NICE guidance - glitazone therapy in clinical practice

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The practicalities as to when use of glitazones are indicated in clinical practice has been outlined by NICE. This guidances have been summarised below (1,2):

In the latest NICE guidance glitazones (pioglitazone) are a treatment option in both possible treatment arms (metformin tolerant or metformin intolerant) (1):

If metformin tolerant then (2):

  • metformin is first line therapy and titrated up to usual maximum dose of 1g bd

  • pioglitazone is an option for first intensifcation of therapy if, despite treatment with metformin, the HbA1c is > 58 (7.5%)

  • if pioglitazone has not been used in the first intensification of therapy then it is an option for the second intensification
    • if HbA1c rises to 58 mmol/mol (7.5%)
    • metformin, pioglitazone and an SU (suphonylurea), or,
    • metformin, pioglitazone and an SGLT-2 inhibitor

If metformin intolerant then (2):

  • pioglitazone is an option for first line therapy as is gliptin therapy or therapy with a sulphonylurea

  • pioglitazone is an option for dual therapy as first intensification of therapy if after initial therapy the HbA1c is > 58 (7.5%)
    • DPP-4i and pioglitazone
    • pioglitazonea and an SU

From previous guidance (1) if metformin is first line therapy

    • pioglitazone
      • should be considered instead of a sulfonylurea as second-line therapy to metformin when control of blood glucose remains or becomes inadequate (HbA1c >= 6.5%, or other higher level agreed with the individual) if:
        • the person is at significant risk of hypoglycaemia or its consequences (for example, older people and people in certain jobs [for example, those working at heights or with heavy machinery] or people in certain social circumstances [for example, those living alone]), or
        • a person does not tolerate a sulfonylurea or a sulfonylurea is contraindicated

    • if using a sulphonylurea as first line therapy
      • a pioglitazone
        • should be considered as second-line therapy when control of blood glucose remains or becomes inadequate (HbA1c >=6.5%, or other higher level agreed with the individual) if:
          • the person does not tolerate metformin or metformin is contraindicated

    • a thiazolidinedione (pioglitazone) should not be initiated or continued in people who have heart failure, or who are at higher risk of fracture
    • when to continue treatment
      • there must be a satisfactory response in glycaemic control in order to justify continuation of thiazolidinedione therapy (glitazone therapy)
        • NICE suggest a reduction of at least 0.5 percentage points in HbA1c in 6 months

    • insulin plus pioglitazone (1)
      • combining pioglitazone with insulin therapy should be considered for a person:
        • if patient had previously had a marked glucose-lowering response to thiazolidinedione therapy (pioglitazone), or
        • who is on high-dose insulin therapy and whose blood glucose is inadequately controlled

    • DPP4-inhibitor or thiazolidinedione
      • when would a glitazone be the preferred option?
        • thiazolidinedione (pioglitazone) may be preferable to a DPP-4 inhibitor if:
          • the person has marked insulin insensitivity, or
          • DPP-4 inhibitor is contraindicated, or
          • the person has previously had a poor response to, or did not tolerate, a DPP-4 inhibitor

For detailed guidance then consult the full guideline (2).

Reference:

Last reviewed 01/2018

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