This guideline replaces earlier publications on management of blood glucose, blood pressure, lipids, renal disease and retinopathy. It also replaces technology appraisals on long-acting insulin analogues (however, surprisingly omitting insulin detemir), patient-education models and glitazones. It mentions the injectable therapy exenatide, but does not address the thorny issue of how to use the new oral medications. Guidelines for these therapies will be published in a ‘rapid update’ document that is due next year.
Right from the first pages it places huge importance on the individual with diabetes, and the need for structured education for each person, or carer, at the time of diagnosis, at annual review and when starting insulin therapy. People are more likely to meet a target if they know what it is, and why it is important!
The emphasis on structured education is strengthened. While I totally agree with the concept of structured education, I fail to be convinced by the focus on specific courses. Don’t get me wrong, I am sure there are excellent courses out there, but recent research on DESMOND demonstrated disappointing results in terms of glycaemic control (Davies et al, 2008). These courses are costly in terms of both finances and health professionals’ time. We are only scratching the tip of the iceberg in our current provision of NICE’s definition of structured education and I fear that it is those who do not attend that suffer. Group education does not fit all and in addressing this, I feel we need to build on the expertise and enthusiasm of practice nurses, having been one myself for many years. It is largely down to practice nurses that QOF clinical indicators have been met and they need time and resources to keep up with developments.
I am sure many nurses will read with interest the requirement to employ structured education when starting insulin. If the NICE definition were applied then some patients would wait a very long time. How many of us starting insulin in people with type 2 diabetes have access to a structured programme that is evidence based, has specific aims and learning objectives, has a structured written curriculum and is delivered by trained educators? Pressure has been put on practices to take on insulin initiation with little support in some cases. Hopefully we can use this document to lobby for improved resources.
A sensible approach to blood glucose monitoring is included. Basically, if someone with type 2 diabetes understands their blood glucose results, and is taking action based on them, then they should not be restricted from self-monitoring. Hopefully, this will prevent the rationing of test strips when used effectively, while discouraging prescriptions for those who monitor but take no action.
Guidance suggests reducing or stopping metformin in the presence of deteriorating kidney function. This has led to an increase in insulin use, often in the elderly, in order to restore good glycaemic control lost when metformin was withdrawn. As a specialist nurse I am glad to see NICE advocate people with diabetes and deteriorating kidney function becoming engaged in discussing their risks before taking that step. The majority of those I have seen recently have been elderly and hypoglycaemia has become a serious risk. Recently, one arm of the ACCORD study has been stopped early due to fears that very tight glycaemic control can increase mortality (Mayor S, 2008). We therefore need to involve people with diabetes in deciding their own future therapies.
The advice NICE offer on insulin regimens is unlikely to appeal to all. It has not changed much from previous guidance and does not consider insulin detemir, although it has been available for some time. Sadly the emphasis on pre-mixed regimens must pre-date the recent withdrawal of some insulin mixtures from the market. We are already in the invidious position of sometimes choosing regimens to suit available nursing hours rather than what truly suits the patients’ needs.
There is much more information on therapy to treat the complications of diabetes, including useful algorithms, and on cardiovascular risk. Bearing that in mind, although waist circumference is only mentioned briefly, nurses may need to invest in tape measures. I feel it is only a matter of time before that appears in the QOF!