Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
6.1 Drugs used in diabetes
Related guidance: NICE NG28 Type 2 diabetes in adults: management July 2016
NICE NG17 Type 1 diabetes in adults:diagnosis and management August 2015
Diabetes (type 1 and type 2) in children and young people: diagnosis and management (NG18) August 2015
NICE type 2 adult pathway
Before any pharmacological interventions are considered there should be a 3 month period of diet & lifestyle interventions.
Education provide structured education to every patient and/or their carer at and around the time of diagnosis and review annually.
Diet provide individualised and ongoing specialist nutritional advice.
Lifestyle encourage weight loss and exercise.

Blood Pressure Control
Evidence from UKPDS indicates that control of blood pressure in people with hypertension & Type 2 diabetes achieves a clinically important reduction in the risk of deaths related to diabetes, complications related to diabetes, progression of diabetic retinopathy, and deterioration in visual acuity.
Blood glucose control
The VADT, ACCORD and ADVANCE trials show that tight control of blood glucose in long standing Type 2 diabetics (reducing HbA1c to below 53mmol/mol or 7%) may be harmful.
• Involve the person in decisions about their individual HbA1c target which may be above the general target of 48mmol/mol or 6.5% especially in long standing diabetes.
• Offer lifestyle advice and medication to help achieve and maintain the HbA1c target.
• Inform patients with a higher HbA1c that any reduction towards the agreed target is advantageous to their health.
• Avoid pursuing highly intensive management to levels of <48mmol/mol or 6.5%.
♦ Self-monitoring of blood glucose should be offered to a patient newly diagnosed with T2DM only as an integral part of his/her self- management education. Its purpose should be discussed and there should be agreement how the results should be interpreted and acted upon.
♦ Eye and kidney damage should be screened annually.
NB DH require that HbA1c should always be measured in millimoles per mol (mmol/mol) as well as by percentage. HbA1c of 6.5% is equivalent to 48mmol/mol.
Self monitoring of blood glucose
Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless:

the person is on insulin
or
there is evidence of hypoglycaemic episodes
or
the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery
or
the person is pregnant, or is planning to become pregnant.
Which test strips should I prescribe?
PAMM agreed in September 2016 that patients should be prescribed test strips which are compatible with an ISO2103 meter and at the lowest acquisition cost, set at under £10 for a box of 50 strips. Some patients will require strips compatible with more sophisticated meters, such as those linked to insulin pumps.
A full list of these formulary approved strips is available here
Type 2 diabetes medications on a low carbohydrate diet.
For patients who choose to follow a low carbohydrate diet to improve their blood glucose control, guidance has been drawn up by our diabetes principals on how medications could be optimised. Website link here

Guide to HbA1c values expressed as mmol/mol:

HbA1c values

 

HbA1c for diagnosis of diabetes mellitus

 

HbA1c diagnosis 2