Diabetes specialists have slammed new UK guidelines on the management of type 2 diabetes, saying they are confusing, unworkable and adopt a “wait for failure” approach.

John Paul O’Hare from the University of Warwick Medical School and colleagues say the pharmacotherapy section in the draft NICE guidelines show 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.

“In our opinion, few patients would be happy to take this drug over safer, albeit more expensive, alternatives once told of the likelihood of side-effects including weight gain, fluid retention, and increased risk of congestive cardiac failure, as well as other potential concerns such as bone fractures,” they wrote in a letter to the Lancet Diabetes and Endocrinology. 

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, they say.

“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,” they wrote.

According to the authors the cost to patients and the health service of the serious side-effects of the treatments was 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,” they said.

Primary care doctors and nurses, in particular, were struggling to look after growing numbers of patients with type 2 diabetes. They needed clear, sensible guidance, based on evidence (and cost), but most importantly on safety.

The authors recommend that repaglinide is withdrawn as a first-line treatment, the prominence given to sulphonylureas at all stages of intensification is reduced, the BMI restrictions and stopping rules for GLP-1 receptor agonists are redrawn, and the SGLT-2 inhibitors are fully included.