The National Institute for Health and Care Excellence (NICE) has been criticised by a group of leading diabetes doctors for its guidelines on treating type 2 diabetes, in an open letter.
The letter, written by researchers from the University of Warwick Medical School, was published in Lancet Diabetes and Endocrinology.
The letter takes issue with an updated draft of clinical practice guidelines for the treatment of type 2 diabetes. The guidelines, which were originally published in January, recommend the use of metformin first, followed by older drugs as second-line therapy. In theory, these drugs, being older, will make type 2 treatment cheaper.
But the letter’s authors disagree. According to them, the guidelines don’t take into account the cost of the side effects associated with these older drugs, such as increased risk of hypoglycemia. In reality, they argue, treatment using older drugs may not turn out to be cheaper after all.
The authors also take issue with the lack of practising diabetologists on NICE’s consultation committee, a decision made to avoid conflicts of interest. But the end result, the open letter suggests, is to have treatment guidelines determined by people who no longer treat type 2 diabetes on a regular basis.
Based on criticism of the original draft, NICE revised the guidelines draft. But J Paul O’Hare, FRCP, who authored the letter with colleagues, believes the revision failed to address the most significant criticisms.
“Little has changed in the guideline regarding advice on drug treatment to control blood glucose despite, and contrary to, the advice of most leading specialists in the specialty,” the authors wrote.
The letter argues that the NICE guidelines are overly driven by the need to reduce costs, but a recent report, which suggests that the cost of diabetes drugs has risen from six per cent to 10 per cent of the NHS’s drug budget, suggests that cost reduction may be the only option.
However, the open letter does not really disagree on this point; it only suggests that the guidelines may incur greater costs in the long-term. For example, NICE recommends that type 2 diabetes is first treated with metformin – something widely accepted as a good plan – but metformin treatment only intensifies in patients with HbA1c levels of 7.5 per cent of more. This decision should in fact be made based on a number of factors particular to individual patients, the letter suggests.
There is also disagreement as to the use of sulphonylureas as a second-line treatment because of its relatively low cost. O’Hare and colleagues argue that using sulphonylureas will lead to greater costs in the future, based on “the well-recognised side effects of hypoglycemia and weight gain – the very issues that NICE states clearly in its preamble should be avoided.
O’Hare added: “Primary-care doctors and nurses, in particular, are struggling to look after growing numbers of patients with type 2 diabetes. These healthcare professionals need clear, sensible guidance, based on evidence (and cost), but most importantly on safety.”

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