Conference urges further consultation on NICE diabetes guidanceBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3203 (Published 11 June 2015) Cite this as: BMJ 2015;350:h3203
Draft guidelines issued by the National Institute for Health and Care Excellence (NICE) for the treatment of type 2 diabetes are a recipe for failure, a Westminster Health Forum seminar was told on 10 June.
The draft guidelines included drugs that should not be offered routinely, they excluded others that NICE has previously found to be cost effective, and they prescribed an overly rigid sequence rather than allowing treatment to be tailored to individual cases, said Lisa Anson, president of AstraZeneca UK/Ireland. After widespread criticism of the draft guidance NICE has said that substantial changes have been made, but Anson pleaded for the revised version to be made the subject of renewed consultation to make sure that it is right.
“There should be a second round of consultation,” she told The BMJ. “Most clinicians would rather wait for a couple of months to get the guidance right rather than be presented with a document that is still flawed and cannot be changed for another five years.”
Her plea supported those already made by the Association of British Clinical Diabetologists and the Royal College of Physicians, which have written to NICE asking whether it intends to give stakeholders a chance to comment on the revised guidance when it is published in August. “If not, we would urge you to consider doing so to ensure the maximum possible support for this important document,” the letter said.
Ever since the draft guidelines were made available for consultation in January they have been subject to criticism. An editorial by eight UK specialists in the British Journal of Diabetes and Vascular Disease1 said that the draft demonstrated “a failure of common sense and clinical judgement” and warned that, if enacted, it would set back diabetes management “by decades.” The editorial singled out the recommendation of repaglinide as a first line therapy for patients who cannot tolerate metformin, despite a limited evidence base; the fact that patients have to take it three times a day; and its known risk of hypoglycaemia.
Anson echoed another point raised in the editorial: the recommendation of pioglitazone as a second line agent. “NICE has recommended pioglitazone because it is cheap,” she told The BMJ. “The guidelines de-prioritise newer drugs in favour of older ones.”
Among those excluded, she said, was the AstraZeneca drug dapagliflozin (Forxiga), despite separate NICE guidance having recommended it as cost effective and having stated that it must be made available for eligible patients in England and Wales. This drug, she told the forum, has the double advantage of lowering blood glucose and body weight, which can greatly encourage adherence to the therapy. “Losing weight is an incredible motivator,” she said.
NICE has not undertaken to make its revised draft subject to further consultation, although its manual said that a second four week consultation may be offered under exceptional circumstances—if, for example, relevant information had been omitted or misinterpreted in the first draft. But Mark Baker, director of clinical practice at NICE, has said that this does not apply because no new analyses have been carried out.
Anson presented figures showing that the uptake of newer therapies for diabetes is much slower in the United Kingdom than in other comparable countries. “We use insulin at the same rate as others, but we use newer medicines much less,” she said. “We spend less on glucose control and end up spending more on complications that could have been avoided.”
Cite this as: BMJ 2015;350:h3203