Shared decision-making in type 2 diabetes Gill Eddy and Michelle Liddy Regional technical advisers, NICE medicines and prescribing programme Full title: Type 2 diabetes in adults: management Available at: http://www.nice.org.uk/guidance/ng28 This slide set is for the use of NICE Medicines and Prescribing Associates. As such, it concentrates on key prescribing and medicines optimisation issues selected by the MPC: see the guideline/evidence summary for full information about other aspects of care. June 2016

What we’re going to cover Quiz – have you read the guideline? NICE guideline NG28: Type 2 diabetes in adults (published December 2015) Focus on key medicines optimisation issues from the guideline Individualised care Patient education HbA1c monitoring Drug treatment ‘Do not do’ recommendations Resources to help with shared decision making Sub-sections of the blood glucose management section

NICE guideline NG28: Type 2 diabetes in adults Updates and replaces NICE guidelines CG87 and CG66 (previous T2DM guidance) NICE TA248 (exenatide prolonged-release suspension) NICE TA203 (liraglutide) Not all recommendations have been updated Areas for update were prioritised through stakeholder feedback NICE is currently considering setting up a standing update committee to enable more rapid update of discrete areas This slide set is an implementation tool and should be used alongside the published guidance. It does not supersede or replace the guidance itself See the guideline for full recommendations All slides refer to the NICE guideline unless otherwise stated Disclaimer: These resources are implementation tools and should be used alongside the published guidance. The information does not supersede or replace the guidance itself. This slide set is for the use of NICE Medicines and Prescribing Associates. As such it concentrates on key prescribing and medicines optimisation issues: see the guideline for full information about other aspects of care. See http://www.nice.org.uk/guidance/ng28/chapter/Update-information This guidance updates and replaces NICE guideline CG87 (published May 2009). It also updates and replaces NICE technology appraisal guidance 203 and NICE technology appraisal guidance 248. It has not been possible to update all recommendations in this update of the guideline. Areas for review and update were identified and prioritised through the scoping process and stakeholder feedback. Areas that have not been reviewed in this update may be addressed in 2 years' time when NICE next considers updating this guideline. NICE is currently considering setting up a standing update committee for diabetes, which would enable more rapid update of discrete areas of the diabetes guidelines, as and when new and relevant evidence is published. Reasons for the update: http://www.nice.org.uk/guidance/ng28/chapter/Introduction#reasons-for-the-update Since the publication of the 2009 guideline, availability of new evidence and several key developments have prompted an update in the following areas: managing blood glucose levels, antiplatelet therapy and erectile dysfunction. In particular, reasons included safety concerns surrounding some blood glucose lowering medicines, new evidence on new dipeptidyl peptidase‑4 (DPP‑4) inhibitors and glucagon‑like peptide‑1 (GLP‑1) receptor agonists, new indications and licensed combinations for licensed class members and the potential impact of drugs coming off patent on health‑economic issues. In addition, new evidence and safety issues relating to the off‑label use of antiplatelet therapy (aspirin and clopidogrel) in the primary prevention of cardiovascular disease motivated an update of this review.

‘Offer’ and ‘consider’ People have the right to be involved in discussions and make informed decisions about their care Take into account the person’s needs and preferences Explain the treatment and care in a way the person understands Some recommendations are made with more certainty than others. We word our recommendations to reflect this We use 'offer' [or similar words] to reflect a strong recommendation, usually where there is clear evidence of benefit We use 'consider' to reflect a recommendation for which the evidence of benefit is less certain See: https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/making-decisions-using-nice-guidelines

Quiz questions 1 – 4

Question 1 The guideline has fully updated NICE guidance on management of hypertension in people with type 2 diabetes True False All reference to ‘the guideline’ are to the 2015 type 2 diabetes guideline NG28, unless otherwise stated. For some questions there is not a ‘right’ answer: this is intended to stimulate discussion. The guideline has fully updated NICE guidance on management of hypertension in people with type 2 diabetes True False All recommendations are retained from the 2009 guideline, CG87, with the addition of a new one (1.4.11 Do not combine an ACE inhibitor with an angiotensin II‑receptor antagonist to treat hypertension), so they are effectively the same as CG66, 2008 (because CG87, 2009 did not look at the BP recommendations either). One other recommendation has been modified (If the person's blood pressure is not reduced to the individually agreed target with first‑line therapy, add a calcium‑channel blocker or a diuretic [usually a thiazide or thiazide‑related diuretic]. Add the other drug [that is, the calcium‑channel blocker or diuretic] if the target is not reached with dual therapy). The previous version said ‘…add a calcium-channel blocker or a diuretic [usually bendroflumethiazide, 2.5 mg daily]….

Question 1 – answer The guideline has fully updated NICE guidance on management of hypertension in people with type 2 diabetes True False All recommendations are retained from the 2009 guideline, CG87, with the addition of a new one (1.4.11 Do not combine an ACE inhibitor with an angiotensin II‑receptor antagonist to treat hypertension) All reference to ‘the guideline’ are to the 2015 type 2 diabetes guideline NG28, unless otherwise stated. For some questions there is not a ‘right’ answer: this is intended to stimulate discussion. The guideline has fully updated NICE guidance on management of hypertension in people with type 2 diabetes True False All recommendations are retained from the 2009 guideline, CG87, with the addition of a new one (1.4.11 Do not combine an ACE inhibitor with an angiotensin II‑receptor antagonist to treat hypertension), so they are effectively the same as CG66, 2008 (because CG87, 2009 did not look at the BP recommendations either). One other recommendation has been modified (If the person's blood pressure is not reduced to the individually agreed target with first‑line therapy, add a calcium‑channel blocker or a diuretic [usually a thiazide or thiazide‑related diuretic]. Add the other drug [that is, the calcium‑channel blocker or diuretic] if the target is not reached with dual therapy). The previous version said ‘…add a calcium-channel blocker or a diuretic [usually bendroflumethiazide, 2.5 mg daily]….

