Pharmacological interventions to prevent type 2 diabetes (1)

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Interventions designed to improve diet and physical activity and reduce excess body weight and ectopic fat remain the cornerstone of treatment for type 2 diabetes risk reduction (see section 3). Recent developments in obesity pharmacotherapy create new possibilities for using these medications as an adjunct to diet and physical activity for the prevention of type 2 diabetes.

There are a number of digital weight-management technologies, available online or via an app, that can support prescribing and monitoring weight-management medicine.45

Good practice

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Consider onward referral to services, such as community link workers, where the individual has wider support needs.

The following recommendation, adapted from NICE PH38: Type 2 diabetes: prevention in people at high risk, applies when prescribing any of the medicines in this section.

Recommendation

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Encourage individuals to adopt a healthful diet and be as active as possible. Where appropriate, emphasise the added health and social benefits of physical activity.

 

Incretin-based therapies demonstrate the potential to treat obesity and type 2 diabetes and reduce cardiovascular disease risk.46-48

These medicines are licensed in the treatment of people living with obesity for use as an adjunct to a reduced-calorie diet and increased physical activity. Clinical trials demonstrated that when used alongside non-pharmacological therapies, incretin-based therapies were more effective for weight loss than non-pharmacological therapies alone.49,50

Glucagon-like peptide-1 receptor agonists

GLP-1 RAs mimic the GLP-1 hormone naturally produced in the body. They act by increasing insulin secretion, suppressing glucagon secretion, delaying gastric emptying so increasing satiety and acting via the central nervous system to reduce hunger and appetite. They can therefore be used to achieve and sustain weight loss for the prevention of type 2 diabetes. Liraglutide (Saxenda) is accepted for restricted use by the SMC as an adjunct to a reduced- calorie diet and increased physical activity for weight management in adults. The SMC restriction is people with BMI of ≥35 kg/m<sup>2</sup> * with:
  • Non-diabetic hyperglycaemia (prediabetes) at high risk of type 2 diabetes which is defined as having either:
ofasting plasma glucose level of 5.5–6.9 mmol/L or oHbA1c of 6.0–6.4% (42–47 mmol/mol), and
  • High risk of cardiovascular disease (CVD):
ototal cholesterol >5mmol/L, or ohigh-density lipoprotein (HDL) <1.0mmol/L for men and <1.3mmol/L for women, or osystolic blood pressure (SBP) >140mmHg oPatients should be treated in a specialist weight management service. Semaglutide (Wegovy) is accepted for restricted use by the SMC as an adjunct to a reduced- calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults. The SMC restriction is people with BMI of ≥30kg/m<sup>2</sup>* in the presence of at least one weight- related comorbidity. Patients should be treated in a specialist weight management service. *For both liraglutide and semaglutide, the SMC restriction notes that a lower BMI cut-off may be more appropriate for those from minority ethnic groups known to be at equivalent risk of the consequences of obesity at a lower BMI than the white population (see section 1.1.1).

Recommendation

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Liraglutide should be considered as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults with a BMI ≥35 kg/m2 with prediabetes (or lower for people from minority ethnic groups at increased risk of diabetes). Patients should be treated within a specialist weight management service.

Recommendation

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Semaglutide should be considered as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults with a BMI 30 kg/m2 with prediabetes (or lower for people from minority ethnic groups at increased risk of diabetes). Patients should be treated in a specialist weight management service.

The Scottish Government has issued a statement to NHS boards on a phased approach to implementation of the SMC advice (see section 7.1.4).

Glucose-dependent insulinotropic polypeptide dual receptor agonists

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