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PCT Prescribing Report (May 2009)
Type 2 Diabetes – Prescribing Guidance and Discussion Points
Discussion Points
1.
Does your PCT have a strategy for the prevention of type 2 diabetes? Does your
PCT have a programme of support for the multifactorial lifestyle interventions
shown to prevent type 2 diabetes?
2.
Does your PCT provide structured education programmes for people with type 2
diabetes in line with the National Institute of Health and Clinical Excellence (NICE)
Commissioning Guide? Does this programme meet the criteria laid down by the
Department of Health and Diabetes UK Patient Education Working Group?
3.
Does local guidance on prescribing for type 2 diabetes follow the NICE guidance
on the management of type 2 diabetes May 2008?
4.
Are you planning to update and/or agree local protocols for the prescribing of
newer agents following the publication of the NICE clinical guideline (expected
May 2009)?
5.
Does local guidance include advice on the role of self-monitoring of blood glucose
in the management of type 2 diabetes? Does this advice include the purpose of
self-monitoring and agreement about how the results should be interpreted and
acted upon? Does local guidance recommend that the person with type 2 diabetes
should be involved in decisions about their individual target level for glycated
haemoglobin (HbA1c)?
Type 2 diabetes is the most common form of diabetes, accounting for 90–95% of
cases. There are estimated to be 1.9 million adults diagnosed with the condition and
around 0.5 million people with undiagnosed diabetes against a background of rising
prevalence. The direct costs of type 2 diabetes are estimated to be around 7 – 12% of
total NHS expenditure. People with type 2 diabetes are at increased risk of developing
microvascular e.g. kidney, eye and nerve damage and macrovascular e.g.
cardiovascular and cerebrovascular disease complications. These multiple vascular risk
factors mean that diabetes care is typically complex and time-consuming. Foot
problems, kidney disease, and the presence of neuropathy should be assessed at
diagnosis and at least annually thereafter. All people with diabetes should be referred
for retinal screening at diagnosis as part of a formal screening programme. The lifestyle
changes, complexities of management and side effects of therapy make self monitoring
and education for people with diabetes central parts of management.
Structured education and self-management programmes aim to improve outcomes by
addressing the person’s health beliefs, optimizing their metabolic control, addressing
their cardiovascular (CV) risk factors, helping them to change behaviour, e.g.
increasing physical activity, improving their quality of life and reducing depression. The
potential consequences of not investing in such programmes are increased
complications, greater future healthcare costs and an inability to make future individual,
local and national improvements. In May 2008 NICE updated its clinical guidance on
the management of type 2 diabetes and recommended that structured education
should be offered to every person and/or their carer at or around the time of diagnosis,
with annual reinforcement and review.
A full lipid profile should be performed when assessing CV risk after diagnosis and
annually, and before starting lipid-modifying therapy. If the person is considered not to
be at high CV risk their CV risk should be estimated annually using the UK Prospective
Diabetes Study risk engine. Simvastatin 40mg or a statin of similar efficacy and cost is
recommended by NICE to achieve target cholesterol levels. NICE recommends offering
lifestyle advice to lower blood pressure (BP) and if this does not reduce BP to below
the target values then medication should be added. The first-choice antihypertensive
drug recommended by NICE is a once-daily ACE-inhibitor. The NICE guidance also
advises the use of aspirin 75mg daily however in October 2008 the results of the
POPADAD trial were published. This study raises questions over the level of CV risk at
which the benefits of aspirin use outweigh the gastrointestinal risks. Aspirin should still
be given for secondary prevention of CV disease in people with type 2 diabetes.
However, for primary prevention in type 2 diabetes, consideration on an individualized
basis following an assessment of the benefits and risks may be more appropriate.
The prescribing and spending on products to control glucose levels has increased
steadily over the last 5 years (Figures 1 and 2).