Question 2 The recommendations on blood pressure thresholds, targets and stepwise drug treatment for people with type 2 diabetes are broadly similar to those for the general population (CG127) Strongly agree Agree Disagree Strongly disagree blocker or a diuretic [usually bendroflumethiazide, 2.5 mg daily]…. The recommendations on blood pressure thresholds, targets and stepwise drug treatment for people with type 2 diabetes are broadly similar to those for the general population (CG127) Strongly agree Agree – but picking this as the best answer might be controversial Disagree Strongly disagree The target for people with type 2 diabetes is <140/80 mmHg (<130/80 mmHg if there is kidney, eye or cerebrovascular damage). The target in the general population is <140/90 mmHg (<150/90 mmHg in people aged ≥90 years). First step treatment for most people in both is an ACE-I (ARB is an equal choice in CG127), but in CG127 a CCB alone is recommended for first step in people >55 years and people of African or Caribbean family origin of any age, whereas in NG28 first step is an ACE-I plus either diuretic or generic calcium channel blocker (CCB) in people of African or Caribbean family origin. See guideline for full details Aim for a target clinic blood pressure below 140/90 mmHg See guideline for targets in people aged 80 years and older and/or with ‘white coat’ effect Step 1: ACE inhibitor or angiotensin II receptor antagonist (ARB) Use a calcium-channel blocker (CCB) in people over 55 years of age and people of African or Caribbean family origin of any age Step 2: CCB plus ACE inhibitor or ARB Use a thiazide-like diuretic if CCB not suitable Step 3: CCB plus thiazide-like diuretic plus ACE inhibitor or ARB Step 4: see guideline

Question 2 – answer The recommendations on blood pressure thresholds, targets and stepwise drug treatment for people with type 2 diabetes are broadly similar to those for the general population (CG127) Strongly agree Agree (but this might be a controversial choice) Disagree Strongly disagree blocker or a diuretic [usually bendroflumethiazide, 2.5 mg daily]…. The recommendations on blood pressure thresholds, targets and stepwise drug treatment for people with type 2 diabetes are broadly similar to those for the general population (CG127) Strongly agree Agree – but picking this as the best answer might be controversial Disagree Strongly disagree The target for people with type 2 diabetes is <140/80 mmHg (<130/80 mmHg if there is kidney, eye or cerebrovascular damage). The target in the general population is <140/90 mmHg (<150/90 mmHg in people aged ≥90 years). First step treatment for most people in both is an ACE-I (ARB is an equal choice in CG127), but in CG127 a CCB alone is recommended for first step in people >55 years and people of African or Caribbean family origin of any age, whereas in NG28 first step is an ACE-I plus either diuretic or generic calcium channel blocker (CCB) in people of African or Caribbean family origin. See guideline for full details Aim for a target clinic blood pressure below 140/90 mmHg See guideline for targets in people aged 80 years and older and/or with ‘white coat’ effect Step 1: ACE inhibitor or angiotensin II receptor antagonist (ARB) Use a calcium-channel blocker (CCB) in people over 55 years of age and people of African or Caribbean family origin of any age Step 2: CCB plus ACE inhibitor or ARB Use a thiazide-like diuretic if CCB not suitable Step 3: CCB plus thiazide-like diuretic plus ACE inhibitor or ARB Step 4: see guideline

Blood pressure management (1) Recommendations 1.4.1–1.4.2 Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease Offer and reinforce preventive lifestyle advice For people on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and medications used Make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-pressure-management-2 T2DM = type 2 diabetes 1.4 Blood pressure management 1.4.1 Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice. [2009] 1.4.2 For an adult with type 2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and medications used. Make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems. [2009]

Blood pressure management (2) Recommendations 1.4.3–1.4.6 Repeat blood pressure measurements within: 1 month if blood pressure is higher than 150/90 mmHg 2 months if blood pressure is higher than 140/80 mmHg 2 months if blood pressure is higher than 130/80 mmHg and there is kidney, eye or cerebrovascular damage Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg below 130/80 mmHg if there is kidney, eye or cerebrovascular damage Monitor blood pressure every 1–2 months, and intensify therapy until the blood pressure is consistently below these levels See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-pressure-management-2 1.4.3 Repeat blood pressure measurements within: 1 month if blood pressure is higher than 150/90 mmHg 2 months if blood pressure is higher than 140/80 mmHg 2 months if blood pressure is higher than 130/80 mmHg and there is kidney, eye or cerebrovascular damage. Provide lifestyle advice (diet and exercise) at the same time. [2009] 1.4.4 Provide lifestyle advice (see section 1.3 in this guideline and the lifestyle interventions section in ‘Hypertension in adults’ [NICE guideline CG127]) if blood pressure is confirmed as being consistently above 140/80 mmHg (or above 130/80 mmHg if there is kidney, eye or cerebrovascular damage). [2009] 1.4.5 Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage). [2009] 1.4.6 Monitor blood pressure every 1–2 months, and intensify therapy if the person is already on antihypertensive drug treatment, until the blood pressure is consistently below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage). [2009]

