The video version of this podcast can be found here: ·      https://youtu.be/z7eZ1MLItGwThe previous episode on first line treatment of T2DM can be found here: ·      https://youtu.be/32Lf5UlyTOAThis episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by them.NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The links to the NICE guideline can be found below. In today’s episode, we are focusing on treatment options if further interventions are needed after first line treatment. If you haven’t already, I recommend that you check the previous episode on the first line drug management of type 2 diabetes. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   Disclaimer:The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through  There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrkThe NICE guideline on Type 2 diabetes in adults: management [NG28] can be found here:·      https://www.nice.org.uk/guidance/ng28 TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome! I’m Fernando, a GP in the UK. In this episode, we’ll go through the NICE recommendations on the drug treatment of type 2 diabetes, included in the NICE guideline NG28. The link to it is in the episode description. In today’s episode, we are focusing on glucose lowering treatment options if further interventions are needed after first line treatment.  If you haven’t already, I recommend that you check the previous episode on the first line drug management of type 2 diabetes. Right, let’s jump into it.So we are going to look at treatment options if further intervention is needed—basically, what to do after first-line treatment.But first, let’s talk about reviewing drug treatments and when we will need to add an SGLT2 inhibitor at any point after starting first-line therapy.For adults with type 2 diabetes, no matter where they are in their treatment journey, if they have or develop chronic heart failure, established atherosclerotic cardiovascular disease, or become high risk for cardiovascular disease, if they are not already on it, we should offer an SGLT2 inhibitor that has proven cardiovascular benefits. This can be added on to their current treatment or used to replace an existing medication.And let’s remember that this is because there is strong evidence in large randomised controlled trials, that has shown that SGLT2 inhibitors not only improve blood glucose control but also reduce the risk of hospitalisation for heart failure, and in some cases lower cardiovascular mortality. These benefits are seen even in patients without diabetes, which highlights their role in protecting the cardiovascular system as well as the kidneys.Right, now, before we look into how to intensify treatment, let’s quickly cover what NICE says about monitoring and targets.Regarding diabetes monitoring, NICE recommends measuring HbA1c every 3 to 6 months until it’s stable on unchanging treatment. After that, once HbA1c is fully stable, measuring every 6 months is usually enough.When it comes to HbA1c targets, we should discuss and agree on an individual goal with each patient. The aim is to help them reach and maintain that target—unless trying to do so causes problems like hypoglycaemia or lowers their quality of life.Generally speaking, for those managing their diabetes with lifestyle changes or a single drug that doesn’t cause hypoglycaemia, the target is around 48 mmol/mol, or 6.5%. For patients on medications that do carry a risk of hypoglycaemia, the target is a bit higher, around 53 mmol/mol, or 7.0%.If an adult’s HbA1c isn’t controlled by a single drug and rises to 58 mmol/mol, or 7.5%, or above, then we need to review and reinforce their current treatment and after that, we usually move to intensify drug treatment by adding a second medication.Now let’s look at treatment options when further intervention is needed.For adults with type 2 diabetes, if monotherapy isn’t enough to keep HbA1c below their individual target, we can consider adding one of the following: ·      a DPP-4 inhibitor, ·      pioglitazone, ·      a sulfonylurea, ·      or an SGLT2 inhibitor.If dual therapy—usually metformin plus another oral drug—still isn’t controlling HbA1c below the agreed threshold, then we have two main options. We can either:·      move to triple therapy by adding a DPP-4 inhibitor, pioglitazone, a sulfonylurea, or an SGLT2 inhibitor, ·      or we can consider starting insulin.In adults with type 2 diabetes, if metformin is contraindicated or not tolerated, and dual therapy with two oral drugs still isn’t keeping HbA1c below the agreed threshold, then insulin should be considered. This essentially means that triple therapy is only recommended by NICE when one of those three drugs is metformin, not otherwiseIf triple therapy with metformin and two other oral drugs isn’t effective, isn’t tolerated, or is contraindicated, we may consider switching one of those drugs for a GLP-1 mimetic—but according to NICE, this is only for adults who:Have a BMI of 35 or higher (with adjustments for people from Black, Asian, and other minority ethnic groups by reducing the BMI by 2.5 to 32.5) and who also have specific psychological or medical problems linked to obesity, orHave a BMI under 35 but for whom insulin would have significant occupational impacts, or where weight loss would help other serious obesity-related health issues.GLP-1 mimetic therapy should only be continued if the patient shows a clear benefit, that is, a drop in HbA1c of at least 11 mmol/mol (or 1%) and a weight loss of at least 3% of their starting body weight within six months.Also, we need to be aware that combining a GLP-1 mimetic with insulin should only be done under specialist care