Figure 1: Trends in prescribing of products to treat Type 2 Diabetes in General Practice
in England
3.5
3.0
Items (Millions)
2.5
2.0
1.5
1.0
0.5
0.0
Dec-08
Sep-08
Jun-08
Mar-08
Dec-07
Sep-07
Jun-07
Mar-07
Dec-06
Sep-06
Jun-06
Mar-06
Dec-05
Biphasic insulins
Sulphonylureas
Glitazones
Other antidiabetic drugs
Sep-05
Jun-05
Mar-05
Dec-04
Sep-04
Jun-04
Mar-04
Dec-03
Quarter to
Other intermediate and long-acting insulins
Metformin
Metformin combination products
Figure 2: Trends in spending on products to treat Type 2 Diabetes in General Practice
in England
35
30
NIC (£ Millions)
25
20
15
10
5
Dec-08
Sep-08
Jun-08
Mar-08
Dec-07
Sep-07
Jun-07
Mar-07
Dec-06
Sep-06
Jun-06
Mar-06
Dec-05
Biphasic insulins
Sulphonylureas
Glitazones
Other antidiabetic drugs
Sep-05
Jun-05
Mar-05
Dec-04
Sep-04
Jun-04
Mar-04
Dec-03
0
Quarter to
Other intermediate and long-acting insulins
Metformin
Metformin combination products
When oral glucose control therapies are required NICE recommends metformin as first
choice. Metformin items have increased by 81% over the last 5 years and account for
56% of antidiabetic drug items (3.1 million for the quarter to December 2008, £12.2
million). Sulphonylureas may be considered in the non-overweight or if metformin is
contraindicated or not tolerated. There has been a 27% increase in items for
sulphonylureas to 1.7 million items for the quarter to December 2008, whereas cost has
fallen by 42% to £5.9 million.
NICE recommends that if blood glucose control remains or becomes inadequate on
metformin then a sulphonylurea may be added. For people with non-routine daily
lifestyle patterns then a rapid acting insulin secretagogue (repaglinide or nateglinide)
may be considered. A thiazoldinedione (pioglitazone or rosiglitazone) should only be
considered at this stage if hypoglycaemia on a sulphonylurea is a problem.
Thiazolidinediones should not be commenced or continued in people who have
evidence of heart failure or who are at higher risk of fracture and account should be
taken of up-to-date advice from the relevant regulatory bodies (European Medicines
Agency and Medicines and Healthcare products Agency) prior to prescribing.
Figure 1 shows the number of items for the thiazolidinediones (glitazones) leveling off,
due to a decrease in the number of items for rosiglitazone (173,000 items for the
quarter to December 2008, £6.8 million) and an increase in the number of items for
pioglitazone (275,000 items, £10.6 million). Prescribing of metformin combinations
(multi-ingredient products containing metformin with either rosiglitazone, pioglitazone or
vildagliptin) is now 144,000 items (3%) and accounts for 12% of all spending on
antidiabetic drugs (£5.3 million). Repaglinide and nateglinide items are 27,300 and
7,800 per quarter at a cost of £365,000 and £215,000 respectively. Sitagliptin and
vildagliptin prescribing for the quarter to December 2008 are 36,000 and 1,500 items,
costing £1.5 million and £52,000 respectively. A new guideline from NICE on the use of
newer agents, glitazones, gliptins and exenatide, in type 2 diabetes mellitus is expected
in May 2009. This guideline has the potential to have significant resource
consequences for service providers.
In 2008 three trials looking at intensive glucose control compared to standard glucose
control were published (ACCORD, ADVANCE and VADT). These studies have
stimulated considerable debate about the benefits of intensive glycaemic control in
older adults with type 2 diabetes and whether there is an increased risk of adverse
outcomes. Self-monitoring of blood glucose should only be offered to a newly
diagnosed patient as an integral part of their self-management education.
The purpose of self-monitoring should be discussed along with agreement about how
the results should be interpreted and acted upon. Prescribing of blood glucose testing
strips has risen by 11% to 1.4 million items per quarter and spending has risen 13% to
£35.2 million over the last 5 years.
Sources of further information
1. Information on prescribing for the PCT is available using ePACT.net and the
Prescribing Toolkit
2. Srinivasan, B, Taub, N, Khunti, K. and Davies, M. (2008) Diabetes: glycaemic
control in type 2. Clinical Evidence. BMJ Publishing Ltd. www.clinicalevidence.com
3. NICE. Type 2 diabetes: the management of type 2 diabetes Clinical Guideline 66.
May 2008. www.nice.org.uk/CG066
4. Commissioning a patient education programme for people with type 2 diabetes.
www.nice.org.uk/usingguidance/commissioningguides/type2diabetes
5. Structured patient education in diabetes: report from the patient education working
group. www.dh.gov.uk
6. Action to Control Cardiovascular Risk in Diabetes study group. Effects of Intensive
Glucose Lowering in Type 2 Diabetes. N Engl J Med 2008;358:2545-2559
7. ADVANCE Collaborative group. Intensive Blood Glucose Control and Vascular
Outcomes in Patients with Type 2 Diabetes. N Engl J Med 2008;358:2560-2572
8. Duckworth W, Abraira C, Moritz T et al Glucose Control and Vascular Complications
in Veterans with Type 2 Diabetes. N Engl J Med 2008;360:129-139
9. Belch J, MacCuish A, Campbell I et al. The prevention of progression of arterial
disease and diabetes (POPADAD) trial: factorial randomized placebo controlled trial
of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral
arterial disease. BMJ 2008;337:a1840