Comorbidities

For people with diabetes and chronic kidney disease, and an estimated glomerular filtration rate [eGFR] less than 30ml/min/1.73m2, the recommendations are tailored to the degree of kidney function. Metformin is not recommended for these people.

A DPP-4 inhibitor should be offered to people with an eGFR below 20ml/min/1.73m2. Those with an eGFR between 20ml/min/1.73m2 and 30ml/min/1.73m2 should be offered dapagliflozin or empagliflozin plus a DPP-4 inhibitor.

Of note is the approach to managing diabetes in those living with obesity without other significant comorbidities (e.g. ASCVD). Unlike some major guidelines (e.g. the American Diabetes Association), NICE has not recommended immediate use of GLP-1 receptor agonists.

The recommendation for this group is the same as for the wider population without significant comorbidity (i.e. metformin MR and SGLT-2 inhibitor). NICE stated that this combination is more clinically effective at reducing cardiovascular events than any other therapy combining metformin with any other medicine.

Adding GLP-1 receptor agonists to the treatment of people living with diabetes and obesity can be considered if further treatment is needed to reach personal HbA1c target after at least three months of initial treatment with metformin and SGLT-2 inhibitor.

These recommendations indicate that initiating the right drug at the right time is essential to improving health outcomes and reducing the development of complications. The recommendations also recognise that those who are frail might do better with fewer medicines. 

Indeed, one of the major themes from this update is the shift from a purely glucose-lowering approach to one that focuses equally on cardiovascular and renal protection. This aligns with the preventive healthcare goals of the 10 Year Health Plan.

A summary of some of the major changes from the 2015 NICE guideline is in the table below.