The decision by NICE to bring forward its review of diabetes therapies from 2012 to later this year is clearly an attempt to impact on prescribing, especially since the last review was only published 2 years earlier in May 2009 (Clinical Guideline [CG] 87, an update on CG 66 published twelve months before). So, what will be the likely focus of this update?
At the time of publication of CG 87, the major interest was how NICE would limit the use of the incretin therapies, namely the oral gliptins and the injectable glucagon-like peptide 1 (GLP-1) therapies. The guidance was relatively flexible for both groups of agents (albeit limiting exenatide to third-line) but with the introduction of ‘stopping rules’ where levels of HbA1c (+/- weight reduction) were not achieved.
Both the gliptins and the GLP-1s have been very popular and have, no doubt, exceeded their anticipated cost to the NHS. For the gliptins, the option of using a thiazolidinedine, approaching the end of their patent life and therefore becoming cheaper, has been hit by the withdrawal of rosiglitazone. This was on the basis of an increased risk of heart attack (and, possibly, lots of other agendae), but has also impacted on the use of pioglitazone which is also associated with increased risk of fluid retention and bone fracture.
The GLP-1 therapies have also proved costly, partly because of their weight advantage over insulin, but also because of off-licence combination prescribing with insulin in many cases. Furthermore, the ‘single technology appraisal’ status of liraglutide means that PCTs are obliged to fund this therapy, a status that would presumably be diluted by a new NICE ‘guideline’.
But perhaps the major focus of the NICE update will be the use of analogue insulins, especially long-acting agents such as glargine and detemir insulins. The NICE guideline from 2009 specifically recommended NPH use as the routine choice for patients with type 2 diabetes but this has clearly not impacted on practice. This area was highlighted by the joint newscast/publication by Channel 4 and the British Medical Journal at the end of 2010 and has since moved up the prescribing agenda with the mention of the glargine ‘cancer scare’ now included in NHS publications.
So the pressure will be on the use of modern, but more expensive, treatments for patients with type 2 (and, by extrapolation, type 1 diabetes). Clinicians will have their own views but it will be of great interest to see the stance of Diabetes UK, the patients’ organisation, in the forthcoming debates.
Professor Steve Bain