Blood pressure management (3) Recommendations 1.4.7–1.4.11 First-line antihypertensive drug treatment should be a once daily, generic angiotensin converting enzyme (ACE) inhibitor Exceptions: ACE inhibitor plus either diuretic or generic calcium channel blocker in people of African or Caribbean family origin Calcium channel blocker for women who might become pregnant Change to an angiotensin II receptor antagonist (ARB) in people with continuing intolerance to an ACE inhibitor (other than renal deterioration or hyperkalaemia) Do not combine an ACE inhibitor with an angiotensin II receptor antagonist to treat hypertension See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-pressure-management-2 ACE =angiotensin converting enzyme CCB = calcium-channel blocker ARB = angiotensin II receptor antagonist 1.4.7 First-line antihypertensive drug treatment should be a once daily, generic angiotensin converting enzyme (ACE) inhibitor. Exceptions to this are people of African or Caribbean family origin, or women for whom there is a possibility of becoming pregnant. [2009] 1.4.8 The first-line antihypertensive drug treatment for a person of African or Caribbean family origin should be an ACE inhibitor plus either a diuretic or a generic calcium channel blocker. [2009] 1.4.9 A calcium-channel blocker should be the first line antihypertensive drug treatment for a woman for whom, after an informed discussion, it is agreed there is a possibility of her becoming pregnant. [2009] 1.4.10 For a person with continuing intolerance to an ACE inhibitor (other than renal deterioration or hyperkalaemia), substitute an angiotensin II receptor antagonist for the ACE inhibitor. [2009] 1.4.11 Do not combine an ACE inhibitor with an angiotensin II receptor antagonist to treat hypertension. [new 2015]

Blood pressure management (4) Recommendations 1.4.12–1.4.14 If the person’s blood pressure is not reduced to the individually agreed target with first line therapy: add a calcium channel blocker or a diuretic (usually a thiazide or thiazide-related diuretic) if the target is not reached with dual therapy, add the other drug (calcium channel blocker or diuretic) if the target is not reached with triple therapy, add an alpha blocker, a beta blocker or a potassium-sparing diuretic Once the person’s target is consistently attained, measure their blood pressure target every 4–6 months Check for possible adverse effects of drug treatment, including the risks from unnecessarily low blood pressure See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-pressure-management-2 CCB = calcium-channel blocker 1.4.12 If the person’s blood pressure is not reduced to the individually agreed target with first line therapy, add a calcium channel blocker or a diuretic (usually a thiazide or thiazide related diuretic). Add the other drug (that is, the calcium channel blocker or diuretic) if the target is not reached with dual therapy. [2009, amended 2015] 1.4.13 If the person’s blood pressure is not reduced to the individually agreed target with triple therapy, add an alpha blocker, a beta blocker or a potassium sparing diuretic (the last with caution if the person is already taking an ACE inhibitor or an angiotensin II receptor antagonist). [2009] 1.4.14 Monitor the blood pressure of a person who has attained and consistently remained at his or her blood pressure target every 4–6 months. Check for possible adverse effects of antihypertensive drug treatment – including the risks from unnecessarily low blood pressure. [2009]

NICE guidance on hypertension: reminder CG127, 2011 See guideline for full details Aim for a target clinic blood pressure below 140/90 mmHg See guideline for targets in people aged 80 years and older and/or with ‘white coat’ effect Step 1: ACE inhibitor or angiotensin II receptor antagonist (ARB) Use a calcium-channel blocker (CCB) in people over 55 years of age and people of African or Caribbean family origin of any age Step 2: CCB plus ACE inhibitor or ARB Use a thiazide-like diuretic if CCB not suitable Step 3: CCB plus thiazide-like diuretic plus ACE inhibitor or ARB Step 4: see guideline See http://www.nice.org.uk/guidance/cg127/chapter/1-Guidance#initiating-and-monitoring-antihypertensive-drug-treatment-including-blood-pressure-targets-2 ACE =angiotensin converting enzyme CCB = calcium-channel blocker ARB = angiotensin II receptor antagonist This is a summary only, to compare and contrast with the guidance for people with type 2 diabetes. See the NICE hypertension guideline for full details, sections 1.5-1.6 The target BP is slightly different: below 140/80 mmHg in people with diabetes (and no kidney, eye or cerebrovascular damage) compared with below 140/90 mmHg in the general population (aged less than 80 years). Drug treatments are also different Note that people with diabetes were not in the scope of the hypertension guideline: see http://www.nice.org.uk/guidance/cg127/chapter/2-Notes-on-the-scope-of-the-guidance

Question 3 NICE guidance for the general population about risk assessment and reduction for cardiovascular disease, including lipid modification, applies equally to people with type 2 diabetes True False NICE guidance for the general population about risk assessment and reduction for cardiovascular disease, including lipid modification, apply equally to people with type 2 diabetes True False Recommendation 1.5.2 says ‘For guidance on the primary and secondary prevention of cardiovascular disease in adults with type 2 diabetes, see the NICE guidelines on cardiovascular disease and myocardial infarction

Question 3 – answer NICE guidance for the general population about risk assessment and reduction for cardiovascular disease, including lipid modification, applies equally to people with type 2 diabetes True False Recommendation 1.5.2 states: For guidance on the primary and secondary prevention of cardiovascular disease in adults with type 2 diabetes, see the NICE guidelines on Cardiovascular disease: risk assessment and reduction, including lipid modification (CG181) Myocardial infarction: cardiac rehabilitation and prevention of further MI (CG172) NICE guidance for the general population about risk assessment and reduction for cardiovascular disease, including lipid modification, apply equally to people with type 2 diabetes True False Recommendation 1.5.2 says ‘For guidance on the primary and secondary prevention of cardiovascular disease in adults with type 2 diabetes, see the NICE guidelines on cardiovascular disease and myocardial infarction

