Professor Wasim Hanif, Dr Nashat Qamar, and Hanadi Alkhder discuss the need for local guidance on non-insulin antidiabetic agents for adults with type 2 diabetes, and the important role played by the multidisciplinary team

Birmingham is a deprived area. It is the seventh most deprived local authority out of the 317 authorities in England.1 Life expectancy in Birmingham is lower than the national average: for males, life expectancy is 77.2 years (versus 79.5 years for England) and for females it is 81.9 years (versus 83.1 years for England).2

As levels of deprivation increase, so does the prevalence of long-term conditions such as diabetes.3 The Office of National Statistics’ data for 2014–16 showed that the death rate for diabetes per 100,000 of the population was higher in Birmingham than the national average in England (16.2 versus 10.3, respectively).4 In 2017–18, prior to the development of the local guideline, the prevalence of type 2 diabetes across the Birmingham, Solihull, and Sandwell area was much higher than in England, ranging from 7.2% in Solihull to 9.1% across Birmingham and Sandwell compared with the England average of 6.8%.5 Spend on antidiabetic drugs in 2017–18 across the Birmingham and Solihull (BSol) CCG area totalled £19.2 million.5 It is therefore important that the prescribing of antidiabetic agents is both clinically appropriate and cost-effective for the NHS.

The need for local guidance on the treatment of type 2 diabetes

In 2015, NICE published NICE Guideline 28 (NG28) on Type 2 diabetes in adults: management.6 The guideline took a more pragmatic approach to patient-centred care and, although considered to be an improvement on previous iterations, it was received with mixed feelings, particularly in primary care, where it was felt by some to be a missed opportunity for clarity.7

Subsequent guidance from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), published in 2018, provided more granular detail than NICE NG28, but did not take into consideration of the financial prescribing considerations within which the NHS operates. With the background of rising spend on antidiabetic agents and confusion over the NG28 recommendations, which were affecting its implementation locally, the Diabetes Medicines Management Advisory Group (DMMAG) decided that the best course of action was to develop a simplified local guideline and pathway on the treatment of type 2 diabetes.5

Development of the DMMAG guideline

The DMMAG is a specialist group established to support the Birmingham, Solihull, Sandwell and environs (BSSE) Area Prescribing Committee (APC). The membership of DMMAG includes doctors, nurses, and pharmacists from across primary and secondary care, including CCGs. This specialist group ensured a multidisciplinary review of the latest evidence and guidance during guideline development.

We reviewed prescribing data for 2012–17 for the newer antidiabetic agents used in BSol CCG, the largest in this APC area, and found that the CCG had spent £9.5 million on glucagon like peptide-1 receptor agonists (GLP-1RAs), £12.2 million on sodium-glucose co-transporter-2 (SGLT2) inhibitors, and £48.9 million on DPP-4 inhibitors.9 This suggested that dipeptidyl-peptidase-4 (DPP4) inhibitors were a default second-line choice despite other drug classes demonstrating greater benefit in patients with diabetes and established cardiovascular disease,8 and this was one key driver for change.

There were a number of challenges to be met by DMMAG during the development of the guideline—we wanted to ensure that it was in line with the NICE recommendations, while taking into account:

  • evidence from the cardiovascular outcome trials in diabetes10 and moving the approach from a gluco-centric to a more cardiometabolic one
  • recommendations from ADA/EASD, considered by many to be the ‘gold standard’ in management of type 2 diabetes8
  • cost-effectiveness and keeping the pathway cost neutral—being mindful of the need to support de-escalation as well as intensification of treatment.

The initial focus of the group was to develop a guideline that covered the choice of oral and non-insulin antidiabetic agents for adults with type 2 diabetes, and this was approved by the BSSE APC in June 2019.5 A separate pathway on the use of insulin medications in type 2 diabetes has also been developed and is currently under review with the BSSE APC; approval is anticipated in early 2021.

