NICE sorts out antidiabetics in draft guideline
This article was originally published in Scrip
A clinical guideline for treating type 2 diabetes in the national health service in England and Wales is being updated to include newer agents for blood glucose control. The National Institute for health and Clinical Excellence(NICE) has published a draft of the guideline for consultation, in which it considers the best use of depeptidyl peptidase-4 inhibitors, thiazolidinediones, the glucagon-like peptide-1 mimetic exenatide (Lilly's Byetta) and long-acting insulin analogues.
The draft was developed using the institute's short guideline programme and aims to recommend the use of newer antidiabetics and their positioning in the care pathway of glucose control in people with type 2 diabetes.
NICE notes that diet and exercise are the first-line treatments for type 2 diabetes, but that a great majority of patients require oral glucose-lowering drugs. Metformin is widely used, with sulfonylurea often used as an add-on second-line therapy if glycaemic control remains poor or deteriorates, the institute says. Most patients eventually require insulin, which may be long-acting, intermediate-acting, short-acting or biphasic (combining short- and intermediate-acting insulin).
The newer products covered in the draft guideline along with exenatide are the long-acting insulin analogues insulin glargine (Sanofi-Aventis's Lantus) and insulin detemir (Novo Nordisk's Levemir), the DPP-4 inhibitors sitagliptin (Merck Sharp & Dohme's Januvia) and vildagliptin (Novartis's Galvus) and the thiazolidinediones pioglitazone (Takeda's Actos) and rosiglitazone (GlaxoSmithKline's Avandia). Acarbose (Bayer's Glucobay) has already been recommended by the institute for some patients, and the draft guideline does not re-examine its use.
The draft outlines the circumstances in which a DPP-4 inhibitor should be considered as a second-line therapy and patients for whom these may be preferable to a thiazolidinedione. A thiazolidinedione may be also be suitable as a second-line therapy, either instead of a sulfonylurea or added to sulfonylurea monotherapy, in certain cases, the draft guideline notes.
A patient's body mass index should be a factor in the choice of adding exenatide to metformin and sulfonylurea, as is ethnicity.
Human NPH insulin, taken at bedtime or twice daily according to need, is preferred when insulin therapy is being initiated, NICE says, but the guideline outlines alternatives for many subgroups of patients, including those who cannot manage the device required for the injection of NPH insulin.