The new NICE guidelines for type 2 diabetes - a critical analysis

Abstract

The latest NICE guidelines for the management of type 2 diabetes are now available for consultation. They contain sensible recommendations regarding lifestyle, patient education, monitoring and targets. Unfortunately, the pharmacotherapy section shows a distinct failure of common sense. The recommendations include using the insulin secretagogue repaglinide as a firstline agent, where metformin is not tolerated or contraindicated, or second-line in combination with metformin. Pioglitazone is recommended as the principal second-line therapy with metformin. The advice on glucagon-like peptide-1 receptor agonist (GLP-1ra) usage and assessment of efficacy and failure to recommend long acting analogue insulins over isophane are also major concerns. The recommendations appear to be based on metaanalyses and pharmacoeconomics, driven by an imperative on costs and failing to appreciate the "value" of the options under consideration. The cost to patients and the health service of the serious side-effects of these treatments is underestimated. Given the emphasis in these guidelines on the importance of lifestyle changes, including weight loss, plus an over-riding need to avoid hypoglycaemia, these pharmacotherapeutic recommendations appear paradoxical in the extreme. We believe that these recommendations, if enacted, will undermine seriously the reputation of NICE both nationally and internationally.