Question 4 NICE no longer recommends aspirin for primary prevention of cardiovascular disease in people with type 2 diabetes but clopidogrel for this indication is a ‘consider’ option, on health economic grounds, because of its low acquisition cost and lower risk of haemorrhage than aspirin True False NICE no longer recommends aspirin for primary prevention of cardiovascular disease in people with type 2 diabetes but clopidogrel for this indication is a ‘consider’ option, on health economic grounds, because of its low acquisition cost and lower risk of haemorrhage than aspirin True False Recommendation 1.5.1 says ‘Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.’ The full guideline (p 97) states ‘Although it was acknowledged that the review only identified studies on aspirin, the GDG considered that the [do not do] recommendation should be extended to include all off-label use of antiplatelet therapy, because it had seen no evidence of the effectiveness and safety of other drugs… ...The GDG discussed the possibility of making no recommendation on the use of clopidogrel; however, the concern was expressed that, when set against the ‘do not do’ recommendation for aspirin, this might be read as tacit approval of clopidogrel, which the GDG wanted to avoid.’

Question 4 – answer NICE no longer recommends aspirin for primary prevention of cardiovascular disease in people with type 2 diabetes but clopidogrel for this indication is a ‘consider’ option, on health economic grounds, because of its low acquisition cost and lower risk of haemorrhage than aspirin True False Recommendation 1.5.1 states: Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease NICE no longer recommends aspirin for primary prevention of cardiovascular disease in people with type 2 diabetes but clopidogrel for this indication is a ‘consider’ option, on health economic grounds, because of its low acquisition cost and lower risk of haemorrhage than aspirin True False Recommendation 1.5.1 says ‘Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease.’ The full guideline (p 97) states ‘Although it was acknowledged that the review only identified studies on aspirin, the GDG considered that the [do not do] recommendation should be extended to include all off-label use of antiplatelet therapy, because it had seen no evidence of the effectiveness and safety of other drugs… ...The GDG discussed the possibility of making no recommendation on the use of clopidogrel; however, the concern was expressed that, when set against the ‘do not do’ recommendation for aspirin, this might be read as tacit approval of clopidogrel, which the GDG wanted to avoid.’

Question 5a The following paragraphs (questions 5a and 5b) summarise NICE guidance on blood glucose (HbA1c) targets and drug therapy for most people. Fill in the blanks: If the person’s HbA1c rises to __ mmol/mol (__%) with lifestyle interventions alone, offer metformin or, if this is contraindicated or not tolerated, _______or _______ or _______. Support the person to aim for an HbA1c level of __ mmol/mol (__%), or __ mmol/mol (__%) if they are taking a sulfonylurea. The following paragraph summarises NICE guidance on blood glucose (HbA1c) targets for most people and intensification of drug therapy. Fill in the missing words: If the person’s HbA1c rises to 48 mmol/mol (6.5%) with lifestyle interventions alone, offer metformin or, if this is contraindicated or not tolerated, a DPP4 inhibitor or pioglitazone or a sulfonylurea. Support the person to aim for an HbA1c level of 48 mmol/mol (6.5%), or 53 mmol/mol (7.0%) if they are taking a sulfonylurea. If their HbA1c level rises to 58 mmol/mol (7.5%) or higher, reinforce advice about diet, lifestyle and adherence to drug treatment; support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment by adding a second drug. If their HbA1c level continues to rise to 58 mmol/mol (7.5%) or higher, consider adding add a third oral drug, changing to insulin-based treatment, or (in certain circumstances) combination therapy with metformin, a sulfonylurea and a GLP-1 mimetic. .

Question 5a – answers The following paragraphs (questions 5a and 5b) summarise NICE guidance on blood glucose (HbA1c) targets and drug therapy for most people. Fill in the blanks: If the person’s HbA1c rises to 48 mmol/mol (6.5%) with lifestyle interventions alone, offer metformin or, if this is contraindicated or not tolerated, a DPP4 inhibitor or pioglitazone or a sulfonylurea. Support the person to aim for an HbA1c level of 48 mmol/mol (6.5%), or 53 mmol/mol (7.0%) if they are taking a sulfonylurea. The following paragraph summarises NICE guidance on blood glucose (HbA1c) targets for most people and intensification of drug therapy. Fill in the missing words: If the person’s HbA1c rises to 48 mmol/mol (6.5%) with lifestyle interventions alone, offer metformin or, if this is contraindicated or not tolerated, a DPP4 inhibitor or pioglitazone or a sulfonylurea. Support the person to aim for an HbA1c level of 48 mmol/mol (6.5%), or 53 mmol/mol (7.0%) if they are taking a sulfonylurea.

Question 5b If their HbA1c level rises to __ mmol/mol (__%) or higher, reinforce advice about diet, lifestyle and adherence to drug treatment; support the person to aim for an HbA1c level of __ mmol/mol (__%) and intensify drug treatment by adding a second drug. If their HbA1c level continues to rise to __ mmol/mol (__%) or higher, consider adding add a third oral drug, changing to ____________, or (in certain circumstances) combination therapy with ___________, __________ and __________. If their HbA1c level rises to 58 mmol/mol (7.5%) or higher, reinforce advice about diet, lifestyle and adherence to drug treatment; support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment by adding a second drug. If their HbA1c level continues to rise to 58 mmol/mol (7.5%) or higher, consider adding add a third oral drug, changing to insulin-based treatment, or (in certain circumstances) combination therapy with metformin, a sulfonylurea and a GLP-1 mimetic.

