NICE Updates Recommendation on the Management of Diabetes
• The 2021 recommendations advise that patients with CKD and T2D and an albumin-to-creatinine ratio (ACR) of 3 mg/mmol or more should be offered an angiotensin receptor blocker (ARB) or an angiotensin‑converting enzyme (ACE) inhibitor, titrated to the highest licensed and tolerated dose.
• For CKD patients who are already receiving an ARB or an ACE inhibitor at the highest licensed tolerated dose, an SGLT2 inhibitor should be offered in addition to the ARB or ACE inhibitor if their ACR is at least 30 mg/mmol and meet the prescribing criteria, including eGFR thresholds.
• NICE also advises that SGLT2 inhibitors can be considered for patients with an ACR of between 3 and 30 mg/mmol, however these drugs may not be suitable for all patients in this group.
The recommendations follow the publication of strong evidence from randomised controlled trials which showed that SGLT2 inhibitors reduced the risk of CKD progression, mortality and cardiovascular events in adults with T2D.
Economic modelling found that SGLT2 inhibitors were likely to be both more effective and cost saving than standard treatment for people with an ACR above 30 mg/mmol at baseline.
The NICE appraisal committee determined that people with a baseline ACR of 3 to 30 mg/mmol will experience fewer cardiovascular events and events relating to chronic kidney disease progression than people with a higher ACR.
• Because of this, SGLT2 inhibitors would prevent fewer events for this group in absolute terms, even if the relative effect was the same.
Economic modelling showed that SGLT2 inhibitors were still likely to be both more effective and cost saving in people with a baseline ACR of between 3 and 30 mg/mol compared with standard treatment.
The guideline calls for research on the effectiveness of SGLT2 inhibitors for people with a baseline ACR less than 3 mg/mmol as there is no evidence looking specifically at this group.
Draft recommendations have also been published on the diagnosis and management of adults with type 1 diabetes.
The draft guidance advises that age or BMI alone should not be used to exclude type 1 diabetes. It must be kept in mind that other diabetes subtypes may be present and the diagnosis of type 1 disease should be reviewed at clinical reviews.
Diabetes-specific autoantibodies should be measured at the time of diagnosis, bearing in mind that these tests have the lowest rate of false negatives at that time.
Serum C-peptide should not routinely be used to confirm a diagnosis of type 1 diabetes, however, in people with a negative diabetes-specific autoantibody result, and uncertain diabetes classification, non-fasting serum C-peptide can be used with a paired blood glucose. Serum C-peptide measurement can also be used to revisit the diabetes classification if there is doubt about the type 1 diagnosis, being mindful that the discriminative value of serum C-peptide to diagnose type 1 diabetes increases the longer the test is conducted after initial diagnosis.
The guidance now recommends that patients should be offered a choice of real-time continuous glucose monitoring (CGM) or intermittently scanned continuous glucose monitoring (isCGM) based on their needs and preferences.
The cheapest device should be offered in the first instance. If a person is unable or does not wish to use any real-time CGM or isCGM device, capillary blood glucose monitoring should be used.
NICE has also published draft guidance on the diagnosis of type 1 and 2 diabetes in children and young people.
The guidance includes updated recommendations on CGM for this age group.
• It is now recommended that all children and young people with type 1 diabetes be offered real-time CGM, accompanied by education. Paediatric patients (aged ≥4 years) who are unable or prefer not to use real-time CGM should be offered isCGM. Patients should be offered a choice of real-time CGM device.
Factors to consider when choosing a device include whether the device provides predictive alerts or alarms and whether these need to be shared with anyone else, the ease of use (including for people with limited dexterity), and how often the device needs to be calibrated. It is also important to consider patient factors, including their insulin regimen and type of insulin pump, as not all devices integrate with pumps as part of a hybrid closed loop or insulin suspend function. Other factors to consider include sports participation, device sensitivity and cosmetic aspects.
If a child or young person is unable or does not wish to use any real-time CGM or isCGM device, capillary blood glucose monitoring should be offered.
The draft guidance includes a number of key recommendations for research, including the effectiveness and cost effectiveness of CGM in children and young people with type 2 diabetes, and the best CGM sensor adhesive to prevent sensitivities.
Both the draft guidance on type 1 diabetes in adults and in children are now open for public consultation. The closing date for receipt of comments is 22 December 2021. The final recommendations are expected to be published at the end of March next year.
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Further Guidelines summaries on NICE diabetes guidance:
- Type 1 diabetes in adults: diagnosis and management
- Type 1 diabetes in children and young people: diagnosis and management
- Type 2 diabetes in children and young people: diagnosis and management
- Type 2 diabetes: prevention in people at risk
- Diabetes in pregnancy: management from preconception to the postnatal period.
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