The first guideline (nice.org.uk/guidance/ph38) focuses on preventing or delaying the onset of type 2 diabetes and “aims to remind practitioners that age is no barrier to being at high risk of, or developing” type 2 diabetes. The recommendations can be used alongside NHS Health Checks.
NICE advocates a two-stage strategy to identify people at high risk of type 2 diabetes, as well as those with undiagnosed diabetes. The strategy comprises a risk assessment followed by blood tests.
Pharmacists should offer validated self-assessment questionnaires or web-based tools, such as that from Diabetes UK (riskscore.diabetes.org.uk/start), and help people complete and interpret the self-assessment. Risk assessment results should be passed to the GP and people at intermediate or high risk encouraged to visit their GP for risk management and, if necessary, a blood test.
In general, NICE suggests offering risk assessments to all eligible adults aged at least 40 years (except pregnant women). Risk assessment is appropriate at a younger age (25-39 years) for high-risk groups, such as those of South Asian, Chinese, African-Caribbean and black African backgrounds (again, except pregnant women).
People with conditions that increase type 2 diabetes risk should also be assessed, such as those with:
• CVD and hypertension
• Polycystic ovary syndrome
• Mental health problems
• A history of gestational diabetes.
NICE suggests advising type 2 diabetes patients to encourage family members to have their risk assessed and stresses that everyone can reduce their risk, including people aged 75 years and over.
Reducing the risk of, or delaying, type 2 diabetes involves increasing physical activity, achieving and maintaining a healthy weight, and eating less fat and more fibre. NICE suggests encouraging patients to use “self-regulation”, such as measuring weight, waist circumference or both. Patients should review progress towards their goals, identify and solve problems and, if necessary, revise their goals and action plans.
The Government recommends at least 150 minutes of “moderate-intensity” activity a week, which can be taken in bouts of at least 10 minutes.
Alternatively, patients could perform 75 minutes of “vigorous- intensity” activity a week. Patients could combine moderate and vigorous-intensity activity and should include activities that increase muscle strength on two days a week.
Even small increases are beneficial and form a base upon which patients can further increase exercise. Pharmacists should encourage overweight and obese people to gradually reduce their calorie intake.
Losing 5-10 per cent of body weight in a year, which is realistic, would help reduce the risk of type 2 diabetes and lead to other health benefits.
The second guideline (nice.org.uk/guidance/ng28) covers management of adults with type 2 diabetes and emphasises the importance of patient education, dietary advice and managing cardiovascular risk, blood glucose and long-term complications.
NICE argues that diabetes care should be individualised to each patient’s “needs and circumstances” based on personal preferences, comorbidities, polypharmacy risks and life expectancy. Patients’ needs and circumstances should be reassessed at each review and NICE suggests considering stopping medicines that are not effective.
Poorly controlled type 2 diabetes is associated with numerous complications. Historically, half of type 2 diabetes patients showed complications when diagnosed. Diabetes UK notes that better screening programmes and raised awareness probably mean fewer people now present with complications than in the past. Nevertheless, care planning and delivery should take account of disabilities, such as visual impairment.
Adults with type 2 diabetes and, when appropriate, family members and carers should be offered evidence-based structured education, delivered by trained educators. NICE regards education as “an integral part of diabetes care” to support self-management. Pharmacists could reinforce the importance of structured education.
All patients should receive “individualised and ongoing nutritional advice from a healthcare professional with specific expertise and competencies in nutrition”. The advice should be “sensitive” to the person’s needs, culture, beliefs and willingness to change. The healthcare professional should also consider the impact of dietary advice on a patient’s quality of life.
In general, patients should eat high-fibre, low-glycaemic-index carbohydrate (e.g. fruit, vegetables, wholegrains and pulses), low-fat dairy products and oily fish, and limit foods containing saturated and trans fatty acids. Pharmacists could also encourage obese and overweight people to lose weight and discourage food marketed specifically at people with diabetes.
People with diabetes are roughly twice as likely to develop CVD as those who do not have diabetes. According to Diabetes UK, CVD accounts for 44 per cent of deaths in people with type 1 diabetes and 52 per cent in those with type 2 diabetes and other forms of diabetes.
NICE states that blood pressure should be measured at least annually in adults with type 2 diabetes without hypertension or renal disease. Adults taking antihypertensives when type 2 diabetes is diagnosed should have their blood pressure control and medications reviewed. Blood pressure should be consistently 140/80mmHg (130/80mmHg if there is kidney, eye or cerebrovascular damage).
If lifestyle advice is inadequate, NICE recommends starting and then intensifying anti-hypertensives, and monitoring blood pressure every one to two months, until control is established.
In general, a once-daily, generic angiotensin-converting enzyme (ACE) inhibitor is the first-line antihypertensive but people of African or Caribbean family origin should receive an ACE inhibitor as well as either a diuretic or a generic calcium-channel blocker (CCB).