Question 5b – answers If their HbA1c level rises to 58 mmol/mol (7.5%) or higher, reinforce advice about diet, lifestyle and adherence to drug treatment; support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment by adding a second drug. If their HbA1c level continues to rise to 58 mmol/mol (7.5%) or higher, consider adding add a third oral drug, changing to insulin-based treatment, or (in certain circumstances) combination therapy with metformin, a sulfonylurea and a GLP-1 mimetic. If their HbA1c level rises to 58 mmol/mol (7.5%) or higher, reinforce advice about diet, lifestyle and adherence to drug treatment; support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment by adding a second drug. If their HbA1c level continues to rise to 58 mmol/mol (7.5%) or higher, consider adding add a third oral drug, changing to insulin-based treatment, or (in certain circumstances) combination therapy with metformin, a sulfonylurea and a GLP-1 mimetic.

HbA1c targets (1) Recommendations 1.6.5–1.6.6 Involve adults with T2DM in decisions about their individual HbA1c target. Encourage them to achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life Offer lifestyle advice and drug treatment to support adults with T2DM to achieve and maintain their HbA1c target (see section 1.3: dietary advice) For more information about supporting adherence, see the NICE guideline on medicines adherence (CG76) See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-glucose-management-2 T2DM = type 2 diabetes Targets 1.6.5 Involve adults with type 2 diabetes in decisions about their individual HbA1c target. Encourage them to achieve the target and maintain it unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target, impair their quality of life. [new 2015] 1.6.6 Offer lifestyle advice and drug treatment to support adults with type 2 diabetes to achieve and maintain their HbA1c target (see section 1.3). For more information about supporting adherence, see the NICE guideline on medicines adherence http://www.nice.org.uk/guidance/cg76. [new 2015]

HbA1c targets (2) Recommendations 1.6.7–1.6.8 For adults whose T2DM is managed by lifestyle and diet, or by lifestyle and diet combined with a single drug Support the person to aim for an HbA1c level of 48 mmol/mol (6.5%) Support people on a drug associated with hypoglycaemia to aim for an HbA1c level of 53 mmol/mol (7.0%) If HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher: reinforce advice about diet, lifestyle and adherence to drug treatment and support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-glucose-management-2 T2DM = type 2 diabetes Targets 1.6.7 For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%). [new 2015] 1.6.8 In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher: reinforce advice about diet, lifestyle and adherence to drug treatment and support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and intensify drug treatment. [new 2015]

HbA1c targets (3) Recommendation 1.6.9 Consider relaxing the target HbA1c level on a case‑by‑case basis, with particular consideration for people who are older or frail, in people who are unlikely to achieve longer‑term risk‑reduction benefits, for example, people with a reduced life expectancy for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job for whom intensive management would not be appropriate, for example, people with significant comorbidities See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-glucose-management-2 Targets 1.6.9 Consider relaxing the target HbA1c level (see recommendations 1.6.7 and 1.6.8) on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes: who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job for whom intensive management would not be appropriate, for example, people with significant comorbidities. [new 2015]

Question 6 Marjorie (72 years old) diagnosed type 2 diabetes 2011 Angina and moderate COPD (stopped smoking 2012); has had exacerbations but no hospital admissions BMI 28 kg/m2, BP 143/88 mmHg HbA1c level has risen to 62 mmol/mol (7.8%). She has negligible diabetes symptoms Takes ramipril 10 mg, amlodipine 10  mg, atorvastatin 40 mg aspirin 75 mg and tiotropium inhaler 18 micrograms all once a day, metformin 1 g twice a day, plus salbutamol PRN Main carer for her husband, Jack (aged 79 years), who has moderate dementia. They live in a village with a limited bus service but Marjorie drives them both where they need to go What factors are likely to be important when she and her diabetes team discuss her target HbA1c level and whether/how to intensify her treatment? Marjorie (aged 72 years) was diagnosed with type 2 diabetes 5 years ago. She has angina and moderate COPD (but stopped smoking 4 years ago) and has had exacerbations but not needed admission to hospital. She uses tiotropium inhaler 18 micrograms once daily and salbutamol as required. Her blood pressure is 143/88 mmHg on ramipril and amlodipine (both 10 mg daily), she takes atorvastatin 40 mg daily; her BMI is 28 kg/m2. She is the main carer for her husband, Jack (aged 79 years) who has moderate dementia. They live in a village with a limited bus service but Marjorie drives them both where they need to go. She has been taking metformin tablets 1 g twice a day since diagnosis, but her HbA1c level has risen to 62 mmol/mol (7.8%). She has negligible diabetes symptoms. What factors are likely to be important when she and her diabetes team discuss her target HbA1c level and whether/how to intensify her treatment? We’d want to discuss her priorities (probably looking after Jack will be high among them). What are the implications for her of an increased risk of hypos? (would hypos affect her ability to look after Jack? What are the implications for driving?). Realistically, what is her life expectancy – can she expect to see long term health benefits? How does she feel about taking more medicines?

Individualised care Recommendations 1.1.1 and 1.1.2 Adopt an individualised approach to diabetes care that is tailored to the person’s needs and circumstances, taking into account their personal preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long term interventions because of reduced life expectancy Such an approach is especially important in the context of multimorbidity Reassess the person’s needs and circumstances at each review and think about whether to stop any medicines that are not effective Take into account any disabilities, including visual impairment, when planning and delivering care See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#individualised-care 1.1 Individualised care 1.1.1 Adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of adults with type 2 diabetes, taking into account their personal preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long term interventions because of reduced life expectancy. Such an approach is especially important in the context of multimorbidity. Reassess the person’s needs and circumstances at each review and think about whether to stop any medicines that are not effective. [new 2015] 1.1.2 Take into account any disabilities, including visual impairment, when planning and delivering care for adults with type 2 diabetes. [new 2015]

