The UK is currently bracing itself for the launch of clinical guidelines (CGs) from NICE for the management of both type 1 (T1) and type 2 diabetes (T2DM). Notwithstanding any massive changes to the latest drafts, the approach of NICE to basal insulin seems to be inconsistent and represents a missed opportunity to make a real impact.

T1DM in the UK is largely managed by secondary care, especially at the point of diagnosis and therapy initiation. So, when the ‘Type 1 diabetes in adults’ CG gives advice on basal insulin treatment, it is doing so to specialist clinicians who probably think they know what they are doing. That the advice is based on a ‘network meta-analysis’ will cut little ice with specialists, especially when the recommended use of twice-daily basal analogue is at odds with their routine practice.

Contrast this scenario with the advice regarding basal insulin use in T2DM. Here one might anticipate the involvement of non-specialists in primary care – clinical teams who really could benefit from specific advice on insulin use. And yet the current ‘Type 2 diabetes in adults’ CG comes up with “offer NPH insulin injected once or twice daily according to need’ and “consider twice-daily pre-mixed (biphasic) human insulin (particularly if HbA1c is 75 mmol/mol [9.0%] or higher)”. Reference to the BNF will lead the prescriber to five different ‘isophane insulins’ and four human biphasics, all to be dosed ‘according to requirements’. NICE then directs the prescriber to the “insulin delivery section in the NICE guideline on type 1 diabetes. [new 2015]” for further guidance (i.e. how much to inject, when, where and how to titrate…)

The average HbA1c at insulin initiation in the UK is around 10% (84mmol/mol), this being preceded by years of so-called clinical inertia. Following initiation, patients are sub-optimally dosed, despite the widespread publication of simple, patient-managed titration algorithms. And NICE, on one hand, makes no reference to any of these issues, but on the other is dictating to specialists. I think someone has lost the plot….

Professor Steve Bain