Individualising targets in diabetes: NICE or not NICE?

Setting the scene: a patient’s perspective

Presented by Laura Cleverly @ninjabetic1

Laura Cleverly is a diabetes blogger known as “Ninjabetic” and a regular contributor to the Diabetes Times

Laura has type 1 diabetes and set the scene for this primary and secondary care session by providing personal insight on the issue of individualising glycaemic targets for adults with type 1 diabetes. Laura talked about the importance of empowering patients and individualising treatment, as well as education for healthcare professionals working in the field of diabetes. Sharing her personal experiences of treatment and her insights into the NICE 2015 glycaemic targets for adults with type 1 diabetes,1 Laura said that as a patient she felt that she had been placed in a box in which she didn’t necessarily fit, and she highlighted the issue of individualisation of treatment/individual treatment targets and the latest NICE guidance. Laura referred to the 6.5% (or lower) HbA1c target recommended by NICE and explained the feelings of failure that she might have if she was not able to achieve this target.

Referring to her stays in hospital as a patient, Laura also questioned the common practice by hospital staff of taking her insulin away from her for storage in the locked fridge. As a person taking full responsibility for her treatment around the clock, Laura said that she felt this practice took away her power and identity, and she emphasised the importance of good communication and engagement between healthcare professionals and patients so that the individual needs of the patient are fully understood e.g. upon admission to hospital.

Which target for which patient?

Presented by Professor Brian Frier.

Professor Brian Frier BSc (Hons), MD, FRCP(Edin), FRCP(Glas), is Honorary Professor of Diabetes at the University of Edinburgh, affiliated to the British Heart Foundation Centre for Cardiovascular Science.

Professor Frier, a leading expert on diabetes and hypoglycaemia, introduced his talk by briefly discussing glycaemic targets in the context of the Quality and Outcomes Framework (QOF) guidelines that reward healthcare practices for quality in clinical care in diabetes. 2, 3

However, Professor Frier pointed out that these guidelines do not use an individualised approach. Referring to major treatment guidelines for adults with diabetes, Professor Frier noted that, since 2006, these have been based on glycaemic targets for the long-term management of patients; in most major guidelines, based on best evidence, the HbA1c targets have been 6.5–7%. Professor Frier said that the latest NICE guidelines have placed more emphasis on the needs of the individual patient.

Reviewing key findings of the major landmark studies: United Kingdom Prospective Diabetes Study (UKPDS)4 and the Diabetes Control and Complications Trial (DCCT),5 Professor Frier reminded the audience that these studies showed that the lower the HbA1c level, the lower the risk of microvascular, cardiovascular and other complications. Referring to the `legacy effect’, Prof Frier emphasised that if good glycaemic control is achieved early on in the treatment of a person with diabetes then a clinical benefit will usually continue over time.

In the Danish STENO 2 study in patients with more advanced type 2 diabetes,6 patients who received intensive multifactorial therapy had a lower incidence of cardiovascular events than patients who received conventional treatment. Professor Frier noted that the lower the HbA1c level the better the outcome, particularly in young people with type 1 diabetes. However, he explained that it can be difficult to achieve strict glycaemic control with insulin treatment and most major studies have shown that relatively small proportions of patients on insulin achieve HbA1c targets of <6.5%.

Morbidity of hypoglycaemia

Morbidities associated with hypoglycaemia include cardiovascular effects, neurological issues, falls and accidents, depending on age. Hypoglycaemia in people with type 2 diabetes is common across all levels of glycaemic control. Also, the longer patients are on insulin, the greater the risk of hypoglycaemia, even in patients with good glycaemic control. Achieving and maintaining strict glycaemic control can therefore be difficult. This poses the question as to whether strict glycaemic control is appropriate for some patients, Professor Frier noted.

Fear of hypoglycaemia and its clinical implications

Professor Frier said that many patients are very concerned about severe hypoglycaemia, sometimes rating it as serious as going blind or developing kidney failure; he explained that some potential risks, such as hypoglycaemia, are associated with the achievement of very tight glycaemic control. Importantly, fear of hypoglycaemia influences self-management, due to concerns about the implications of hypoglycaemia in terms of social relationships and other factors, including driving licence restrictions. This in turn fuels anxiety. Therefore, patients on insulin may relax their glycaemic control.

Concluding his interesting and insightful presentation, Prof Frier noted that for some patients with type 2 diabetes, glycaemic targets are unattainable, and he stressed the importance of a “common sense approach”, as has been taken by the American Diabetes Association (ADA) in the ADA 2016 guidelines7 and other treatment guidelines. Professor Frier reinforced the message that glycaemic targets should be individualised for individual patients.