Question 7 NICE guideline recommends against routinely offering self- monitoring of blood glucose (SMBG) for adults with type 2 diabetes. Which of the following is not given in the NICE guideline as a reason when SMBG should be offered? the person is on insulin there is evidence of hypoglycaemic episodes the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery as part of a structured education programme the person is pregnant, or is planning to become pregnant The NICE guideline recommends against routinely offering self-monitoring of blood glucose (SMBG) for adults with type 2 diabetes. Which of the following is not given in the NICE guideline as a reason when SMBG should be offered? the person is on insulin there is evidence of hypoglycaemic episodes the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery as part of a structured education programme the person is pregnant, or is planning to become pregnant see recommendations 1.6.13 and 1.6.14 (and section 1.2: patient education and section 1.3: dietary advice)

Question 7 – answer NICE guideline recommends against routinely offering self- monitoring of blood glucose (SMBG) for adults with type 2 diabetes. Which of the following is not given in the NICE guideline as a reason when SMBG should be offered? the person is on insulin there is evidence of hypoglycaemic episodes the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery as part of a structured education programme the person is pregnant, or is planning to become pregnant see recommendations 1.6.13 and 1.6.14 (and section 1.2: patient education and section 1.3: dietary advice) The NICE guideline recommends against routinely offering self-monitoring of blood glucose (SMBG) for adults with type 2 diabetes. Which of the following is not given in the NICE guideline as a reason when SMBG should be offered? the person is on insulin there is evidence of hypoglycaemic episodes the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery as part of a structured education programme the person is pregnant, or is planning to become pregnant see recommendations 1.6.13 and 1.6.14 (and section 1.2: patient education and section 1.3: dietary advice)

Question 8 The DVLA requires all people with type 2 diabetes who hold a Group 1 (car, motorcycle) license and who are taking a sulfonylurea to monitor their blood glucose at least twice daily and at times relevant to driving True False The DVLA requires all people with type 2 diabetes who hold a Group 1 (car, motorcycle) license and who are taking a sulfonylurea to monitor their blood glucose at least twice daily and at times relevant to driving True False This is the requirement for holders of Group 2 (lorry/ bus) licences. The recommendation for Group 1 license holders is ‘It may be appropriate to monitor blood glucose (depending on clinical factors including frequency of driving) at times relevant to driving to enable the detection of hypoglycaemia.’ See www.gov.uk/government/publications/at-a-glance, chapter 3

Question 8 – answer The DVLA requires all people with type 2 diabetes who hold a Group 1 (car, motorcycle) license and who are taking a sulfonylurea to monitor their blood glucose at least twice daily and at times relevant to driving True False This is the requirement for holders of Group 2 (lorry/ bus) licences. The recommendation for Group 1 license holders is ‘It may be appropriate to monitor blood glucose (depending on clinical factors including frequency of driving) at times relevant to driving to enable the detection of hypoglycaemia.’ See Assessing fitness to drive - a guide for medical professionals The DVLA requires all people with type 2 diabetes who hold a Group 1 (car, motorcycle) license and who are taking a sulfonylurea to monitor their blood glucose at least twice daily and at times relevant to driving True False This is the requirement for holders of Group 2 (lorry/ bus) licences. The recommendation for Group 1 license holders is ‘It may be appropriate to monitor blood glucose (depending on clinical factors including frequency of driving) at times relevant to driving to enable the detection of hypoglycaemia.’ See Assessing fitness to drive - a guide for medical professionals, chapter 3 (https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals).

Question 7 The guideline recommends that, if GLP-1 mimetic therapy is started, it should be continued only if the person has had a beneficial metabolic response. This is defined as either a reduction of at least 11 mmol/mol [1.0%] in HbA1c or a weight loss of at least 3% of initial body weight in 6 months. True False The guideline recommends that, if GLP-1 mimetic therapy is started, it should be continued only if the person has had a beneficial metabolic response. This is defined as either a reduction of at least 11 mmol/mol [1.0%] in HbA1c or a weight loss of at least 3% of initial body weight in 6 months. True False The requirement is for both criteria to be met. Page 256 of the full guideline makes this clear: ‘The GDG noted the ABCD audit which indicated that individuals on GLP-1s may show benefit from improvement in HbA1c levels and inadequate weight loss or inadequate improvement in HbA1c levels and adequate weight loss. However, the GDG agreed that, given the lack of cost effectiveness of GLP-1s demonstrated in the health economic modelling, the starting and stopping rules from CG87 should be retained.’

Question 7 – answer The guideline recommends that, if GLP-1 mimetic therapy is started, it should be continued only if the person has had a beneficial metabolic response. This is defined as either a reduction of at least 11 mmol/mol [1.0%] in HbA1c or a weight loss of at least 3% of initial body weight in 6 months. True False The requirement is for both criteria to be met: page 256 of the full guideline makes this clear The guideline recommends that, if GLP-1 mimetic therapy is started, it should be continued only if the person has had a beneficial metabolic response. This is defined as either a reduction of at least 11 mmol/mol [1.0%] in HbA1c or a weight loss of at least 3% of initial body weight in 6 months. True False The requirement is for both criteria to be met. Page 256 of the full guideline makes this clear: ‘The GDG noted the ABCD audit which indicated that individuals on GLP-1s may show benefit from improvement in HbA1c levels and inadequate weight loss or inadequate improvement in HbA1c levels and adequate weight loss. However, the GDG agreed that, given the lack of cost effectiveness of GLP-1s demonstrated in the health economic modelling, the starting and stopping rules from CG87 should be retained.’

