Draft guidance from NICE recommends SGLT2 inhibitors first line for the prevention of cardiovascular disease in high-risk patients type 2 diabetes.
NICE recommends this class of drugs, with metformin, for patients with T2D with congestive heart failure (HF) or established atherosclerotic cardiovascular disease (ASCVD), or who are at high risk of developing CVD from the start of treatment.
However, when starting dual therapy, the treatments should be introduced sequentially to enable assessment of the tolerability of each agent.
If metformin is contraindicated or not tolerated, an SGLT2 inhibitor can be offered as monotherapy. For patients who do not have HF or ASCVD, and who are not at high risk of CVD based on their QRISK2 score, treatment recommendations remain unchanged.
NICE specifically states that GLP-1 receptor agonists should NOT be offered to solely for cardiovascular risk reduction. Restrictions on who should be offered these drugs remain unchanged from the 2015 guideline, putting the draft guideline at odds with the highly respected American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) consensus statements from 2018 and 2019.
The guideline development committee claimed that GLP-1 RAs were ‘not cost effective at any stage of economic modelling’ in terms of cardiovascular benefits, and that their use ‘solely to reduce cardiovascular risk could not be justified’. The committee did not examine the evidence for GLP-1 RAs to control blood glucose levels, and the ‘tight limits’ on access to this class of drugs have not been updated.
The recommendations to offer an SGLT2 inhibitor to people with T2D, HF and established ASCVD as first line treatment is likely to substantially increase the numbers of people taking these drugs at the start of their treatment. This is also expected to be the case for people with high risk of developing CVD, as this category covers a large proportion of the people with T2D.
NICE will only be accepting comments on new recommendations for 2021, and not on those that have been retained from the earlier guideline. The consultation closes on 14 October, and the expected publication date for the final guideline is February 2022.