NICE type 2 diabetes draft guidance released for consultation

NICE has released the first draft of the long-awaited update to its guideline on the management of type 2 diabetes. However, diabetes healthcare professionals who were hoping the update would bring the guidance more in line with the ADA/EASD Consensus are likely to be disappointed.

Although the reason for the update is stated to have been the publication of new evidence from cardiovascular outcomes trials, GLP-1 receptor agonists remain as a fourth-line option only, with advice specifically stating that the class should not be offered to people with type 2 diabetes solely for cardiovascular risk reduction.

SGLT2 inhibitors, however, have been given higher priority in the treatment pathway, which advises to offer them to people with established cardiovascular disease (CVD), and to consider them in those with high risk of CVD, in combination with metformin (or alone if metformin is contraindicated or not tolerated), as the first line. Advice on using SGLT2 inhibitors in those with chronic kidney disease is outlined in separate draft guidance, also out for consultation.

The guideline is expected to be published in February 2022. Consultation with stakeholders is open until 14 October 2021. Click here to view the draft guidance.

Improving identification of monogenic diabetes

NHS England is rolling out a new programme to support Trusts across the country to help improve identification of monogenic diabetes. The initiative will ensure training and support for a designated nursing and medical lead in each Trust, with a national virtual training package developed by an expert monogenic diabetes team at the Royal Devon and Exeter NHS Foundation Trust, and practical support provided by 15 specialist genetic diabetes nurses.

The estimated prevalence of monogenic diabetes is eight cases per 100000 people, with more than 170 cases of monogenic diabetes diagnosed each year, accounting for 1–2% of all diabetes diagnoses and 3.6% of those diagnosed in people under the age of 30 years.

Monogenic diabetes lacks any clear distinguishing features to discern it from type 1 or type 2 diabetes. Clinicians can use the online probability calculator from Exeter University to help them to decide whether it is appropriate to refer for genetic testing. Monogenic diabetes can usually be managed with oral medication, so diagnosing it correctly can help the person to receive the optimal treatment, in addition to aiding identification of the condition in the person’s children and other family members.

Body weight increased in people at high risk of type 2 diabetes over lockdown

Analysis of data from the NHS Diabetes Prevention Programme (DPP) suggests that lockdown policies have coincided with an increase in mean body weight among people who entered the programme.

Compared with the previous three years, mean body weight in people who entered the programme between 1 April 2020 and 31 March 2021 was 2.4 kg higher, while mean BMI was 0.4 kg/m² higher. The increase was greatest in women, those from more deprived areas and younger people (although the latter group may have been over-represented in the analysis as the DPP moved to online delivery during the pandemic and a greater proportion of younger people attended compared with previous years).

This increase is likely to lead to a higher incidence of type 2 diabetes, and the authors highlight the importance of ongoing access to the NHS DPP in England.

Click here to read the full study results.

Empagliflozin and HFpEF

Data from the EMPEROR-Preserved trial show that empagliflozin improves cardiovascular outcomes in people with heart failure with preserved ejection fraction (HFpEF).

After a median follow-up of 26 months, the primary endpoint, a composite of cardiovascular death or hospitalisation for heart failure (HHF), was significantly reduced with empagliflozin compared to placebo (hazard ratio, 0.79; 95% confidence interval, 0.69–0.90). This was driven almost entirely by a reduction in HHF.

Previously, no drug had been shown to be effective in improving cardiovascular outcomes in this subgroup of heart failure, and the aim of treatment had largely been to manage symptoms.

The EMPEROR-Preserved results were simultaneously presented at the European Society of Cardiology Congress and published in the New England Journal of Medicine. Click here to read the full results.

A detailed summary of the results in Diabetes Distilled is available here.