NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Diabetes: updated NHSGGC guidelines

The NHSGGC guidelines for the management of diabetes have recently been updated and are now available on Staffnet. They appear as 15 separate sections so that future updates can be made to individual sections without having to renew the entire work. 

 

There are two new guidelines on The Treatment of Hypoglycaemia in Adults with Diabetes in Hospital and, for diabetes nurses, Guidelines for Insulin Initiation and Adjustment in Primary Care in Patients with Type 2 Diabetes. There is an additional section on structured education for patients with both Type 1 and Type 2 diabetes and an updated section on insulin pump therapy.   The topic of diabetes and pregnancy has also been rewritten.  

 

The new guidelines take account of the newer DPP-4 inhibitors (gliptins) and GLP-1 agonists as well as the new class of SGLT2 inhibitors. The algorithm for the treatment of Type 2 diabetes now suggests that all oral hypoglycaemic agents at step 2 should be reviewed six months after initiation and withdrawal considered if HbA1c has not fallen by at least 5.5mmol/mol. 

 

The SGLT2 inhibitors are a new class of drug and inhibit the reabsorption of glucose in the kidney.  The resultant loss of glucose in the urine lowers blood glucose and leads to weight loss. The glycosuria can be responsible for genital tract infections (mainly candidiasis) and an increased risk of urinary tract infections. SGLT2 inhibitors are not included in the Formulary for monotherapy but can be added as alternative second or third line therapies. See SPC for individual drugs, but in general they should not be initiated in patients with eGFR < 60ml/min and should be stopped if eGFR < 45ml/min. 

 

The restrictions on the use of GLP-1 agonists have been relaxed. Their use is restricted to patients with BMI > 30kg/m² and there is a target for HbA1c reduction of > 5.5mmol/l. A joint target for HbA1c and an individualised weight reduction remains at 6 months. Patients failing to meet one or other of the targets should be referred to secondary care for a specialist decision on future treatment. The 1.8mg dose of liraglutide can now be prescribed under the guidance of a diabetes specialist.    

 

A new table lists for each hypoglycaemic agent lists its relative efficacy, effect on weight, risk of causing hypoglycaemia, variability of response and availability of long term safety data. Relative cost for each agent is also displayed. These are all factors which should be taken into consideration before deciding on the best treatment for individual patients. 

 

Work on the guideline is ongoing in the rapidly changing world of diabetes. Look out for updates which take into account the recent changes to DVLA regulations on driving and diabetes, in particular, new recommendations on self monitoring.