and advice.So, as we’ve just seen, NICE recommends using GLP-1 mimetics mainly for people with type 2 diabetes who have a higher BMI or specific obesity-related problems. They also set clear criteria for continuing treatment, based on how well the patient responds metabolically and whether they lose enough weight.Now, we should also point out that other guidelines, like those from the ADA and EASD, take a fairly different approach. They suggest considering GLP-1 receptor agonists earlier in the treatment journey—especially for patients who already have cardiovascular disease or are at high risk of developing it, no matter their BMI. These guidelines focus more on the cardiovascular benefits of GLP-1 therapies, in addition to blood sugar control.So, while NICE tends to emphasize weight and BMI, the ADA and EASD put more weight on cardiovascular risk when they recommend GLP-1 receptor agonists.This is because research has shown that GLP-1 receptor agonists can reduce the risk of major cardiovascular events in people with type 2 diabetes who either have established cardiovascular disease or are at high risk.For example, the LEADER trial looked at liraglutide, and the SUSTAIN-6 trial studied semaglutide. Both showed significant reductions in cardiovascular events compared to placebo. Next, let’s move on to insulin-based treatments for adults with type 2 diabetes.When starting insulin therapy, we are likely to continue offering metformin—provided there are no contraindications or intolerance. At the same time, we should review whether other blood glucose-lowering medications are still needed.For insulin options, we have several choices. The first line option for NICE is NPH insulin, which can be given once or twice daily, depending on the person’s needs.A quick note about NPH insulin: it’s an intermediate-acting insulin with an onset of action around 1 to 2 hours after injection. Its peak effect usually occurs between 4 to 8 hours, and it lasts for about 12 to 16 hours. Because of this profile, it’s useful for covering blood sugar levels between meals and overnight.We should consider starting both NPH and short‑acting insulin particularly if the person's HbA1c is 75 mmol/mol [9.0%] or higher. This can be administered either:separately oras a pre-mixed (or biphasic) human insulin preparation.However, NICE also suggests we can consider using insulin detemir or insulin glargine as alternatives to NPH insulin in certain situations. For example:If the person needs help with injections,If they experience recurrent symptomatic hypoglycaemia, orIf they would otherwise need twice-daily NPH insulin injections along with other medications.And now a quick note on insulin detemir and glargine:Insulin glargine is a long-acting basal insulin that provides a steady release over about 24 hours with no pronounced peak, which helps maintain more stable blood sugar levels throughout the day and night.Insulin detemir is also a long-acting insulin but usually has a slightly shorter duration, lasting around 16 to 20 hours. It tends to have a mild peak and may require twice-daily dosing in some people to maintain adequate coverage.Both glargine and detemir offer a more predictable action profile than NPH insulin, which can help reduce the risk of hypoglycaemia and improve blood glucose control.When it comes to pre-mixed, or biphasic, insulin preparations, NICE recommends considering short-acting insulin analogues rather than short-acting human insulin—particularly if:The person prefers injecting insulin just before a meal,Hypoglycaemia is a concern, orTheir blood glucose levels spike significantly after eating.This is because short-acting analogue insulins are rapid-acting insulins designed to manage the blood sugar spikes that happen around meal times.They start working fast—usually within 10 to 20 minutes—peak around 1 to 3 hours, and their effects last for about 3 to 5 hours. Because of this quick action and shorter duration, they can be injected right before or just after eating, offering more flexibility.Common examples include insulin lispro, insulin aspart, and insulin glulisine.One key advantage of these analogues over regular human insulin is a lower risk of hypoglycaemia, especially overnight or between meals. Their rapid onset and shorter duration mean insulin levels drop off sooner, reducing the chance of blood sugar dipping too low when it’s not needed.Finally, if someone is already on NPH insulin, we should also consider switching from NPH insulin to a long-acting analogue like insulin detemir or insulin glargine if:They experience significant hypoglycaemia while using NPH insulin,They are unable to use the device required for NPH, orThey need help with injections, and switching to a long-acting insulin analogue could reduce the number of daily injections needed.We will need to monitor patients on a basal insulin regimen—whether that’s NPH, detemir, or glargine—for the possible need to add short-acting insulin before meals, or to switch to a pre-mixed, biphasic insulin preparation.Similarly, adults on pre-mixed insulin should be regularly assessed to see if they need an additional injection of short-acting insulin before meals or if their blood glucose control would benefit from moving to a basal-bolus regimen with NPH, detemir, or glargine.This ongoing review helps ensure insulin therapy is tailored to achieve the best possible blood sugar control for each patient.So that is it, a review of the treatment options in type 2 diabetes if further interventions are needed after first line treatment. We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.Thank you for listening and goodbye.

Ver todos los episodios