent illness to help manage their treatment as necessary. 

What about the new technology of continuous glucose monitoring?

Well, we should offer intermittently scanned continuous glucose monitoring (isCGM), commonly referred to as 'flash' if they are on multiple insulin injections and:

·      they have recurrent or severe hypoglycaemia or impaired hypoglycaemia awareness or

·      they are unable to self-test or

·      they have to self-test at least 8 times a day.

We can consider real-time continuous glucose monitoring as an alternative to isCGM if it is available for the same or lower cost.

However, we should advise patients using CGM that they will still need to take capillary blood glucose measurements (although they can do this less often). This is because:

·      they need it to check the accuracy of their CGM device and also because

·      they need it as a back-up

Now let’s have a look at the drug treatment.

In terms of rescue therapy at any stage of treatment, if someone is symptomatically hyperglycaemic, we should consider insulin or a sulfonylurea, and review the treatment when blood glucose control has been achieved. 

Then, as first line drug treatment we will offer standard-release metformin. We will gradually increase the dose over several weeks to minimise the risk of gastrointestinal side effects and, if they appear, we will consider a trial of modified‑release metformin. 

After metformin, we should assess the cardiovascular risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of it. And then, if they have chronic heart failure or established cardiovascular disease, or are at high risk of it, we will go for an SGLT2 inhibitor. 

When starting dual therapy with metformin and an SGLT2 inhibitor, we will start them sequentially, commencing with metformin and adding the SGLT2 inhibitor as soon as we confirm that metformin is well tolerated.

Now, if metformin is contraindicated or not tolerated, we will do the same. That is, we will assess the cardiovascular risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of it. And then, if the patient is in any of these categories, we will also go for an SGLT2 inhibitor as monotherapy.

However, if they don’t have chronic heart failure or established atherosclerotic cardiovascular disease, and they are not at high risk of it, we have a lot of flexibility because we can consider:

·      a DPP‑4 inhibitor or

·      pioglitazone or

·      a sulfonylurea or, also,

·      an SGLT2 inhibitor. 

SGLT2 inhibitors have been associated to an increased risk of diabetic ketoacidosis and therefore, before starting them, we need to check whether the person may be at increased risk of DKA, for example if:

·      they have had a previous episode of DKA

·      they are unwell with intercurrent illness or

·      they are following a very low carbohydrate or ketogenic diet

If the patient is following a very low carbohydrate or ketogenic diet, they may need to delay the SGLT2 inhibitor until they have changed their diet, and, once they are on an SGLT2 inhibitor, we will advise them against following this type of diet in the future. 

If a patient’s first line treatment does not include an SGLT2 inhibitor because they do not have chronic heart failure or established atherosclerotic cardiovascular disease, and they are not at high risk of it, but later they fall into one of these categories, we will start an SGLT2 inhibitor either by adding it to their current treatment or by replacing an existing drug with the SGLT2 inhibitor depending on our clinical judgement.

Now, in general, if we need to intensify the drug treatment because monotherapy with metformin is not enough, we also have a lot of flexibility and we will consider adding:

·      a DPP‑4 inhibitor or

·      pioglitazone or

·      a sulfonylurea or

·      an SGLT2 inhibitor. 

Then, if we need to intensify the drug treatment again because dual therapy with metformin and another oral drug is not enough, we will either:

·      start triple therapy by adding a further oral agent, that is, a DPP‑4 inhibitor, pioglitazone, a sulfonylurea or an SGLT2 inhibitor or

·      consider starting insulin

However, if metformin is contraindicated or not tolerated and dual therapy with 2 oral drugs is not enough, we should go straight for insulin. That is, NICE only recommends triple oral therapy if one or the drugs is metformin.

Now, so far, we have not mentioned GLP-1 receptor agonists at all. When does NICE recommend them? Well, if triple therapy with metformin and 2 other oral drugs is not enough, we can consider triple therapy by switching one oral drug for a GLP‑1 receptor agonist if:

·      The BMI is 35 or higher and there are problems associated with obesity, although for people from Black, Asian and other minority ethnic groups we will reduce the BMI to 32.5  or

·      The BMI lower than 35 and:

o  insulin would have occupational implications or

o  weight loss would benefit other comorbidities. 

We will only continue the GLP‑1 receptor agonist if there has been a beneficial metabolic response, which is a reduction of at least 11 mmol/mol or 1.0% in HbA1c and a weight loss of at least 3% of the initial body weight in 6 months. 

NICE also says that a GLP‑1 receptor agonist and insulin should only be combined with specialist advice and ongoing support. 

Now, let’s have a look at the drug management specifically for people with both type 2 diabetes and CKD.

And the guideline on type 2 diabetes says that people with both type 2 diabetes and CKD should have standard CKD treatment with an ACEI or ARB, titrated to the highest licensed dose that the person can tolerate if the ACR is 3 or more.

And once they are on a fully titrated dose of the ACEI or ARB, we will add an SGLT2 inhibitor if:

·      ACR is over 3 (and particularly if it is over 30) and

·      they meet the eGFR thresholds to prescribe the SGLT2 inhibitor.

However, this area is a little confusing because this is the advice on the NICE guideline on type 2 diabetes NG28. However, more recently published NICE guidance in the form of technology appraisals, NICE says that Dapagliflozin is recommended as an add-on to ACEIs or ARBs, if their eGFR is between 25 and 75 and they have type 2 diabetes, without mentioning any ACR thresholds.

And a similar approach appears in the technology appraisal on empagliflozin which says that empagliflozin is recommended as an add-on to ACEIs or ARBs if the patient has type 2 diabetes and their eGFR is between 20 and 90, again without mentioning any ACR levels.

