A SIGN of the times: Implementing the new SIGN 154 diabetes guideline in primary care

SIGN 154 (2017), Pharmacological management of glycaemic control in people with type 2 diabetes, incorporates considerable new clinical trial data that has been published since both SIGN 116 (2010) and NG28 (NICE, 2015) were issued. Specifically, SIGN 154 focuses on the cardiovascular (CV) outcomes of diabetes drugs, rather than simply their glucose-lowering effects.

Metformin remains first-line oral treatment choice for those with type 2 diabetes. However, for individuals with type 2 diabetes and established CV disease, sodium–glucose cotransporter 2 (SGLT2) inhibitors with proven CV benefit (currently empagliflozin and canagliflozin) should be preferentially considered. Moreover, for individuals with type 2 diabetes and established CV disease, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) with proven CV benefit (currently liraglutide) should also be considered.

On page 30, SIGN 154 also provides us with a new pragmatic, user-friendly and patient-centred algorithm for glucose lowering in type 2 diabetes that usefully differentiates therapies by their efficacy, any CV benefit, risk of hypoglycaemia, impact on weight, main adverse effects and prescribing restrictions in renal impairment (http://bit.ly/2F3fXml). If a patient’s individualised HbA_1c target has not been reached after 3–6 months, adherence should be reviewed and then intensification of treatment should be considered, guided by the patient profile. Medication should be continued at each stage if either individualised HbA_1c target is achieved or HbA_1c falls more than 5.5 mmol/mol (0.5%) in 3–6 months. Note that the SIGN 154 algorithm does not apply in the context of severe renal or hepatic insufficiency.

Importantly, only the section in SIGN 116 on the pharmacological management of glycaemic control in people with T2D was updated and republished as a stand-alone guideline, SIGN 154. SIGN 116 continues to be current, although the material relating to glucose-lowering therapies for people with type 2 diabetes has been removed and replaced by SIGN 154. As such, SIGN 154 refers back to SIGN 116 for recommendations regarding lifestyle and it is still necessary to refer to SIGN 116 for recommendations on the management of diabetes complications.

The key clinical recommendations published in SIGN 154 are presented in Box 1.

Conclusion
SIGN 154 joins the growing suite of international diabetes guidelines (e.g. Diabetes Canada [2016], American Diabetes Association [2018] and American Association of Clinical Endocrinologists/American College of Endocrinology [2018]) that consider the CV outcomes of diabetes drugs, rather than simply their glucose-lowering properties. Cardiovascular disease remains the leading cause of death in those with type 2 diabetes; the key new clinical recommendations in SIGN 154 will help drive improvement in the outcomes of those with type 2 diabetes and established CV disease in Scotland.

A fuller analysis of the recommendations on the pharmacological management of glycaemic control in people with type 2 diabetes will be contained in a more detailed article in the next issue of Diabetes & Primary Care.