Updated NICE diabetes guideline backs SGLT2 inhibitors for cardiovascular protection

The latest NICE guideline on type II diabetes recommends SGLT2 inhibitors 'with proven cardiovascular benefit' in patients at increased cardiovascular risk.

Conceptual illustration of human heart anatomy as a transparent visualisation of a torso with bones shown in blue and the heart and its vessels in red.
NICE recommends assessing cardiovascular risk in patients with type II diabetes to help determine which treatments they should receive. | GETTY IMAGES

Healthcare professionals can find a quick-reference MIMS summary of the updated NICE type II diabetes guidance online and in the forthcoming March print issue of MIMS.

For patients with type II diabetes, NICE now recommends SGLT2 inhibitors at any stage of treatment, including as first-line treatment when metformin is contraindicated or not tolerated, as follows:

  • For patients with chronic heart failure or atherosclerotic vascular disease: prescribers should add (or switch an existing drug to) an SGLT2 inhibitor with proven cardiovascular benefit.
  • For patients at high risk of developing cardiovascular disease: prescribers should consider adding (or switching an existing drug to) an SGLT2 inhibitor with proven cardiovascular benefit.

To assess cardiovascular risk, NICE recommends using the QRISK2 tool. High risk in patients with type II diabetes is defined as a score of more than 10% in adults aged 40 and over, or an elevated lifetime risk of cardiovascular disease (defined as 1 or more cardiovascular risk factors in someone under 40).

The guideline committee opted to recommend SGLT2 inhibitors as a class for cardiovascular protection, and highlighted 'varying levels of certainty' in the clinical data about differences in cardiovascular benefits between the different SGLT2 inhibitors. The committee noted that there was greater uncertainty around the cardiovascular benefits associated with ertugliflozin than there was for empagliflozin, canagliflozin and dapagliflozin

Diabetic ketoacidosis

When starting dual therapy with metformin and an SGLT2 inhibitor as first-line therapy, NICE recommends introducing the drugs sequentially, starting with metformin and checking tolerability. The SGLT2 inhibitor should be started as soon as metformin tolerability is confirmed.

The updated guideline highlights some important safety considerations to take into account before starting an SGLT2 inhibitor. 

The prescriber should check whether the person may be at increased risk of diabetic ketoacidosis (DKA), for example if:

  • they have had a previous episode of DKA
  • they are unwell with intercurrent illness
  • they are following a very low carbohydrate or ketogenic diet.

Modifiable risks for DKA should also be addressed. For example, for people who are following a very low carbohydrate or ketogenic diet, they may need to delay treatment until they have changed their diet.
People who are taking an SGLT2 inhibitor should be warned not to start a very low carbohydrate or ketogenic diet without discussing it with their healthcare professional. 

For people with established cardiovascular disease or a high risk of developing cardiovascular disease who are unable to take an SGLT2 inhibitor, metformin alone should be offered as first-line treatment. GLP‑1 mimetics were not considered cost-effective options in this setting.

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