NICE Guidelines
NICE:T2(2008)
- 5 Education
- R1: offer structured edu to pt and/or carer at diagnosis, with annual reinforcement and review as integral part of diabetes care
- R2: patient-edu programme as per DoH and DUK Patient Edu Working Group: evidence-based, structured curriculum, written down, trained educators, quality-assured, audited
- R3: provide necessary resources to educators
- R4: group education programmes as preferred option
- R5: meet cultural, linguistic, cognitive, and literacy needs
- R6: ensure awareness of diabetes healthcare team with locally available patient edu programmes
- 6 Dietary advice
- R7: provide individual and ongoing nutritional advice from expert healthcare professional
- R8: provide dietary advice sensitive to individual's needs, culture and beliefs, sensitive to their willingness to change and effects on QoL
- R9: healthy balanced eating; high-fibre, low GI sources of CH (fruit, veg, wholegrains, pulses); low-fat dairy products and oily fish; control intake of saturated and trans-fatty acids
- R10: integrate dietary advice with personalised diabetes management plan (icr phys activ, losing wt)
- R11: aim for initial weight loss of 5-10% in overweight pts (less still beneficial, more better in long term)
- R12: individualise recommendations for CH and alcohol intake, and meal patterns; esp dcr risk of hypos on insulin or secretagogue
- R13: limited substitution of sucrose-containing food for other CH is allowable
- R14: discourage foods marketed specifically for diabetes
- R15: when inpatient, implement meal planning consistent in CH content of meals and snacks
- 7 Glucose control levels
- R16: HbA1c
- individual targets (may be >6.5%)
- aim to achieve target unless unacceptable SE or QoL
- offer Rx and lifestyle interventions
- inform pt that any dcr of a high A1c is beneficial
- avoid intensive Rx levels < 6.5%
- R17: measure A1c 2-6m intervals (until stable), then 6mthly
- R18: if hi A1c but premeal SMBG<7, consider postprandial SMBG (aim <8.5)
- R19: measure DCCT aligned A1c
- R20: if A1c invalid (disturbed erythrocyte turnover; or abnml Hb type), assess
- fructosamine, or
- SMBG, or
- total glycated Hb (for abnml Hb)
- R21: Ix unexplained discrepancies betw A1c and other glu measurements
- 8 Self-monitoring of plasma glucose (aj:SMPG)
- R22: offer SMPG only as part of self-management edu
- R23: SMPG for insulin Rx, infos on hypos, assessing effect of Rx or lifestyle changes, monitor during intercurrent illness, to ensure safety during activities eg driving
- R24: assess at least annually skills, quality, frequency, use of results, impact on QoL, continued benefit, equipment
- R25: if SM is appropriate but SMPG unacceptable, discuss urine glucose monitoring
- 9.5 Oral glucose therapies: recommendations (aj:GLM=glucose-lowering medications)
- Metformin
- R26: start MF in overweight patients if lifestyle interventions alone inadeq
- R27: consider MF as 1st line if not overweight
- R28: continue MF and add eg SU if needed
- R29: icr MF over weeks (re GI SE), consider MXR if necessary
- R30: prescribe MF cautiously in patients with
- risk of { sudden dcr in eGFR | dcr in eGFR < 45 };
- dcr dose of MF if Crea>130 or eGFR<45;
- stop MF if Crea>150 or eGFR<30
- R31: discuss benefits of MF in patients with mild/moderate liver dysfx or cardiac impairment: cardioprotective
- Insulin-secretagogues
- R32: consider SU as 1st line if
- not overweight
- does not tolerate MF (or MF contraindicated), or if
- hyperglycaemic symptoms (ie rapid response required)
- R33: add SU to MF if needed
- R34: cont SU if other glu.-lowering medication added
- R35: Rx SU with low acquisition cost (but not glibenclamide)
- R36: when drug concordance a problem, offer OD LA SU
- R37: educate about risk of hypos (esp if CKD)
- Rapid-acting insulin secretagogues
- R38: consider rapid-acting secretagogue if erratic lifestyle
- Acarbose
- R39: consider acarbose if unable to use other oral GLM
- 10 Other oral agents and exenatide:
- Thiazolidinediones (glitazones)
- R40: consider adding TZD to MF+SU if
- insulin unacceptable, or
- TZD to SU if MF not tolerated, or
- TZD to MF if SU-hypo-risk an issue (job, etc)
- R41: warn re. oedema and advise action
- R42: do not Rx TZD in heart failure or in higher risk of fracture
- R43: get up-to-date advice (EMA, MHRA), cost and safety issues
- Gliptins: GLP-1 enhancers: not covered by guideline
- Exenatide: GLP-1 mimetic
- R44: not recommended for routine use in T2DM [a/w NICE 2009 guideline]
- R45: consider exenatide if all of the following:
- BMI>35 (European, else: adjust)
- specific problems (psy, biochem, physical) arising from high body weight
- inadeq BG control with MF+SU
- other high-cost Rx (TZD, insulin) would otherwise be started
- R46: cont exenatide only if
- >=1.0% dcr in A1c in 6m
- and wt loss >=5% in 1y
