Draft guideline re-sets clinical priorities in T2D management

Draft guidelines from NICE on type 2 diabetes published today (20 August 2025) signal a move away from a 'one-size-fits-all' approach, shifting from automatically starting everyone on one medicine to personalised treatment plans that aim to prevent cardiovascular and renal disease.

In what is described as ‘the biggest shake-up in care for a decade’ the draft guideline aims to re-set clinical priorities in line with the 10-Year Health Plan for the NHS to shift from treatment to prevention, through an approach designed to prevent the future complications of diabetes.

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).

NICE’s guideline committee has expanded access to SGLT-2 inhibitors (such as canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) from being second-line drugs to first-line treatment.

NICE has also relaxed its approach to GLP-1 receptor agonists, such as liraglutide or semaglutide, to enable patients with atherosclerotic cardiovascular disease to access them earlier rather than keeping them for later stages of treatment. Subutaneous 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. 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 ).

For patients who cannot tolerate metformin, the new guidelines recommend starting SGLT-2 inhibitors as monotherapy. The change has been made because of the indisputable evidence for their cardiovascular and renal protective effects, beyond blood glucose control.

NICE suggests that nearly 22,000 lives could be saved once uptake of the recommended changes for SGLT-2 inhibitors, as a joint first line treatment option with metformin, reach 90% of the patient population.

Professor Jonathan Benger, deputy chief executive and chief medical officer at NICE said the draft guideline ‘represents a significant evolution in how we approach type 2 diabetes treatment. We're moving beyond simply managing blood sugar to taking a holistic view of a person's health, particularly their cardiovascular and kidney health.

‘The evidence shows that certain medicines can provide important cardiovascular benefits, and by recommending them as part of initial treatment, we could help prevent heart attacks, strokes and other serious complications before they occur. This is particularly important given that cardiovascular disease is the leading cause of death in people with type 2 diabetes.’

The guidelines also address concerns about under-prescribing of SGLT-2 inhibitors, with real-world evidence showing these medicines are not being offered equitably across the UK. NICE analysed records of almost 590,000 people and found that SGLT-2 inhibitors are under-prescribed, particularly to women, older people, and Black or Black British individuals.

General practice nurses should use the individual patient’s next annual diabetes review to discuss which treatment options may be best for them.

RECOMMENDATIONS FOR DRUG THERAPY

The draft guideline introduces different treatment approaches based on patient characteristics and other health conditions:

• Adults with cardiovascular disease should be offered triple therapy including a GLP-1 receptor agonist.
• Adults with early onset type 2 diabetes (diagnosed before age 40) are offered dual therapy before a GLP-1 receptor agonist is considered.
• People living with obesity will receive specific treatment combinations.
• Those with chronic kidney disease have tailored recommendations based on their kidney function.
• Adults with frailty should be considered for metformin alone initially.

The new guidelines also include recommendations for adults who have multiple comorbidities or who may be frail, for whom a single drug, metformin, is recommended. If metformin alone fails to control blood glucose levels, they may be offered a DPP-4 inhibitor instead. NICE suggests their overall diabetes treatment plan to ensure that they are taking the smallest effective number of medications, at the lowest effective dosage.

Around 4.6 million people are diagnosed with diabetes in the UK according to Diabetes UK with about 90% of those having type 2. Additionally, it is estimated that almost 1.3 million people in the UK are likely to have undiagnosed type 2 diabetes.

The draft guideline is open for public consultation until Thursday 2 October 2025. NICE’s guideline committee will consider all feedback received before publishing the final recommendations at a date to be confirmed. The consultation document and details of how to respond are available on the NICE website at https://www.nice.org.uk/guidance/indevelopment/gid-ng10336/documents.