Type 2 Diabetes Mellitus - quality prescribing strategy: improvement guide 2024 to 2027

Executive summary

Diabetes presents a major challenge for those with the condition and the National Health Service (NHS) in Scotland. The number of people with diabetes continues to grow with 1 in 17 adults in Scotland now living with diabetes, the majority of which is type 2 Diabetes Mellitus (T2DM). The prevalence of age-standardised diabetes in 2020 was higher among those living in the most deprived quintile (10%) compared with those living in the least deprived quintile (4%), showing significant variation associated with deprivation. T2DM is chronic in nature and associated with multiple morbidities and reduced life expectancy.

This guidance is designed to keep the person with diabetes at the centre of their treatment and disease management. The individual, their families and their carers should be actively involved with their treatment and care decisions at all stages. The first step in T2DM management is to make diet and lifestyle changes, as remission is possible if people are given the right intervention within six years of diagnosis. Due to the chronic and progressive nature of T2DM, it is often treated with multiple medicines (polypharmacy) to control not only blood glucose but to treat comorbidities such as diabetic kidney disease, cardiovascular disease (CVD) and neuropathic pain. People prescribed treatment for T2DM should have regular diet, lifestyle and medication reviews to ensure effective use of medicines, optimise outcomes and minimise harm. At the centre of this approach is using “What matters to you?”, a person-centred approach to reviewing treatment, as part of the 7-Steps medication review process.

This quality prescribing guide is intended to support clinicians across the multidisciplinary team and people with T2DM in shared decision-making and the effective use of medicines, applying the principles of value-based healthcare and Realistic Medicine.^[9]

SIGN 116 and 154^[1] were published in 2010 (updated 2017) and in 2017 respectively. Since then, there have been numerous studies supporting the use of newer therapies. The expert working group considered these and the recently published NICE guidance (NG28),^[2] and recommend the use of sodium-glucose co-transporter-2 inhibitor (SGLT-2i) and glucagon-like peptide 1 receptor agonist (GLP-1RA) therapies, for the treatment of those with cardiovascular and renal disease and for consideration for those at higher cardiovascular risk. The group acknowledges the increased incidence of euglycaemic diabetic ketoacidosis (eDKA) with SGLT-2i and has provided additional advice to support appropriate prescribing of these agents and minimise the risk of harm in their use.

To support this work, a suite of safety and medication effectiveness data indicators have been developed with a multiprofessional and expert by experience group. These indicators will enable benchmarking at Health Board and GP practice level to drive quality improvement through reducing unwarranted variation in prescribing practice.