Guideline in a nutshell: Game-changing update to NICE guideline on type 2 diabetes

Draft guidance from NICE on the management of type 2 diabetes signals a sea-change from previous guidelines by introducing initial dual therapy with metformin and an SGLT2 inhibitor.

The guideline update moves away from NICE’s previous 'one-size-fits-all' approach, shifting from automatically starting everyone on one medicine (usually metformin) to personalised treatment plans that aim to prevent cardiovascular and renal disease.¹

In line with the 10-Year Health Plan for the NHS,² the guideline re-sets clinical priorities from treatment to prevention, through an approach designed to prevent the future complications of diabetes.

Significantly, the changes also bring NICE guidelines into closer alignment with guidance from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).³

NICE’s guideline development committee (GDC) has expanded access to SGLT2 inhibitors (such as canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) from being second-line drugs to first-line treatment, even for people with type 2 diabetes and no significant comorbidities.

The GDC says: ‘There is a significant body of evidence showing that type 2 diabetes management should aim at holistic health improvements (in particular, cardiovascular and renal protection), rather than just HbA1c targets.’

Comparisons of antidiabetic therapies have demonstrated that therapy combining metformin with an SGLT2 inhibitor was more clinically effective at reducing cardiovascular events than metformin alone or any other regimen combining metformin with one other diabetes medication.

The GDC explains: ‘Cardiovascular risk rises with age, therefore, while there is a younger group who are not currently at high risk of cardiovascular disease, they still have an increased lifetime risk, and they will all move into the high-risk group as they age.’

The consultation on the draft guideline closes on 2 October 2025, and the guideline has a provisional publication date of 18 February 2025.

THE RECOMMENDATIONS

INITIAL AND SUBSEQUENT THERAPY

Recommendation: For people with type 2 diabetes and no relevant comorbidities, offer:

• Metformin, and
• An SGLT2 inhibitor

If metformin is contraindicated or not tolerated, offer an SGLT2 inhibitor as mono-therapy.

For those who require further medicines to reach their glycaemic targets:

• Add a DPP-4 inhibitor to current treatment. If not tolerated or not effective, offer:
• A sulfonylurea
• Pioglitazone
• Insulin-based treatment

HEART FAILURE

Recommendation: For people with type 2 diabetes and heart failure (HF), offer:

• Metformin, and
• An SGLT2 inhibitor

If metformin is contraindicated or not tolerated, offer an SGLT2 inhibitor as mono-therapy.

Consider adding a GLP-1 receptor agonist (GLP-1 RA), specifically subcutaneous semaglutide, for adults with type 2 diabetes and HF who need further medication to reach their weight management targets, if:

• They are living with obesity
• There are no concerns about frailty that may increase the risk of adverse events with a GLP-1 RA, and
• They have a preserved ejection fraction.

If they need further treatment to reach their glycaemic targets, add:

• A sulfonylurea, or
• An insulin-based treatment.

ASCVD

For people with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD), NICE recommends initial triple therapy with metformin, and SGLT2 inhibitor and a GLP-RA.

Recommendation: For people with type 2 diabetes and ASCVD, offer:

• Metformin
• An SGLT2 inhibitor, and
• Subcutaneous semaglutide

Previously, GLP-1 RAs were reserved for later treatment phases (and subject to strict criteria for body mass index (BMI) and comorbidities), but the GDC considers that even though recommending this class of drug for some people as part of initial therapy will increase costs, early intervention could lead to weight loss, leading to better long term prognosis, and reduced need for other long term or later stage treatment.

Subcutaneous semaglutide can be added to current treatment for adults with type 2 diabetes who develop ASCVD after starting initial treatment.

Subcutaneous semaglutide can also be offered to adults with early onset type 2 diabetes (diagnosed before the age of 40), and adults with type 2 diabetes and obesity.

OBESITY

Recommendation: For people with type 2 diabetes living with obesity, offer:

• Metformin
• An SGLT2 inhibitor

If metformin is contraindicated or not tolerated, offer an SGLT2 inhibitor as monotherapy.