- 11 Insulin
- 11.1 Oral agent combination with insulin
- R47: when starting basal insulin: cont MF and SU (and acarbose if used); review SU if hypos occur
- R48: when starting pre-mixed insulin: cont MF; cont SU initially but review if hypos
- R49: consider pioglitazone with insulin if previously marked glucose response to TZD, or if inadeq controlled on high-dose insulin therapy; warn about fluid retention and action
- 11.2 Insulin therapy
- R50: discuss benefits and risks of insulin if inadeq glucose control; start insulin if pt agrees
- R51: when starting insulin, use structured programme employing active insulin dose titration, incl structured education, telephone support, frequent self-monitoring, dose titration to target, dietary understanding, management of hypoglycaemia, management of acute changes in PG control, support from healthcare professional
- R52: Initial insulin therapy
- preferably start insulin Tx with { bedtime | bd } NPH insulin, or LA insulin analogue (insulin glargine) if
- assistance required to administer insulin
- significant lifestyle restriction by recurrent hypos
- consider bd biphasic human insulin (pre-mix) regimens esp if A1c>9.0%
- consider bd pre-mixed insulin analogues when
- immediate injection before meals preferred, or
- hypos are a problem, or
- there are marked pp BG excursions
- R53: offer trial of glargine if NPH insulin causes significant nocturnal hypos
- R54: monitor basal insulin regime: intensify regime if inadeq control + hypos: additional mealtime insulin (human/analogues)
- R55: monitor premixed insulin regime (od / bd) for need for further preprandial injection or changes to basal-bolus regime
- 11.3 not covered by this guideline
- Insulin detemir: future guideline
- Sitagliptin: future guideline
- 11.4 Insulin delivery devices
- Insulin pumps: recent NICE TA
- R56: offer edu about injection device (pen injector + cartridge; or disposable pen)
- R57: arrangements for sharps disposal
- R58: if manual or visual disability: offer appropriate device
- 12 Blood pressure therapy
- R59: measure BP at least annually in pt w/o Htn or CKD
- R60: review BP Tx if already on Tx at diagnosis of DM
- R61: repeat BP measurements within 1m if >150/90, 2m if >140/80, or >130/80 + kidney/eye/cerebrovascular damage; offer lifestyle advice
- R62: offer lifestyle advice (see diet, and Htn guidelines) if >140/80 or >130/80 + kidney/eye/cerebrovascular damage;
- R63: add Rx if lifestyle measures inadeq
- R64: intensify Rx if BP>=140/80 (>=130/80 if kidney/eye/cerebrovascular damage);
- R65: 1st line: OD generic ACEI (except R66 & R67)
- R66: 1st line for African-Carribean descent: ACEI + { diuretic | CCB }
- R67:1st line for woman with possibility of becoming pregnant: CCB
- R68: if continued ACEI intolerance: Rx ARB
- R69: if 1st line Rx inadeq: add { CCB | diuretic: usu BFZ 2.5mg od }, and add the other if still inadequate
- R70: if triple Rx inadeq: add { alpha-blocker | beta-blocker | potassium-sparing diuretic with caution if already on ACEI or ARB}
- R71: monitor BP q4-6m if adeq'ly controlled, and check for low BP
- 13 Cardiovascular risk estimation
- R72: consider pt to be at high premature cardiovascular risk unless
- not overweight
- normotensive <140/80 (in absence of antihypertensive therapy)
- no MA
- non-smoker
- nml lipid profile
- no Hx/FHx of cardiovascular dis
- R73: if not high cardiovascular risk, use UKPDS risk engine
- R74: consider using UKPDS risk engine for educational purposes
- R75: full lipid profile annually, and before starting lipid-modifying therapy
- 14 Management of blood lipid levels
- R76: review risk status annually (risk factors, metabolic syndrome, waist circumference, change in personal and FHx)
- Statins and ezetimibe
- R77: if >=40y: initiate Rx with Simvastatin to 40mg (or similar efficacy and cost) unless low risk (<=20% in 10y)
- R78: if <40y: consider Rx with Simvastatin to 40mg (or similar efficacy and cost) if high cardiovascular risk
- R79: once started on cholesterol-lowering therapy, assess after 1-3m, then annually
- R80: icr statin dose to Simvastatin 80mg unless TC<4.0mmol/L or LDL-C<2.0mmol/L
- R81: consider intensifying cholesterol-lowering therapy (if cardiovascular disease, icrd ACR) if TC>=4 and HDL-C<=1.4 and LDL-C>=2
- R82: do not Rx statins for women with possibility of becoming pregnant unless discussed and agreed
- Fibrates
- R83: if hi TG, perform fasting lipid profile (incl HDL-C and TG estimation)
- R84: consider 2ry causes of hi TG (hypothyr, CKD, liver inflammation esp alcohol), and treat if identified
- R85: Rx fibrate (1st line fenofibrate) if TG>4.5mmol/L despite attention to other causes (may need to start before statin b/o pancreatitis risk)
- R86: if hi cardiovasc risk, consider adding fibrate to statin if TG 2.3-4.5
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