Practice Guidelines

Newer agents for blood glucose control in type 2 diabetes: summary of NICE guidance

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1668 (Published 22 May 2009) Cite this as: BMJ 2009;338:b1668
  1. Amanda I Adler, consultant physician 1,
  2. Elizabeth J Shaw, technical adviser2,
  3. Tim Stokes, associate director2,
  4. Francis Ruiz, technical adviser (health economics)3
  5. on behalf of the Guideline Development Group
  1. 1Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ
  2. 2National Institute for Health and Clinical Excellence, Manchester M1 4BD
  3. 3National Institute for Health and Clinical Excellence, London WC1V 6NA
  1. Correspondence to: A Adler aia31{at}medschl.cam.ac.uk

    Why read this summary?

    Management of type 2 diabetes is complex and aims to prevent and reduce the impact of complications by encouraging a healthy lifestyle, controlling blood pressure and blood lipids, and lowering blood glucose concentrations. In recent years new drugs have become available for blood glucose control, including the long acting insulin analogues (insulin detemir and insulin glargine); glucagon-like peptide-1 (GLP-1) mimetics (exenatide); and dipeptidylpeptidase-4 (DPP-4) inhibitors (sitagliptin and vildagliptin). In addition, safety concerns have surfaced recently about the use of the thiazolidinediones (pioglitazone and rosiglitazone).

    This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the use of newer agents for control of blood glucose in type 2 diabetes1 and updates the relevant section of the NICE clinical guideline on the management of type 2 diabetes.2

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    DPP-4 inhibitors and thiazolidinediones

    DPP-4 inhibitors stabilise concentrations of endogenous glucagon-like peptide and increase insulin secretion.

    • Consider adding a DPP-4 inhibitor or a thiazolidinedione as second line treatment with metformin instead of a sulphonylurea when blood glucose control remains or becomes inadequate (haemoglobin A1c ≥6.5% or a higher level agreed with the individual) if:

      • -The person is at serious risk of hypoglycaemia and its consequences, or

      • -A sulphonylurea is not tolerated or is contraindicated—for example, because of severe renal impairment.

    [Based on evidence ranging from low to moderate quality from randomised controlled trials; a meta-analysis; current NICE guidance2; and a health economic analysis]

    • Consider adding a DPP-4 inhibitor or a thiazolidinedione as second line treatment to sulphonylurea alone when blood …

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