In summary, the technology appraisals recommend the SGLT2 inhibitors dapagliflozin and empagliflozin for people with type 2 diabetes and CKD if eGFR thresholds are met but without ACR thresholds at all. This is in contradiction to the guideline NG28 on type 2 diabetes where ACR thresholds of 3 and 30 are stipulated. Until the situation has been clarified, my personal view would be to follow the most recent guidance, that is, the technology appraisals on dapagliflozin and empagliflozin and offer these drugs to people with type 2 diabetes and CKD if the eGFR thresholds are met without taking into consideration ACR levels.

Now let’s have a look at what NICE says in respect of insulin therapy.

Firstly, when starting insulin, an insulin-specific structured educational programme should be offered to the patient.

If there are no issues, on starting insulin, we will continue to offer metformin and we will review the continued need for other diabetic agents. 

NICE recommends starting insulin following one of these regimens:

·      NPH insulin injected once or twice daily according to need.

·      NPH and short‑acting insulin, administered either:

o  separately or

o  as a pre-mixed or biphasic human insulin preparation.

·      Insulin detemir or insulin glargine can be used, as an alternative to NPH insulin, if:

o  the person needs help to inject insulin, or

o  there is recurrent hypoglycaemia or

o  the person would otherwise need twice‑daily NPH insulin injections as well as oral medication.

·      Pre-mixed or biphasic preparations including short‑acting insulin analogues, rather than short‑acting human insulin preparations, can be used if:

o  injecting immediately before a meal is preferred or

o  hypoglycaemia is a problem or

o  blood glucose levels rise markedly after meals. 

We will switch to insulin detemir or glargine from NPH insulin if:

·      there is hypoglycaemia on NPH insulin or

·      the HbA1c target is not met or

·      they have issues with the device or

·      they need help to inject insulin. 

We will monitor patients on a basal insulin regime, that is, NPH insulin, insulin detemir or glargine for the need for short‑acting insulin. Equally, we will monitor patients on pre‑mixed or biphasic insulin for the need for a further injection of short‑acting insulin before meals or for a change to a basal-bolus regimen, if control remains inadequate. 

Now let’s have a look at the complications and how we would manage them.

We will advise patients at their annual review that:

·      they are at higher risk of periodontitis and that

·      if they get it, managing it can improve their diabetic control and that

·      they should have regular oral health reviews, as advised by their dental team. 

We will suspect gastroparesis if there is erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses and referring if the diagnosis is in doubt or there are persistent or severe symptoms. 

We need to explain to patients with vomiting caused by gastroparesis that:

·      there is no strong evidence that antiemetic therapy is effective

·      some people have had benefit with domperidone, erythromycin or metoclopramide and that

·      the strongest evidence for effectiveness is for domperidone, but its prescribing is limited by its safety profile, in particular its cardiac risk and potential interactions. 

To treat vomiting caused by gastroparesis:

·      we will consider alternating the use of erythromycin and metoclopramide first line and

·      we will consider domperidone only in exceptional circumstances and in accordance with MHRA advice.

For guidance on managing painful diabetic peripheral neuropathy, we are advised to consult the specific guideline on neuropathic pain.

My summary of this guideline is this:

If the neuropathic pain is localised and they wish to avoid oral treatments, we will consider topical treatment in the form of capsaicin cream. 

Otherwise, if oral therapy is preferred, we will offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as the initial treatment. Gabapentin and pregabalin are controlled drugs so it would make sense to start with either amitriptyline or duloxetine first.

If the initial treatment is not effective or tolerated, we will offer one of the remaining 3 drugs, and consider switching again if the second and third drugs are also not effective or tolerated.

And, as a general rule, when withdrawing or switching treatment, we will taper the dose to minimise any withdrawal symptoms.

So, for me, considering the cost of drugs and controlled drug status, I would consider:

1.   Amitriptyline first

2.   Then duloxetine,

3.   Then gabapentin and

4.   Lastly pregabalin

We will obviously refer if despite treatment the pain is severe, disabling or affecting their sleep or if their underlying condition has deteriorated.

As acute rescue therapy for neuropathic pain, we could consider tramadol, but only for short term use, as this is counterproductive in the long term.

When it comes to autonomic neuropathy, we will suspect it if there is a loss of hypoglycaemia awareness. 

After excluding other diagnoses, we will also consider the possibility of autonomic neuropathy affecting the gut or the bladder if there is unexplained diarrhoea or unexplained bladder‑emptying problems respectively. 

In addition, we will bear in mind that patients with autonomic neuropathy who are taking tricyclic drugs and antihypertensive drug treatments, have an increased risk of side effects such as orthostatic hypotension.

For men with erectile dysfunction, also after excluding other diagnoses, we will consider a phosphodiesterase‑5 inhibitor taking into account their cardiovascular state and any contraindications and we will refer them to specialist services if this treatment is unsuccessful. 

I will not go into the management of diabetic foot problems because this is covered in a separate guideline, and in terms of eye disease, I will only say that they need to be referred immediately to the local eye screening service as soon as they are diagnosed with type 2 diabetes.

Right, so this is it, this is the summary of the actual guideline. We will now have a look at some MCQs which will hopefully help you to test your knowledge and also assist you in remembering the facts more effectively.

The range of questions varies from fairly easy and straightforward ones to others which are more complex and require more thinking. After each question and their four options, there will be a pause of a few seconds only.

I also want to stress that the MCQs are intended only to revise concepts in the guideline from a general point of view. We know that diabetes management can be very flexible and it is perfectly fine to deviate from the guideline using our clinical judgement.

Finally, I am going to delegate the reading of the questions to an automated voice. I hope that you find it useful.

Right, so good luck with your self-test!

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.