Total disagreement of the British over the treatment of T2D

The “British Medical Journal” has just published the new British recommendations for National Institute for Health and Care Excellence (NICE) Concerning the Management of Medications for Hyperglycaemia in Type 2 Diabetes.

In terms of glycemic goals, it is suggested to target HbA1c at 7%, and to ramp up treatment only if it is greater than 7.5%.

Metformin remains the recommended first-line treatment.

According to the risk of cardiovascular disease

Then, everything is based on the calculated cardiovascular risk, Qrisk 2 in the UK (10-year morbidity and mortality is considered more accurate than score 2). The authors recommend systemically adding an SGLT2 inhibitor in addition to metformin in all of these situations: if Qrisk 2 is >10% (considered to be high risk), if there is at least one CV risk factor before age 40 (tobacco, obesity, dyslipidemia) ) or if there is heart disease or kidney disease (microalbuminuria > 30 mg/mmol).

Next, other treatments are suggested according to HbA1c taking into account other limiting factors: either iDPP4, or sulfonamides (or even glitazones, not available in France).

GLP-1 agonists are withdrawn, and they are recommended in the third line only. It is preferred over insulin only in cases of obesity and according to the patient’s desire.

Step by step introduction

For iSGLT2, it should be administered after metformin, rather than immediately, to ensure that metformin is well tolerated. Then, they should be prescribed after evaluating the various possible adverse effects: infectious, of course, and especially ketoacidosis. There is an increased risk in the event of a history of ketoacidosis, a deterioration in the general condition of the patient, severe intercurrent diseases, a severe reduction in carbohydrates (<10%) and/or a ketogenic diet.

Finally, NICE specifies that in CV prevention, aspirin should not be prescribed to diabetic patients without cardiovascular disease.

Effects can be transferred, or not, in real life

In fact, NICE suggests that iSGLT2 be used extensively. There is no doubt that it takes into account above all the excellent quality of the profile of this category (phase 3 trials and real-life studies). There are indeed CV benefits in general, over heart failure, and renal effects, in all patients (even non-diabetics), and these benefits can be measured as early as three months after their introduction, all with a very high level of evidence.

They are also oral medications and are therefore not injectable, which could contribute to adherence.

Next, Nice defends the place of iSGLT2 strongly in the case of microalbuminuria >30 mg/mmol, a proven renal disease, in secondary prevention of CV, with high cardiovascular and heart failure risks.

How do we understand the humble niche assigned to arGLP1? Perhaps the duration of treatment, injectable, with arGLP1 is necessary to obtain an effect on Wand (at least three years without interruption) makes CV benefits more random in real life, and The number needed to treat (NNT) Too high, three to six years before treatment? Some commentators make this renunciation of arGLP1 a decision motivated exclusively by medical economics considerations, which are very important to the British system, as we all know.

NICE reserves a place for arGLP1 in the third line, by limiting its indications to oral triple therapy failure, in some T2DM subjects with a BMI of 35 kg/m2 or less than 35 but as a substitute for insulin or when comorbidities can be significantly reduced by weight loss. In summary, CV benefits attributable to arGLP1 were not cited in randomized controlled trials, and in no way influence their choice here.

A radical break with the group of experts and international recommendations, such as the consensus American Diabetes Association (ADA) or, in France, the French-speaking Diabetes Association (SFD), which ranks this class very highly in CV prevention of T2DM.

It’s hard to imagine that Nice experts dismiss arGLP1 these benefits only for savings reasons. Furthermore, they recommend iSGLT2, despite its additional cost, due to its CV and renal effects, which are very important and obvious to all practitioners. Do they really question the biographical effects of arGLP1 in real life? Remember, again, it’s not even mentioned in this update!

Professor Emeritus at the University of Grenoble Alps

(1) Moran GM, Bakhai C, Song SH, Agwu JC. Guidelines Committee. Type 2 diabetes mellitus: Summary of updated NICE guidelines. BMJ. 2022 May 18; 377: o775.doi: 10.1136 / bmj.o775. PM ID: 35584815

#Total #disagreement #British #treatment #T2D

Leave a Comment

Your email address will not be published.