The approved guideline contains easy-to-follow treatment pathways that provide treatment recommendations at the point of diagnosis, and show when first and second intensification is indicated (see Figure 1, below).5 They are accompanied by a table of key considerations to support drug selection decisions and give prescribing advice. The DMMAG guideline also highlights the importance of:

  • basing medication choice on patient choice and clinical characteristics such as presence of established cardiovascular disease, frailty, other co-morbidities, polypharmacy, and adverse effects
  • assessing response to treatment, and discontinuing ineffective therapies or escalating treatment where necessary.

Figure 1- Antihyperglycaemic treatment options for adults with type 2 diabetes

Figure 1: Antihyperglycaemic treatment options for adults with type 2 diabetes5

Implementation across Birmingham, Solihull, and Sandwell 

The multidisciplinary nature of DMMAG meant that there was local buy-in to the guideline across primary and secondary care from the outset. We ran an educational programme consisting of half-day, face-to-face sessions, which were promoted via the APC and CCGs and were well attended. Consultants, along with specialist nurses and pharmacists from within the multidisciplinary diabetes service, upskilled GPs on the new pathway. An additional unexpected success of the guideline development and roll-out has been evidence of more integrated ways of working across the region. Regular sessions and update meetings have continued throughout 2020, but as virtual meetings because of COVID-19.

Monitoring effectiveness

To measure effectiveness of implementation of the guideline on patient outcomes, the following parameters have been measured from the outset:

  • glycated haemoglobin (HbA1c)
  • lipid profiles
  • blood pressure.

The unexpected focus on dealing with COVID-19 during 2020 has delayed reporting of these outcome measures, which are now planned for 2021. Uptake of the guideline is, however, indicated through prescribing data, which showed that, since the launch of the guideline in June 2019, use of cardioprotective SGLT2 inhibitors has increased in CCGs across the APC (see Figure 2), whereas use of DPP-4 inhibitors has now stabilised following year-on-year increases (see Figure 3), in line with the guideline’s aims.11

Total prescribing for Empagliflozin + Dapagliflozin + Ertugliflozin + Canagliflozin across NHS BIRMINGHAM AND SOLIHULL CCG + NHS SANDWELL AND WEST BIRMINGHAM CCG

Figure 2: Prescribing of SGLT2 inhibitors at NHS Birmingham and Solihull (Bsol) CCG and NHS Sandwell and West Birmingham (SWB) CCG, and other CCGs11

Source: Source: OpenPrescribing.net, EBM DataLab, University of Oxford, 2020

Number of items (Empagliflozin + Dapagliflozin + Ertugliflozin + Canagliflozin) prescribed by CCG. Shown in pink: NHS Birmingham and Solihull CCG (top); NHS Sandwell and West Birmingham CCG (bottom).

Total prescribing for Alogliptin + Linagliptin + Sitagliptin + Saxagliptin + Vildagliptin across NHS BIRMINGHAM AND SOLIHULL CCG + NHS SANDWELL AND WEST BIRMINGHAM CCG

Figure 3: Prescribing of DPP-4 inhibitors at NHS Birmingham and Solihull (Bsol) CCG and NHS Sandwell and West Birmingham (SWB) CCG, and other CCGs11

Source: OpenPrescribing.net, EBM DataLab, University of Oxford, 2020

Number of items (Alogliptin + Linagliptin + Sitagliptin + Saxagliptin + Vildagliptin) prescribed by CCG. Shown in pink: NHS Birmingham and Solihull CCG (top); NHS Sandwell and West Birmingham CCG (bottom).

Summary 

We have shown that it is possible to develop and implement an evidence-based, cardiometabolic pathway for managing type 2 diabetes, which is based on the principles of ‘right patient, right therapy’ and best practice recommendations, but also follows a cost-effective framework. Although developed for use in our own locality, the recommendations are not specific to Birmingham and are just as applicable to other regions to support implementation of best practice. The guideline is open access and available online.

Through DMMAG, we have brought together individuals from across primary and secondary care, with input from CCG medicines management teams, to deliver the guidance, and this has improved both team working and diabetes care across the locality.

Professor Wasim Hanif

Professor of Diabetes & Endocrinology, Consultant Physician, and Head of Service in Diabetes at University Hospitals Birmingham NHS Foundation Trust; Co-Chair of DMMAG—Birmingham, Solihull, Sandwell and environs APC.

