GLP-1 Receptor Agonists in T2DM -- Guidelines vs Practice
GLP-1 Receptor Agonists in T2DM -- Guidelines vs Practice
The NICE guidelines for the use of diabetes therapies serve an important purpose of recommending use of treatments that are evidence-based and cost-effective. This is particularly pertinent in an era of rising healthcare costs. However, in their present form, the NICE guidelines for GLP-1ras essentially prevent their use in patients with more advanced diabetes who still requireeffective treatment. Specifically:
Conclusions and Recommendations
The NICE guidelines for the use of diabetes therapies serve an important purpose of recommending use of treatments that are evidence-based and cost-effective. This is particularly pertinent in an era of rising healthcare costs. However, in their present form, the NICE guidelines for GLP-1ras essentially prevent their use in patients with more advanced diabetes who still requireeffective treatment. Specifically:
More clinical trials and cost-effectiveness analyses are needed in obese patients with more advanced diabetes. The issue is not the comparative costs of third line diabetes treatment, but that of the comparative costs and effectiveness in patients already on third line therapy who require treatment intensification (such as by escalating insulin doses or using a GLP-1ra). Creative solutions such as an agreement to combine cheaper human insulin with a GLP-1ra could be explored, but requires considerations of the potential disadvantages of older insulins compared with insulin analogues.
The addition of a GLP-1ra to three oral antidiabetic drugs was as effective as adding a GLP-1ra to one or two drugs, thus the escalation to GLP-1ra rather than insulin should be considered a viable treatment algorithm among patients on three oral antidiabetic drugs.
Due to the risk of glycaemic deterioration we would caution clinicians against substituting concurrent diabetes treatment to appear to adhere to guidelines when a GLP-1ra is started.
The general requirement by NICE for BMI to be >35 kg/m is not strictly evidenced-based. This strategy to improve cost-effectiveness may be counter-productive if glycaemic improvement is diminished in more obese patients.
Few patients also meet the criteria for continuing GLP-1ra therapy. We propose that patients who achieved significant HbA1c reduction but not weight reduction be allowed to continue GLP-1ra treatment.
The NICE criterion of ≥1% HbA1c reduction as a requirement for continued GLP-1ra treatment unfairly favours patients with higher baseline HbA1c. This should be replaced by a target HbA1c reduction that is indexed to an individual's baseline HbA1c.