A CCB should be the first-line antihypertensive for women when there is a possibility of pregnancy.
If blood pressure is not reduced to the target with first-line therapy, NICE advocates adding a CCB and then, if the target is still not reached, a diuretic (usually a thiazide or thiazide-related diuretic) – or vice versa.
If triple therapy still fails, patients may benefit from adding in an alpha-blocker, a beta-blocker or a potassium-sparing diuretic. The latter needs to be prescribed cautiously in patients taking an ACE inhibitor or angiotensin II-receptor antagonist.
Pharmacists should check and be vigilant for hypotension and other adverse effects. Once the patient reaches the target, NICE suggests monitoring blood pressure every four to six months.
Blood glucose control is essential to avoid serious complications. For adults with type 2 diabetes, NICE recommends measuring HbA1c levels every:
• Three to six months (depending on the patient’s needs) until HbA1c is stable on unchanging therapy
• Six months once the HbA1c level and blood glucose lowering therapy are stable.
Management of adults with type 2 diabetes by lifestyle and diet, with or without a single drug not associated with hypoglycaemia, should aim for a HbA1c of 48mmol/mol (6.5 per cent). The target for adults taking a drug associated with hypoglycaemia is 53mmol/mol (7.0 per cent).
If HbA1c levels on a single drug rise to at least 58mmol/mol (7.5 per cent), NICE suggests reinforcing advice about diet, lifestyle and adherence, supporting the person to aim for an HbA1c of 53mmol/mol (7.0 per cent) and intensifying treatment. In some people, such as the frail or elderly, healthcare professionals and patients may agree more relaxed targets.
NICE has published an algorithm for blood glucose lowering therapy in type 2 diabetes, which has standard-release metformin as the first-line drug. The dose is gradually increased over several weeks to minimise the risk of gastrointestinal side-effects.
Modified-release metformin may help if a patient experiences gastrointestinal side-effects on the standard formulation. The dose may need to be reduced or the drug stopped in patients with kidney impairment. A dipeptidyl peptidase-4 (DPP-4) inhibitor, pioglitazone, a sulfonylurea or sodium-glucose co-transporter 2 (SGLT-2) inhibitor may be appropriate for some patients if metformin is contraindicated or not tolerated.
If monotherapy fails to adequately control HbA1c, treatment can be intensified, such as combining metformin with a DPP-4 inhibitor, pioglitazone, sulfonylurea or SGLT-2 inhibitor. If this still fails, the patient may need triple therapy (e.g. metformin, a DPP-4 inhibitor and a sulfonylurea) or insulin-based treatment.
There is no single simple answer to preventing and tackling type 2 diabetes. However, a collaborate approach including community pharmacists and a multifaceted approach to assessment, prevention and management, such as those outlined by NICE in these two guidelines, should help reduce the human, clinical and economic tolls exerted by this now very common disease.
More than a third of people in the UK are not aware that foot ulcers are a serious complication of diabetes, despite being a leading cause of diabetes-related amputations, a new survey commissioned by Diabetes UK has revealed.
The survey of 2,055 adults, conducted for Diabetes UK by YouGov, found that while 79 per cent of people know that an amputation is a major complication of diabetes, 36 per cent did not know that people with diabetes are susceptible to foot ulcers which, when unhealed, are responsible for as many as four in five diabetes-related amputations.
As part of its Putting Feet First campaign, Diabetes UK is calling for urgent improvements to community diabetes foot services. Nearly a quarter of hospitals in England still do not have a specialist diabetes foot care team, and the quality of community diabetes foot services across England varies significantly.
As foot problems, such as infections or ulcers, can deteriorate quickly and have devastating consequences, Diabetes UK wants to see people with diabetes receive routine access to podiatrists and foot protection teams, who can assess problems early and treat them.
The number of diabetes-related amputations in England is at an all-time high, with more than 8,500 procedures being carried out each year. This equates to 23 minor and major amputations a day (more than 160 a week). Up to 80 per cent of people with diabetes die within five years following surgery.
Diabetes-related amputations devastate lives, says Dan Howarth, head of care at Diabetes UK. “While it is positive that the majority of people are aware that amputation is a complication of diabetes, it is very worrying that so many don’t know the dangers posed by foot ulcers.
“That is why it is essential that people living with diabetes know how to look after their feet, and that they check them daily. It is also crucial that they know to seek urgent medical attention if they notice any problems with their feet – a matter of hours can make the difference between losing and keeping a limb.
“With the right support, four out of five amputations are preventable but the quality and availability of services still varies significantly across England. We want to see greater commitment from Government to improving diabetes foot services, ensuring routine, high-quality care for those who need it, regardless of where they live.”
To mark the launch of Putting Feet First, Diabetes UK has made a video showing people with diabetes how to check their feet at home, and urging them to do it daily, to identify problems early. The video can be seen at here.
NICE argues that diabetes care should be individualised to each patient’s needs and circumstances