Current NICE guidelines on type 2 diabetes do not consider the benefits of early introduction of more modern and expensive glucose-lowering therapies, notes Stephen C Bain
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Prior to 2020, the major global pandemic exercising health economies was that of type 2 diabetes mellitus. According to the International Diabetes Federation, in 2019 around 463 million adults were afflicted, a number anticipated to rise to 700 million by 2045 (1). This increase is driven by an ageing population, characterised by sedentary lifestyle and high prevalence of overweight and obesity. The associated co-morbidities of cardiovascular disease (myocardial infarction and stroke) and cancer lead to significant premature mortality.
There are numerous classes of glucose-lowering therapy for the management of type 2 diabetes and this complexity has led to a plethora of guidelines. The widely adopted position statement from the American Diabetes Association and European Association for the Study of Diabetes (ADA/EASD) advocates early introduction of modern and more expensive treatments. This is based on clinical trial evidence that these medicines also reduce the risk of cardiovascular disease, heart failure and progression to end-stage kidney disease. In contrast, guidelines in the United Kingdom (UK), from the National Institute for Health and Care Excellence (NICE), do not take into account these benefits. NICE guidelines are widely seen as an attempt at cost containment, despite evidence that 80% of the £9.8 billion cost of diabetes to the National Health Service is attributed to complications of poor control, rather than therapies (2).
Whatever the motivation behind guidelines, it is clear that they are not being followed, a phenomenon termed ‘clinical inertia’. A UK literature review in 2017 focussed on the failure of clinicians to intensify glucose-lowering therapy; it found a reactive approach, with clinicians waiting for deterioration of hyperglycemia or complications before escalating treatment (3). The median time to intensification with insulin, the final therapy in all guidelines, was 6–7 years for people on multiple oral medicines. This finding is consistent with the UK National Diabetes Audit in 2016-17, showing that one-third of people with type 2 diabetes had suboptimal glucose control. We have published an analysis that suggests this inertia comes with a massive economic burden, even in the short term (4).
Currently, the reality of clinical inertia is not factored into any guidelines and surely the time has come for change. We know that modern glucose-lowering therapies have clinical advantages and it makes no sense to restrict their use to patients in whom older therapies have failed (and have been allowed to fail for an excessive period). Conversely, this approach also fits with the agenda of therapy deintensification for the frail and elderly, in whom aggressive glucose control might impart harm (5). By avoiding the use of medicines with high risk of hypoglycaemia in the first place, costs of patient review and subsequent medication withdrawal can be avoided (6). NICE is currently performing a major overhaul of its guideline for the management of type 2 diabetes in adults; now is the time to grasp the nettle and produce a document which acknowledges the reality of clinical practice and can produce major benefits for patients.
1. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, Colagiuri S, Guariguata L, Motala AA, Ogurtsova K, Shaw JE, Bright D, Williams R; IDF Diabetes Atlas Committee. Diabetes Res Clin Pract. 2019 Nov;157:107843. doi: 10.1016/j.diabres.2019.107843.
2. Diabetes UK Cost of Diabetes Report https://www.diabetes.org.uk/resources-s3/2017-11/diabetes%20uk%20cost%20of%20diabetes%20report.pdf
3. Clinical inertia to insulin initiation and intensification in the UK: A focused literature review. Khunti K, Millar-Jones D. Prim Care Diabetes. 2017 Feb;11(1):3-12. doi: 10.1016/j.pcd.2016.09.003.
4. Evaluating the burden of poor glycemic control associated with therapeutic inertia in patients with type 2 diabetes in the UK. Bain SC, Bekker Hansen B, Hunt B, Chubb B, Valentine WJ. J Med Econ. 2020 Jan;23(1):98-105. doi: 10.1080/13696998.2019.
5. Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes. Seidu S, Kunutsor SK, Topsever P, Hambling CE, Cos FX, Khunti K. Diabetes Obes Metab. 2019 Jul;21(7):1668-1679. doi: 10.1111/dom.13724.
6. Approach to assessing the economic impact of insulin-related hypoglycaemia using the novel Local Impact of Hypoglycaemia Tool. Parekh W et al. Diabet. Med. 32, 1156–1166 (2015). doi: 10.1111/dme.12771
This commentary has been commissioned and funded by Novo Nordisk.