On the subject of incentives and QOFs, a member of the audience commented that if GPs are rewarded for “achieving targets”, this will not encourage individualised care. This topic is likely to continue to be the subject of debate among healthcare providers, including primary care physicians, and people affected by diabetes.

NICE guidelines: Type 2 diabetes

Presented by David Millar-Jones.

David Millar-Jones is the Chair of the Primary Care Diabetes Society UK and Ireland, and the Associate Specialist and GP lead for diabetes in Aneurin Bevan LHB. David is involved in establishing an integrated service for diabetes and is actively involved in education and diabetes support within Primary Care.

During the introduction to his talk, Dr Millar-Jones stressed the high incidence of diabetes, stating:

"the tsunami of diabetes …is set to unfold"

Dr Millar-Jones presented an overview of the current NICE guidelines for adults with type 2 diabetes,8 reviewing the current guidance on treatment options for type 2 diabetes and emphasising the importance of an individualised approach, tailored to the needs and circumstances of the patient. He emphasised that patient status should be assessed regularly and that patients should have their say in treatment selection, taking into consideration the potential risks, benefits and effectiveness of treatment. Dr Millar-Jones explained that patients are more likely to be compliant with treatment if they are involved in treatment selection. He reminded the audience that, as stated in the NICE guidelines, drug treatments that are not effective for an individual patient should be discontinued.

Dr Millar-Jones also talked about current NICE recommendations for the use of metformin, including the use of standard-release metformin as initial drug treatment for patients with type 2 diabetes. If metformin is an unsuitable treatment option (e.g. due to tolerability issues, or contraindications), initial treatment with a dipeptidyl peptidase-4 (DPP-4) inhibitor, or pioglitazone, or a sulphonylurea should be considered as potential treatment options. [NICE guidance should be referred to for other treatment options]. Highlighting the importance of an individualised approach to treatment, Dr Millar-Jones concluded:

"Guidance is NICE to have but the best treatment will always be bespoke"

NICE guidelines: Type 1 diabetes: a utopian fantasy?

Presented by Dr Partha Kar @parthaskar

Dr Partha Kar is Clinical Director of Diabetes, Portsmouth Hospitals NHS Trust, and also the Associate Editor of the Diabetes Times

Introducing his talk on the updated NICE guidelines for adults with type 1 diabetes, Dr Kar reflected on the 2004 NICE guidelines, comparing these with the current guidelines. Dr Kar raised questions about the NICE 2015 HbA1c targets for patients with type 1 diabetes, which may be difficult for some patients to attain. In response, Professor Stephanie Amiel, who was involved in writing the guidelines, explained that the glycaemic targets in the revised NICE guidelines should be considered “aspirational goals”.

During his excellent and thought-provoking presentation, Dr Kar urged the audience to use their strong voice to help improve care for people with diabetes.

"You cannot escape the responsibility of tomorrow by evading it today" Abraham Lincoln

The importance of structured education was also highlighted by Dr Kar and he asked NICE to commission Dose Adjustment for Normal Eating (DAFNE) across the UK.9

DAFNE provides people with diabetes, as well as healthcare providers and commissioners, with the skills that are required to estimate the carbohydrate content of each meal and to inject the correct amount of insulin.

References

1. Type 1 diabetes in adults: diagnosis and management. NICE guidelines [NG17] Published August 2015: https://www.nice.org.uk/guidance/ng17
2. BMA QOF Guidance: https://www.bma.org.uk/advice-and-support/gp-practices/funding-and-contracts/quality-and-outcomes-framework-qof
3. The NICE Indicatory Menu for the QOF: https://www.nice.org.uk/standards-and-indicators/indicators
4. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. [UKPDS study]. N Engl J Med 2008; 359:1577-1589 October 9, 2008 DOI: 10.1056/NEJMoa0806470. http://www.nejm.org/doi/full/10.1056/NEJMoa0806470
5. The Diabetes Control and Complications Trial Research Group.The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus. [DCCT study]. N Engl J Med 1993; 329:977-986 September 30, 1993 DOI: 10.1056/NEJM199309303291401
   http://www.nejm.org/doi/full/10.1056/NEJM199309303291401
6. Gæde P, Vedel P, Larsen N, et al. Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes. [STENO 2 study]. N Engl J Med 2003; 348:383-393. January 30, 2003. DOI: 10.1056/NEJMoa021778 http://www.nejm.org/doi/full/10.1056/NEJMoa021778#t=articleDiscussion
7. American Diabetes Association. Standards of Medical Care ADA in Diabetes – 2016 http://care.diabetesjournals.org/site/misc/2016-Standards-of-Care.pdf
8. NICE Type 2 diabetes in adults: management. NICE guidelines [NG28] Published date: December 2015.