Question 8 – fill in the blanks

Simplified blood glucose lowering pathway See the guideline algorithm for definitive guidance Metformin contraindicated Lifestyle interventions Initial drug therapy Metformin Initial drug therapy 1 of DPP-4i, pioglitazone, SU (or repaglinide) Metformin not tolerated First intensification Metformin + 1 of DPP-4i, pioglitazone, SU or SGLT-2i First intensification 2 of DPP-4i, pioglitazone, SU Second intensification Insulin-based treatment Note this is a simplified version of the blood glucose lowering therapy algorithm. Some clinical situations (such as symptomatic hyperglycaemia) and considerations (such as comorbidities, ethnicity, cost, occupation, and safety issues) have been omitted for simplicity. See the guideline algorithm for blood glucose lowering therapy for definitive guidance: http://www.nice.org.uk/guidance/ng28/resources DPP-4i =Dipeptidyl peptidase-4 inhibitor GLP-1 = Glucagon-like peptide-1 SGLT-2i = Sodium-glucose co-transporter - 2 SU = sulfonylurea Second intensification Metformin + SU + DPP-4i or pioglitazone or Metformin + SGLT-2i + SU or pioglitazone or Insulin-based treatment or Metformin + SU + GLP-1 mimetic (in specified circumstances) DPP-4i, dipeptidyl peptidase 4 inhibitor; GLP-1 mimetic, glucagon like peptide 1 mimetic; SGLT-2i, sodium–glucose cotransporter 2 inhibitor; SU, sulfonylurea

Algorithm for blood glucose lowering therapy www. nice. org Algorithm for blood glucose lowering therapy www.nice.org.uk/guidance/ng28/resources INSERT ALGORITHM This is too small to read here, but is given for illustration. A pdf of this algorithm is available at http://www.nice.org.uk/guidance/ng28/resources

Drug treatment Recommendation 1.6.17 Discuss the benefits and risks of drug treatment, and the options available. Base the choice of drug treatment(s) on: the effectiveness of the drug treatment(s) in terms of metabolic response safety (see Medicines and Healthcare products Regulatory Agency [MHRA] guidance) and tolerability of the drug treatment(s) the person’s individual clinical circumstances, for example, comorbidities, risks from polypharmacy the person’s individual preferences and needs the licensed indications or combinations available cost (if 2 drugs in the same class are appropriate, choose the option with the lowest acquisition cost) See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-glucose-management-2 MHRA = Medicines and Healthcare products Regulatory Agency Drug treatment 1.6.17 For adults with type 2 diabetes, discuss the benefits and risks of drug treatment, and the options available. Base the choice of drug treatment(s) on: the effectiveness of the drug treatment(s) in terms of metabolic response safety (see Medicines and Healthcare products Regulatory Agency [MHRA] guidance) and tolerability of the drug treatment(s) the person’s individual clinical circumstances, for example, comorbidities, risks from polypharmacy the person’s individual preferences and needs the licensed indications or combinations available Cost (if 2 drugs in the same class are appropriate, choose the option with the lowest acquisition cost) [new 2015]

Key medicines optimisation messages Emphasis on an individualised approach to care Patient education Limited role for self-monitoring of blood glucose Specific recommendation to involve the person in decisions about their individual HbA1c target Specific advice on when to relax HbA1c targets NICE patient decision aid to help discussions at first intensification Simpler 3-stage approach for blood glucose Metformin (still) to the fore Choice of treatments at each stage Detemir and glargine (but not degludec) as alternatives to NPH insulin in specified circumstances NPH insulin= Neutral Protamine Hagedorn insulin; an intermediate-acting insulin

Patient education Recommendations 1.2.1–1.2.6 Offer structured education to adults with type 2 diabetes (T2DM) and/or their family members or carers (as appropriate) at and around the time of diagnosis, with annual reinforcement and review Explain to people and their carers that structured education is an integral part of diabetes care Ensure that any structured education programme is evidence- based, and suits the needs of the person Offer group education programmes as the preferred option. Provide an alternative of equal standard for a person unable or unwilling to participate in group education See the guideline for further details See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#patient-education-2 T2DM = type 2 diabetes 1.2 Patient education 1.2.1 Offer structured education to adults with type 2 diabetes and/or their family members or carers (as appropriate) at and around the time of diagnosis, with annual reinforcement and review. Explain to people and their carers that structured education is an integral part of diabetes care. [2009] 1.2.2 Ensure that any structured education programme for adults with type 2 diabetes includes the following components: It is evidence-based, and suits the needs of the person. It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self manage diabetes. It has a structured curriculum that is theory driven, evidence based and resource effective, has supporting materials, and is written down. It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme. It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency. The outcomes are audited regularly. [2015] 1.2.3 Ensure the patient-education programme provides the necessary resources to support the educators, and that educators are properly trained and given time to develop and maintain their skills. [2009] 1.2.4 Offer group education programmes as the preferred option. Provide an alternative of equal standard for a person unable or unwilling to participate in group education. [2009] 1.2.5 Ensure that the patient-education programmes available meet the cultural, linguistic, cognitive and literacy needs within the local area. [2009] 1.2.6 Ensure that all members of the diabetes healthcare team are familiar with the patient education programmes available locally, that these programmes are integrated with the rest of the care pathway, and that adults with type 2 diabetes and their family members or carers (as appropriate) have the opportunity to contribute to the design and provision of local programmes. [2009]

