Quality standard

Quality statement 5: Treatment with an SGLT2 inhibitor

Quality statement 5: Treatment with an SGLT2 inhibitor

Quality statement

Adults with type 2 diabetes are offered an SGLT2 inhibitor if they would benefit because of co-existing chronic heart failure, cardiovascular disease or chronic kidney disease (CKD). [new 2023]

Rationale

SGLT2 inhibitors improve cardiovascular outcomes in adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease. They also reduce the risk of CKD progression and mortality, as well as the risk of cardiovascular events in adults with type 2 diabetes and CKD. SGLT2 inhibitors should be offered in line with NICE guidance, in accordance with criteria in their marketing authorisation, including estimated glomerular filtration rate (eGFR) thresholds, to adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor and who have a urine albumin-to-creatinine ratio (ACR) over 30 mg/mmol.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

a) Proportion of adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease prescribed an SGLT2 inhibitor.

Numerator – the number in the denominator who are prescribed an SGLT2 inhibitor.

Denominator – the number of adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

b) Proportion of adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor and have an ACR over 30 mg/mmol prescribed an SGLT2 inhibitor.

Numerator – the number in the denominator who are prescribed an SGLT2 inhibitor.

Denominator – the number of adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor and have an ACR over 30 mg/mmol.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

Outcome

Prevalence of cardiovascular complications in adults with type 2 diabetes.

Data source: The National Diabetes Audit's report on complications and mortality includes data on the number of people with type 2 diabetes who are admitted to hospital with cardiovascular complications (angina, myocardial infarction, heart failure and stroke).

What the quality statement means for different audiences

Service providers (such as GP practices and secondary care providers) ensure that SLGT2 inhibitors are included in formularies for prescribing to adults with type 2 diabetes and chronic heart failure, established atherosclerotic cardiovascular disease or CKD.

Healthcare professionals (such as GPs, consultant diabetologists, advanced nurse practitioners, diabetes specialist nurses and pharmacists) offer an SGLT2 inhibitor as a first-line treatment to adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease and to adults with type 2 diabetes and CKD. They should address modifiable risk factors for diabetic ketoacidosis (DKA) before starting an SGLT2 inhibitor. They should also advise adults with type 2 diabetes who are taking an SGLT2 inhibitor about minimising the risk of DKA when there is intercurrent illness and not to start a very low carbohydrate or ketogenic diet.

Integrated care systems ensure that services can offer SGLT2 inhibitors to adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease or CKD.

Adults with type 2 diabetes and heart failure, cardiovascular disease or CKD with severely increased protein in their urine are offered an SGLT2 inhibitor along with their other medication to help reduce the risk of developing complications from their diabetes.

Source guidance

Type 2 diabetes in adults: management. NICE guideline NG28 (2015, updated 2022), recommendations 1.7.5, 1.7.9, 1.7.16 and 1.8.17

Definitions of terms used in this quality statement

Established atherosclerotic cardiovascular disease

This includes:

  • coronary heart disease

  • acute coronary syndrome

  • previous myocardial infarction

  • stable angina

  • previous coronary or other revascularisation

  • cerebrovascular disease (ischaemic stroke and transient ischaemic attack)

  • peripheral arterial disease.

[NICE's guideline on type 2 diabetes in adults, terms used in this guideline]

SGLT2 inhibitor

Adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease should be offered an SGLT2 inhibitor with proven cardiovascular benefit.

It should be offered:

  • in addition to metformin as a first-line treatment for type 2 diabetes or

  • for first-line treatment if metformin is contraindicated or not tolerated or

  • at any stage after they have started first-line treatment if they have or develop chronic heart failure or established atherosclerotic cardiovascular disease, taking into account their current treatment regimen and preferences.

Adults with type 2 diabetes and CKD should be offered an SGLT2 inhibitor licensed for use in CKD, if:

  • they are taking the highest tolerated licensed dose of an ARB or ACE inhibitor

  • they have an ACR over 30 mg/mmol and

  • they meet the criteria in the marketing authorisation for the SGLT2 inhibitor (including relevant eGFR thresholds).

In November 2021, not all SGLT2 inhibitors were licensed for this indication. See NICE's information on prescribing medicines. [Adapted from NICE's guideline on type 2 diabetes in adults, recommendations 1.7.5, 1.7.9, 1.7.16 and 1.8.17]