The new NICE guidelines for type 2 diabetes – a critical analysis


  • J Paul O’Hare University of Warwick Medical School, Coventry and University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
  • David Miller-Jones Royal Gwent Hospital and Oak Street Surgery, Cwmbran, UK
  • Wasim Hanif University Hospital Birmingham, UK
  • Deborah Hicks Barnet, Enfield and Haringey Mental Health Trust, UK
  • Marc Evans University Hospital Llandough, Cardiff, UK
  • David Leslie Queen Mary, University of London, and St Bartholomews Hospital, London, UK.
  • Stephen C Bain Swansea University and Abertawe Bro Morgannwg University Health Board, UK
  • Anthony H Barnett University of Birmingham and Heart of England NHS Foundation Trust, Birmingham, UK



“Common sense is not so common”

– Voltaire (1694–1778)

The latest NICE guidelines for the management of type 2 diabetes are now available for consultation. They contain sensible recommendations regarding lifestyle, patient education, monitoring and targets.

Unfortunately, the pharmacotherapy section shows a distinct failure of common sense. The recommendations include using the insulin secretagogue repaglinide as a first-line agent, where metformin is not tolerated or contraindicated, or second-line in combination with metformin. Pioglitazone is recommended as the principal second-line therapy with metformin. The advice on glucagon-like peptide-1 receptor agonist (GLP-1ra) usage and assessment of efficacy and failure to recommend long acting analogue insulins over isophane are also major concerns.

The recommendations appear to be based on meta- analyses and pharmacoeconomics, driven by an imperative on costs and failing to appreciate the “value” of the options under consideration. The cost to patients and the health service of the serious side-effects of these treatments is underestimated.

Given the emphasis in these guidelines on the importance of lifestyle changes, including weight loss, plus an over-riding need to avoid hypoglycaemia, these pharmacotherapeutic recommendations appear paradoxical in the extreme.

We believe that these recommendations, if enacted, will undermine seriously the reputation of NICE both nationally and internationally.


NICE. Type 2 diabetes: guideline consultation 2015. (Accessed January 2015)

Khunti, K, Gray LJ, Skinner T, et al. Effectiveness of a diabetes education and self-management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. BMJ 2012;344:e2333.

Deakin TA, Cade JE, Wiliams R, Greenwood DC. Structured patient education: the Diabetes X-PERT Programme makes a difference. Diabet Med 2006 23;9:944-54.

Farmer A, Wade A, Goyder E, et al. Impact of self-monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ 2007;225:132.

Viberti G, Kahan SE, Greene DA, et al. A diabetes outcome progression trial (ADOPT): an international multicentre study of the comparative efficacy of rosiglitazone, glyburide, and metformin in recently diagnosed type 2 diabetes. Diabetes Care 2002;25:1737-43.

Leese GP, Wang J, Broomhall J, et al. for the DARTS/MEMO Collaboration. Frequency of severe hypoglycaemia requiring emergency treatment in type 1 and type 2 diabetes: a population-based study of health service resource use. Diabetes Care 2003;26:1176-80.

Rajendran R, Hodgkinson D, Rayman G. Patients with diabetes requiring emergency department care for hypoglycaemia: characteristics and long-term outcomes determined from multiple data sources. Postgrad Med J 2015 (in press).

UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia 2007;50;1140-7.

Shah ZH, Saleem KO. A comparative study of repanglinide and glibenclamide in type 2 diabetic patients. Pakistan J Med Health Sci 2011;5:476-9.

Phung OJ, Scholle JM, Talwar M, Coleman CL. Effect of noninsulin anti-diabetic drugs added to metformin therapy on glycaemic control, weight gain, and hypoglycaemia in type 2 diabetes. JAMA 2010;303:1410-18.

World Health Organisation. Adherence to long term therapies. Evidence for action. Switzerland, 2003.

Just what the doctor ordered: a EU response to medication non-adherence. Tuesday 28 September 2010, Bibliotheque Solvay, Brussels.

Grant RW, Devita NG, Singer DE, Meigs JB. Polypharmacy and medication adherence in patients with type 2 diabetes. Diabetes Care 2003;26:1408-12.

Khunti K, Davies M. Glycaemic goals in patients with type 2 diabetes: current status, challenges and recent advances. Diabetes Obes Metab 2010;12:474-84.

Robinson LE, Holt TA, Rees K, et al. Effects of GLP-1 agonists on heart rate, blood pressure and body weight: Systematic review and meta-analysis. BMJ Open 2013;3:pii:e001986.

Thong KY, Gupta PS, Cull ML, et al. GLP-1 receptor agonists in type 2 diabetes – NICE guidelines versus clinical practice. Br J Diabetes Vasc Dis 2014;14:52-9.

Gerstein HC, Miller ME, Genuth S, et al. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med 2011;364: 818-28.

Skyler JS, Bergenstal R, Bonow RO, et al. Intensive glycaemic control and the prevention of cardiovascular events: implications of the ACCORD, ADVANCE, and VA diabetes trials: a position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. Diabetes Care 2009;32:187-92.

Inzucchi SE, Berganstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: A patient-centered approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015;38:140-9.