Evidence

2022 exceptional surveillance of type 1 diabetes in adults: diagnosis and management (NICE guideline NG17)

Surveillance decision

Surveillance decision

An enquirer highlighted that the recent update of the NICE guideline on chronic kidney disease had removed a recommendation that provided a blood pressure target for people with diabetes and chronic kidney disease. As a result of this change, the NICE guideline on chronic kidney disease was now inconsistent with the advice provided on blood pressure targets in the NICE guideline on type 1 diabetes in adults, and therefore this inconsistency was unhelpful in clinical practice. We propose to editorially amend recommendations 1.13.8, 1.13.13 and 1.15.14 in the NICE guideline on type 1 diabetes in adults.

Methods

The surveillance process:

  • Considered comments received by the enquirer.

  • Considered evidence and committee rationale used to develop recommendations in the NICE guidelines on type 1 diabetes and chronic kidney disease.

  • Developed a summary report (see appendix A) to seek views from the existing NICE diabetes committee.

  • Consulted with stakeholders (see appendix B for comments and responses).

Approach for handling the inconsistency

It is proposed that an amendment to recommendations 1.13.8, 1.13.13 and 1.15.14 in NICE's guideline on type 1 diabetes in adults is needed because the evidence base for recommendations on blood pressure within this guideline dates to 2004. In contrast, the evidence base included in NICE's guideline on chronic kidney disease dates to the 2021 update (see appendix A for further details).

Feedback from the existing NICE diabetes committee on an initial proposal to undertake a minor amendment highlighted that this would not be sufficient as blood pressure targets are now understood to be more influenced by urine albumin:creatinine ratio (ACR), and more in keeping with the NICE's guideline on chronic kidney disease. As such, amendments to recommendations within NICE's guideline on type 1 diabetes in adults was proposed to stakeholders (see table 1).

Table 1 Current recommendations within the type 1 diabetes in adults guideline and proposed changes to recommendations

Current guideline recommendations

Proposed changes to recommendations

1.13.8 Recommend blood pressure management at 135/85 mmHg for adults with type 1 diabetes. If they have albuminuria or 2 or more features of metabolic syndrome, recommend blood pressure management at 130/80 mmHg. See also the recommendations on diabetic kidney disease and NICE's guideline on hypertension in adults. 

1.13.8 In adults with type 1 diabetes, aim for blood pressure targets as follows:

  • For adults with a urine albumin:creatinine ratio (ACR) under 70 mg/mmol, aim for a clinic systolic blood pressure under 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure under 90 mmHg.

  • For adults with an ACR of 70 mg/mmol or over, aim for a clinic systolic blood pressure under 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure under 80 mmHg.

  • In adults aged 80 and over, whatever the ACR, aim for a clinic systolic blood pressure under 150 mmHg (target range 140 to 149 mmHg) and a clinic diastolic blood pressure under 90 mmHg.

Use clinical judgement for adults with frailty, target organ damage or multimorbidity. See NICE's guidelines on chronic kidney disease, hypertension in adults, and multimorbidity. 

1.13.13 For guidance on blood pressure management in adults with type 1 diabetes and evidence of renal involvement, see the section on blood pressure control in NICE's guideline on chronic kidney disease.

Delete recommendation 1.13.13 as the NICE guideline on chronic kidney disease no longer provides this information.

1.15.14 Maintain the person's blood pressure below 130/80 mmHg by adding other anti‑hypertensive drugs if necessary. 

1.15.14 Maintain the person's blood pressure (see recommendation 1.13.8 for blood pressure targets) by adding other anti‑hypertensive drugs if necessary.

Views of stakeholders

Seven stakeholders responded to the consultation. Six stakeholders agreed with our proposed editorial amendments or expressed no concerns. One stakeholder, which was a medical imaging company, disagreed with the wording for the amendment to recommendation 1.13.8 but the disagreement was deemed to be outside the scope of this amendment. Instead, the stakeholder's issues have been noted for future surveillance. See appendix B for consultation comments and responses for full details.

Equalities

One stakeholder stated that by relying solely on clinical judgement for assessing patients for target organ damage, multimorbidity or frailty, there will be an inherent bias in clinicians' assessment towards clinical experience gained from treating and serving a particular population that might adversely affect the correct diagnosis for those from underserved or minority backgrounds. This issue was deemed to be broader than this specific editorial amendment but has been noted for future surveillance.

Overall decision

We propose to editorially amend recommendations 1.13.8, 1.13.13 and 1.15.14 in NICE's guideline on type 1 diabetes in adults.

ISBN: 978-1-4731-4719-5


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