In May 2009, NICE published recommendations on the use of newer agents for the control of blood glucose in type 2 diabetes. This guideline provides a partial update for NICE Clinical Guideline 66 on the management of type 2 diabetes that was published last year. These newer agents include the dipeptidyl peptidase-4 (DPP-4) inhibitors, thiazolidinediones (TZDs), the glucagon-like peptide-1 (GLP-1) mimetic exenatide and the long-acting insulin analogues (insulin detemir and insulin glargine).
A new Cochrane Review highlights the value of nurse-led titration of ACE inhibitors, beta-blockers and angiotensin II receptor blockers in patients with chronic heart failure. All-cause mortality and hospitalisations were lower in the nurse-led titration group compared with the usual care of titration by GPs.
Primary care nurses play a central role in the management of type 2 diabetes in the community. This includes helping patients to use their drug treatment correctly. Although many patients with type 2 diabetes initially respond well to weight loss and exercise, most require oral hypoglycaemics and half of all patients eventually require insulin to control their glucose levels in order to prevent the devastating long-term complications of inadequately controlled diabetes. Linda Goldie gives an up-to-date review of the newer insulins – including the insulin analogues, insulin lispro, insulin aspart and insulin glargine – that have been introduced.
There is good evidence that tight glycaemic control significantly improves outcomes in patients with type 2 diabetes. All practice nurses will be looking to achieve the new General Medical Services contract (GMS2) targets for HbA1c reduction in diabetes (see box). Practices will be developing prescribing strategies to achieve this reduction, in accordance with good clinical practice. Metformin offers an important first-line therapy for type 2 diabetes. The introduction of a new, sustained-release formulation – Glucophage SR – should improve patient compliance with metformin and so improve glycaemic control.