Consider adding a GLP-1 RA if they have been taking initial therapy for at least 3 months and require further medication to reach their glycaemic targets. If a GLP-1 RA is contraindicated, not tolerated, not appropriate, or not effective, add

• A sulfonylurea
• Pioglitazone, or
• An insulin-based treatment.

Tirzepatide (GIP/GLP-1 RA) can also be offered to some patients with type 2 diabetes that is insufficiently controlled. (See https://www.nice.org.uk/guidance/ta924/chapter/1-Recommendations (https://www.nice.org.uk/guidance/ta924/chapter/1-Recommendations)).

CHRONIC KIDNEY DISEASE

Recommendations for treatment vary according to the eGFR of the patient with both type 2 diabetes and chronic kidney disease (CKD). Prescribers are urged to refer to the individual summary of product characteristics for contraindications and precautions.

Recommendations: For people with type 2 diabetes and CKD, offer:

• eGFR above 30 ml/min/1.73m²: metformin and a SGLT2 inhibitor (either dapagliflozin or empagliflozin)
• eGFR between 20 and 30 ml/min/1.74m²: either dapagliflozin or empagliflozin alone
• eGFR below 20 ml/min/1.74m²: consider a DPP-4 inhibitor. If not tolerated or ineffective, consider:
  • Pioglitazone, or
  • Insulin-based treatment

FRAILTY

NICE recommends reviewing the overall treatment plan of adults with type 2 diabetes and frailty to ensure they are taking the smallest effective number of medications at the lowest effective dosage. The GDC said that concerns about adverse effects and polypharmacy meant that SGLT2 inhibitors may not be appropriate for some patients with clinically significant frailty. The GDC said there was no specific evidence to enable them to recommend a particular cut-off point, so the decision should be based on clinical judgement.

Recommendation: If the person has a level of frailty that puts them at risk of adverse events from SGLT2 inhibitors, offer:

• Metformin alone

If metformin is contraindicated or not tolerated, consider a DPP-4 inhibitor

INTRODUCING MEDICINES

NICE recommends introducing initial therapies one at a time, starting with metformin and checking tolerability. Once this has been established, an SGLT2 inhibitor can be started. If using a GLP-1 RA, start it as soon as the tolerability of the SGLT2 inhibitor has been confirmed.

When reviewing treatment, optimise the patient’s current treatment regimen before changing treatments, considering factors such as:

• Adverse effects
• Adherence to, and management of existing medicines
• The need to revisit advice about diet and self-management
• Prescribed doses and formulations

Reviewing medication

• For patients taking standard-release metformin, continue if it is effective and tolerated. If it is not tolerated, offer modified-release metformin.
• If the person has reached their glycaemic and weight targets, continue medicines that have contributed to these effects.
• Consider continuing SGLT2 inhibitors for their cardiovascular or renal benefits even if they do not help the individual achieve their glycaemic or weight targets
• Stop GLP-1 RAs if:
  • They do not help the person reach targets for blood glucose or weight
  • The person does not have ASCVD or early onset type 2 diabetes
• Take into account the possible adverse events from combining medications, e.g., hypoglycaemia,
• Do not offer a GLP-1RA and DPP-4 inhibitor together

INSULIN-BASED TREATMENTS

The insulin-based treatment recommendations have undergone a ‘pragmatic refresh’ to reflect the withdrawal of some insulin products and known insulin brand shortages. Based on the GDC’s clinical experience and consensus, this refresh acknowledges the increased use of analogue insulin. The committee agreed that:

• Different insulin therapies may be more useful for different people, depending on their symptoms (for example: if there is a risk of nocturnal hypoglycaemia, a longer acting basal insulin might be more suitable), and
• The added flexibility of recommending broad drug classes rather than specific insulins will support people with diabetes and healthcare professionals to choose the most suitable treatment.

1. NICE. Draft guideline on Type 2 diabetes: management; 20 August 2025. https://www.nice.org.uk/guidance/gid-ng10336/documents/450
2. NHS England. Fit for the future: 10 year health plan for England. https://www.england.nhs.uk/long-term-plan/
3. Davies MJ, ARoda VR, Collins BS, et al. Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2022;45(11):2753-86