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The Diabetes Forum - find support, ask questions and share your experiences with 209,001 people. 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 authors also take issue with the lack of practising diabetologists on NICE's consultation committee, a decision made to avoid conflicts of interest. 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.
There is also disagreement as to the use of sulphonylureas as a second-line treatment because of its relatively low cost. O'Hare added: "Primary-care doctors and nurses, in particular, are struggling to look after growing numbers of patients with type 2 diabetes. Find support, ask questions and share your experiences with 209,001 members of the diabetes community.
10 week (free) low-carb education program developed with the help of 20,000 people with T2D and based on the latest research. The first comprehensive, free and open to all online step-by-step guide to improving hypo awareness. Diet, exercise, and education remain the foundation of any type 2 diabetes treatment program. Ultimately, many patients will require insulin therapy alone or in combination with other agents to maintain glucose control. The American Diabetes Association and the European Association for the Study of Diabetes have updated guidelines on the management of hyperglycemia in nonpregnant adults with type 2 diabetes. The novel position statement on the management of hyperglycemia in type 2 diabetes was necessary because since the last similar treatment algorithm, which is more than 3 years old, a lot of new insights have been generated that required an update. According to the ADA, to reduce the incidence of macrovascular disease, HbA1c should be lowered to less than 7% in most patients.
For strong recommendations in favour (or against) certain diabetes medications, the evidence is not strong enough; choices and preferences will differ with different patients, their characteristics and attitudes.
Several therapeutic options were discussed, including lifestyle interventions to change physical activity levels and food intake; oral agents and noninsulin injectables, as well as insulin.

The second step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-1) receptor agonist, it can be a thiazolidinedione, it can be a sulfonylurea agent, or it could be basal insulin. If a patient needs a more intensive insulin regimen, then it is recommended to add 1 or 2 - maybe even 3 - doses of mealtime insulin. The position statement lists all commonly used medications with all their properties (positive and negative), and gives all the information to make good choices based on priorities (ie, avoiding hypoglycemia at all costs) and preferences. Overall, comparative evidence for antihyperglycemic treatment of type 2 diabetes is lacking, and there is a considerable need for high-quality, comparative-effectiveness research on costs and outcomes important to patients, including quality of life and the avoidance of life-limiting complications such as cardiovascular disease. Because of the rapid change in lifestyle in China, there is concern that diabetes may become epidemic.
A nationally representative sample of 46,239 adults, 20 years of age or older, from 14 provinces and municipalities participated in the study.
These results indicate that diabetes has become a major public health problem in China and that strategies aimed at the prevention and treatment of diabetes are needed.
In an editorial comment in the European Heart Journal, some opinion leaders indicate what might be the reasons for the failure of the dal-HEART programme.Both the on-treatment vascular effects and the underlying molecular mechanism causing increased HDL-c are important in determining the vascular effects of an HDL-c raising therapy. The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study assessed how to manage diabetes in children and adolescents. The China National Survey of Chronic Kidney disease was a cross-sectional study to evaluate the prevalence of CKD and associated factors in Chinese adults between 2007 and 2010.CKD has become an important public health issue in China, maybe as a consequence of increased diabetes and hypertension.
DPP-4 inhibitors can be used as second line treatment in patients with type 2 diabetes who do not achieve their glycaemic targets with metformin alone. The study was set up to determine all cause mortality and deaths from cardiovascular events related to intensive glucose lowering treatment in people with type 2 diabetes. In GPRD data, current use of sulphonylureas only (with active or inactive metabolites) was associated with an increased risk of hypoglycaemic events, as compared with current use of metformin.
Recent outcome trials of novel antidiabetic drugs shed new light on why diabetes patients develop heart disease. Out of 18 biomarkers, Lp-PLA2 and adiponectin were independently associated with a decreased risk for T2DM. In females with gestational diabetes, the future risk of developing type 2 diabetes depends on certain pregnancy-related and maternal factors that could be used for postnatal counselling. The guidelines, which were originally published in January, recommend the use of metformin first, followed by older drugs as second-line therapy. 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.
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.

But J Paul O'Hare, FRCP, who authored the letter with colleagues, believes the revision failed to address the most significant criticisms. 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.
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. Combination therapy with an additional 1–2 oral or injectable agents is reasonable, aiming to minimize side effects where possible. The update is based on new evidence of risks and benefits of glycemic control, evidence on safety and efficacy of new drug classes, the withdrawal and restriction of other drug classes and the increasing need for a more patient-centered approach to care. However, data from type 2 diabetes cardiovascular trials have demonstrated that not all patients benefit from aggressive glucose maintenance, again pointing toward a more individualized approach to treatment.
In contrast to previous statements, the present one is based on a patient-centered approach. According to the guidelines, when it comes to prescribing oral agents and noninsulin injectables, agent- and patient-specific properties, such as dosing frequency, side effect profiles, cost and other benefits, are often used to guide drug selection. Anticipated glucose-lowering effects should be balanced with the convenience of the regimen, in the context of an individual’s specific therapy goals. We conducted a national study from June 2007 through May 2008 to estimate the prevalence of diabetes among Chinese adults. In reality, they argue, treatment using older drugs may not turn out to be cheaper after all. This decision should in fact be made based on a number of factors particular to individual patients, the letter suggests.
The authors recommend combination therapy with the addition of one to two oral or injectable agents, with the goal of reducing side effects when possible. The prevalence of diabetes was higher among urban residents than among rural residents (11.4% vs. Insulin therapy, whether alone or in combination, will ultimately be required to maintain glucose control for many patients.
The prevalence of isolated impaired glucose tolerance was higher than that of isolated impaired fasting glucose (11.0% vs.

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