Diabetes is on the rise in Britain – at a frightening rate. Yet NICE, the health regulator, doesn’t seem to know how best to treat it. Doctors specialising in diabetes described its recent recommendations as ‘bonkers’. And now they’ve forced NICE into an embarrassing U-turn.
First, some statistics. In 2010, 3.1 million people over 16 suffered from diabetes, according to the NHS. By 2030 that figure will be 4.5 million – and 90 per cent will have type 2 diabetes. That’s the type sufferers tend to develop after the age of 40 and it’s strongly associated with being overweight.
In other words, selecting the right treatment has implications for millions of people.
Last week, NICE agreed plans for a second round of feedback on clinical recommendations for type 2 diabetes – after originally opposing the move. That will come as a relief to the Primary Care Diabetes Society (PCDS), which was among NICE’s sternest critics.
Essentially, the health regular was accused of recommending ineffective treatments as a cost-cutting measure. To quote Pulse magazine back in February:
The experts said the [NICE] recommended treatment algorithm for glycaemic control was ‘nonsensical’, drawing particular attention to the promotion of the insulin secretagogue repaglinide – which primary care has ‘little understanding of’ because it is rarely prescribed.
The article contained a devastating quote from Prof Roger Gadsby of Warwick University, a GP who teaches the management of diabetes. He said:
Many experts in diabetes have labelled part of this draft guidance as ‘bonkers’… A particular area of concern is the recommendation that, in the 15 per cent or so [of diabetes patients] who cannot tolerate metformin as initial monotherapy for glycaemic control the drug repaglinide should be used.
It is a drug that was launched in the 90s but never caught on. There are very few people taking it today so there is no real understanding in general practice of how to use the drug, what dose should be given, and what dose escalation is appropriate.
That’s particularly worrying when you consider that replaglidine – though cheaper than alternatives – has to be taken by type 2 diabetes patients 15 minutes before each meal. (Note that this affects only 15 per cent of patents – but that’s not much consolation if you’re one of them.)
Also, it causes hypoglycaemia (low blood sugar), which can cause anxiety and stress among patients, and weight gain, which may lead them to stop taking it. So it’s hardly surprising that, although it’s cost-effective, clinicians didn’t often advise taking replaglidine – until NICE suddenly recommended it.
Now it’s been forced to think again. You can’t help wondering how much time and money could have been saved if it had consulted more widely in the first place. To state the obvious, it doesn’t matter how cost-effective a diabetes drug is if patients take the wrong dose by mistake or stop taking it altogether.