‘Do not do’ statements in the guideline 1.4.11 Do not combine an ACE inhibitor with an angiotensin II- receptor antagonist to treat hypertension 1.5.1 Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with T2DM without cardiovascular disease 1.6.13 Do not routinely offer self-monitoring of blood glucose levels for adults with T2DM except in specified circumstances (see guideline) 1.6.24 In adults with T2DM do not offer or continue pioglitazone if they have heart failure or a history of heart failure; hepatic impairment; diabetic ketoacidosis; current, or a history of, bladder cancer; uninvestigated macroscopic haematuria 1.4.11 Do not combine an ACE inhibitor with an angiotensin II‑receptor antagonist to treat hypertension. [new 2015] (see http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-pressure-management-2) 1.5.1 Do not offer antiplatelet therapy (aspirin or clopidogrel) for adults with type 2 diabetes without cardiovascular disease. [new 2015] (see http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#antiplatelet-therapy) 1.6.13 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. For more information, see the NICE guideline on diabetes in pregnancy (NG3). [new 2015] See http://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations#blood-glucose-management-2 1.6.24 In adults with type 2 diabetes, do not offer or continue pioglitazone if they have any of the following: heart failure or history of heart failure hepatic impairment diabetic ketoacidosis current, or a history of, bladder cancer uninvestigated macroscopic haematuria. [new 2015]

Diabetes NICE Pathway See http://pathways.nice.org.uk/pathways/type-2-diabetes-in-adults A series of algorithms have been produced that summarise the guidelines on diabetes.

Type 2 diabetes NICE Pathway See http://pathways.nice.org.uk/pathways/type-2-diabetes-in-adults A series of algorithms have been produced that summarise the guidelines on diabetes. Visit the NICE Pathway on type 2 diabetes for fast access to all NICE recommends

Evidence into practice Maskrey N, 2014 Research National guidance Local implementation See: http://blogs.bmj.com/bmj/2014/08/21/neal-maskrey-tipping-the-balance-towards-individualised-care/ [Nowadays] there’s a general acknowledgement that few people go searching PubMed after constructing an answerable clinical question. There are excellent guidelines on how to construct guidelines, and if they are followed—and often they aren’t—there’s a robust summary of the available evidence in the end product. But even if guidelines are well constructed, they may not be based on all of the evidence, and their volume has created information overload for generalists. I find it difficult to write this, but multiple finely grained guidelines—containing scores of recommendations for practice—can be part of the problem, rather than a contributor towards the Holy Grail of individualised, optimal care. Somehow, EBP has become a systematic review and guidance production line. We spend lots of time and money translating research (R) into national guidance (N) around the globe. But we know that clinicians rely on mindlines rather than guidelines in their consultations; local (L) policies, pathways, and formularies abound but guidance on how to optimally translate from the N to the L is thin or absent. It’s definitely a different process from the R to N translation. And when we come to translate from the local policy (L) in individual (I) consultations that’s a different process yet again, and we’re back round to dealing with consultations skills and (especially) shared decision making. There’s a bunch of dedicated shared decision making researchers and teachers, but it’s clear that their work hasn’t penetrated mainstream, day to day clinical encounters. I’ve found that the RNLI model helps shape more constructive discussions when we are investigating why the use of high quality evidence to guide clinical practice is patchy, and slower to catch on than perhaps patients and payers would like. If we compare the public resources devoted to optimising the R to N translation, to those available for the N to L, and the L to I translations, it’s no contest. Well constructed guidance and systematic reviews are of course essential, but they’re a point in the journey and not the destination. Care of Individual people RNLI NICE Medicines and Prescribing Associates Programme October 2013

Possible implementation issues for medicines optimisation (N  L) Role of blood glucose control in the context of other health issues for people with T2DM Review use of: Dual ACE inhibitor – angiotensin II receptor antagonist therapy Aspirin/clopidogrel for primary prevention of cardiovascular disease Pioglitazone (see MHRA warnings) Insulin degludec Self-monitoring of blood glucose Treatments for gastroparesis Choice of insulin Managed entry of biosimilar insulin glargine These are the key medicines optimisation issues for local implementation that have been identified by the Medicines and Prescribing Centre. This is an opportunity to discuss within the group what other people consider to be the key issues, challenges, implications for current practice, and how implementation can be supported T2DM= type 2 diabetes MHRA = Medicines and Healthcare products Regulatory Agency

Possible issues for individual patient decision-making (L  I) Patient-centred, shared decision-making about: The person’s individual HbA1c target and choice of treatment See the NICE patient decision aid Changes in/discontinuation of current therapy Aspirin/clopidogrel for primary prevention of cardiovascular disease Pioglitazone (see MHRA warnings) Insulin degludec Self-monitoring of blood glucose Treatments for gastroparesis These are the issues for individual patient decision making that have been identified by the medicines education team at the MPC. This is an opportunity to discuss within the group what other people consider to be the key issues, challenges, implications for current practice, and how implementation can be supported. MHRA = Medicines and Healthcare products Regulatory Agency

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources Intended for use in adults with T2DM at first intensification Supports decision-making about: Optimal individualised target HbA1c level Taking a second medicine for blood glucose control Contains information about: Advantages and disadvantages of blood glucose control Factors that will affect the choice of target HbA1c level Medicines recommended as options at first intensification (includes metformin) A user guide explaining how the decision aid was produced (including the sources of information) is also available T2DM = type 2 diabetes

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

NICE patient decision aid for type 2 diabetes www. nice. org NICE patient decision aid for type 2 diabetes www.nice.org.uk/guidance/ng28/resources From the NICE patient decision aid for type 2 diabetes: www.nice.org.uk/guidance/ng28/resources

Guidelines. Not tramlines..

NICE Associate Programme Regional Technical Advisers North of England & Northern Ireland Jodie Tyrrell: jodie.tyrrell@nice.org.uk Midlands, East of England & Wales Gill Eddy: gill.eddy@nice.org.uk London Michelle Liddy: michelle.liddy@nice.org.uk South of England and Channel Islands Zoe Girdis: zoe.girdis@nice.org.uk NICE Medicines and Prescribing Associates Programme October 2013

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