Dr Nashat Qamar

GP Principal, Birmingham; Strategic Clinical Lead Diabetes, NHS Birmingham and Solihull CCG; member of DMMAG—Birmingham, Solihull, Sandwell and environs APC.

Hanadi Alkhder

Senior Prescribing Advisor, Medicines Management and Optimisation Team, NHS Birmingham and Solihull CCG; Co-Chair of DMMAG—Birmingham, Solihull, Sandwell and environs APC.

Key points

  • Birmingham is the seventh most-deprived local authority in England, with a much higher prevalence of type 2 diabetes compared with the national average
  • In 2019, the Birmingham, Solihull, Sandwell and environs (BSSE) APC Diabetes Medicines Management Advisory Group (DMMAG) published its local guideline on the choice of oral and non-insulin antidiabetic agents for adults with type 2 diabetes
  • The DMMAG guideline:
    • is within the scope of the NICE Guideline 28 recommendations for management of type 2 diabetes
    • includes two treatment pathways covering diagnosis and first and second intensification, and a table of key considerations to support with drug selection
    • moves the focus from a gluco-centric to a cardiometabolic approach under a cost-effective framework
    • provides guidance on de-escalation of treatment and management of diabetes in older adults and/or those with frailty
  • The multidisciplinary nature of the DMMAG ensured buy-in across primary and secondary care from the outset, which supported with implementation
  • Initial results have demonstrated a move towards the use of more cardioprotective antidiabetic agents—further results and a new pathway on insulin medications in type 2 diabetes are planned for early 2021
  • The guideline and pathways are not specific to Birmingham and implementation in other regions is encouraged.

References

  1. Birmingham City Council website. Index of deprivation 2019. Available at: www.birmingham.gov.uk/downloads/file/2533/index_of_deprivation_2019 (accessed 14 December 2020).
  2. Birmingham City Council website. Population and census—overview. Available at: www.birmingham.gov.uk/info/20057/about_birmingham/1294/population_and_census (accessed 14 December 2020).
  3. Millett C, Car J, Eldred D et al. Diabetes prevalence, process of care and outcomes in relation to practice size, caseload and deprivation: national cross-sectional study in primary care. J R Soc Med 2007; 100 (6): 275–283.
  4. Birmingham City Council website. Birmingham health profile 2019. Available at: www.birmingham.gov.uk/downloads/file/11845/birmingham_health_profile_2019 (accessed 14 December 2020).
  5. Birmingham, Solihull, Sandwell and environs APC—Diabetes Medicines Management Advisory Group. Type 2 diabetes: guideline for the choice of oral and non-insulin antihyperglycaemic agents in adults. Birmingham: DMMAG, June 2019. Available at: www.birminghamandsolihullccg.nhs.uk/about-us/publications/policies/2674-antidiabetics-therapy-guideline-for-type-2-diabetes/file
  6. NICE. Type 2 diabetes in adults: management. NICE Guideline 28. NICE, 2015 (updated 2019). Available at: www.nice.org.uk/ng28
  7. Meetoo D, Alsomali S. NG28: promoting patient-centred care for adults with type 2 diabetes. Nurse Prescribing 2016; 14 (5). 
  8. Davies M, D’Alessio D, Fradkin J et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018; 61: 2461–2498. 
  9. NHS Business Services Authority website. Prescription data—ePACT. Available at: www.nhsbsa.nhs.uk/epact2 (accessed 14 December 2020).
  10. Cefalu W, Kaul S, Gerstein H et al. Cardiovascular outcomes trials in type 2 diabetes: where do we go from here? Reflections from a Diabetes Care editors’ expert form. Diabetes Care 2018; 41 (1): 14–31. 
  11. OpenPrescribing.net, EBM DataLab, University of Oxford, 2020
  12. OpenPrescribing website. Analyse. Search GP prescribing data. Available at: openprescribing.net/analyse/#org=CCG&orgIds=15E,05L&numIds=0601023AK,0601023AE,0601023X0,0601023AC,0601023AA&denom=nothing&selectedTab=chart (accessed 14 December 2020).

Showcasing local best practice in diabetes