The National Institute for Health and Clinical Excellence has updated its recommendations for the treatment of type 2 diabetes on the National Health Service to include advice on the use of DPP-4 inhibitors.

The Institute’s new guidelines recommend that DPP-4 inhibitors – such as Merck Sharp & Dohme's Januvia (sitagliptin) and Novartis’ Vildagliptin - should be considered as a second-line therapy instead of a sulphonylurea when metformin is failing to adequately control blood glucose levels in patients at significant risk of hypoglycaemia (low blood sugar), or in patients who cannot take SUs for some reason.

Current care of patients with type 2 diabetes is focused on encouraging a healthy lifestyle, modifying blood pressure and lipid levels, and lowering the amount of glucose in the blood. The new DPP-4 inhibitor class of drugs has not only been shown to be effective at managing blood glucose levels but also carries the added advantage of being associated with a low risk of hypoglycaemia – which can be life threatening - and weight gain, as can be caused by traditional diabetes drugs.

According to Merck, a recent study found that 38% of patients experienced symptoms of hypoglycaemia during a 12-month period, while other research has estimated that every year over 5,000 patients in the UK will experience a severe hypoglycaemic event requiring emergency intervention as a result of their SU therapy, illustrating the urgent need for better blood glucose control.

According to Professor Anthony Barnett, Heart of England NHS Foundation Trust, Birmingham: “One of the key issues when considering treatment options is striking a balance of achieving optimal glycaemic control while also minimising the risk of hypoglycaemia”. Newer treatments provide healthcare professionals with a wider choice of options, he said, and stressed that “NICE should be applauded for giving practical guidelines for the place of these new agents in the treatment algorithm”.

QOF holding back care?
Meanwhile, an analysis published in the British Medical Journal has questioned the impact of the Quality and Outcomes Framework – an annual reward and incentive scheme for GPs – on the care of patients with diabetes.

Researchers from Universities in London, Manchester and Birmingham looked at the management of diabetes during the three years before and the three years after the QOF was introduced (2001-2007), and found that achievements in meeting targets reached their peak just after the incentive scheme was rolled out.

Although they say diabetes care has improved in the last decade, the researchers found that the introduction of the QOF did not improve the management of patients with type 1 diabetes nor did it reduce the number of type 2 diabetes patients with HbA1c levels greater than 10%.

The researchers conclude that the impact of the QOF on the care of patients “is not straightforward”, but they suggest that “upper thresholds may need to be removed or targets made more challenging if people are to benefit” from the scheme.

In addition, they claim that the current diagnostic criteria for the QOF means that up to two thirds of patients with type 1 and a third with type 2 diabetes are not being included, a point that urgently needs to be addressed to ensure care equality across the nation.