MedWire News: The UK National Institute for Health and Clinical Excellence (NICE) has recently updated their guidelines for the treatment of Type 2 diabetes to encompass new drugs that have been developed in recent years.
The first of these is the class of dipeptidyl peptidase (DPP)-4 inhibitors – vildagliptin and sitagliptin (currently approved in the UK), which act to stabilize concentrations of glucagon-like peptide and increase the secretion of insulin, say Amanda Adler (University of Cambridge, UK) and fellow authors of a summary of the new guidelines published in the British Medical Journal.
Other recently developed drugs approved for use in the UK include the glucagon-like peptide (GLP)-1 mimetic exenatide and the long acting insulin analogues insulin detemir and insulin glargine.
The guidelines recommend that clinicians should consider adding a DPP-4 inhibitor instead of a sulfonylurea to metformin if a patient’s blood glucose control becomes or remains inadequate after treatment with metformin plus a sulfonylurea (glycated hemoglobin [HbA1c] of 6.5% or higher), or if they cannot tolerate taking a sulfonylurea, for example due to renal impairment.
Due to the lower risk for hypoglycemia associated with these drugs, they are also recommended for use if a patient is at severe risk for hypoglycemia.
GLP-1 mimetics, such as exenatide, act by increasing insulin secretion, inhibiting glucagon secretion, and delaying gastric emptying. Unlike many other anti-diabetic drugs exenatide actually promotes weight loss.
The guidelines therefore recommend its use as a third line treatment for Type 2 diabetics taking metformin plus a sulfonylurea, particularly if they have a body mass index (BMI) of 35 kg/m2 or above (Caucasians), as well as specific medical or psychological problems associated with high weight.
Exenatide is also suggested as an alternative to insulin in patients with a lower BMI if insulin use would have substantial occupational implications or if weight loss would have a beneficial effect on other obesity-related comorbidities.
The guidelines suggest that long-acting insulin should be considered for patients with recurrent symptomatic episodes of hypoglycemia, those who would otherwise need two injections of insulin per day plus oral drugs, and those who are unable to inject normal insulin themselves.
Recent safety concerns regarding the use of thiazolidinediones – rosiglitazone and pioglitazone – are addressed in the guidelines. Clinicians are advised not to prescribe thiazolidinediones if a patient has a high risk for heart failure or fracture. They are also advised to check their relevant regulatory body for up to date advice.
Most importantly: “Healthcare professionals caring for people with diabetes should consider their needs and preferences and give them the opportunity to make informed decisions about their care and treatment,” conclude Adler et al.
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a part of Springer Science+Business Media. © Current Medicine Group Ltd; 2009
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