People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Healthcare professionals should follow our general guidelines for people delivering care:
Read this guideline alongside the NHS Type 2 diabetes Path to Remission Programme.
Measure HbA1c levels in adults with type 2 diabetes every:
3 to 6 months (tailored to individual needs) until HbA1c is stable on unchanging therapy
6 months once the HbA1c level and blood glucose lowering therapy are stable. [2015]
Measure HbA1c using methods calibrated according to International Federation of Clinical Chemistry (IFCC) standardisation. [2015]
If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using one of the following:
quality-controlled plasma glucose profiles
total glycated haemoglobin estimation (if abnormal haemoglobins)
fructosamine estimation. [2015]
Investigate unexplained discrepancies between HbA1c and other glucose measurements. Seek advice from a team with specialist expertise in diabetes or clinical biochemistry. [2015]
NICE has produced a patient decision aid on agreeing HbA1c targets, which also covers factors to weigh up when discussing HbA1c targets with patients.
Discuss and agree an individual HbA1c target with adults with type 2 diabetes (see recommendations 1.5.6 to 1.5.10). Encourage them to reach their target and maintain it, unless any resulting adverse effects (including hypoglycaemia), or their efforts to achieve their target impair their quality of life. Think about using the NICE patient decision aid on weighing up HbA1c targets to support these discussions. [2015, amended 2022]
Offer advice on healthy living, and medicines, to support adults with type 2 diabetes to reach and maintain their HbA1c target (see the sections on dietary advice, bariatric surgery, and person-centred medicines, and the NHS Better Health website). For more information about supporting adherence, see NICE's guideline on medicines adherence. [2015, amended 2026]
For adults whose type 2 diabetes is managed either by healthy living and diet, or healthy living and diet combined with an initial medication regimen that is not associated with hypoglycaemia (see the section on initial medicines), support them to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a medicine associated with hypoglycaemia, support them to aim for an HbA1c level of 53 mmol/mol (7.0%). [2015, amended 2026]
In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by the initial medication regimen and rise to 58 mmol/mol (7.5%) or higher:
reinforce advice about diet, healthy living and adherence to medicines and
support the person to aim for an HbA1c level of 53 mmol/mol (7.0%) and
intensify medicines. [2015, amended 2026]
Consider relaxing the target HbA1c level (see recommendations 1.5.7 and 1.5.8 and NICE's patient decision aid on type 2 diabetes: agreeing someone's blood glucose (HbA1c) target) on a case-by-case basis and in discussion with adults with type 2 diabetes, with particular consideration for people who are older or frailer, if:
they are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
tight blood glucose control would put them at high risk if they developed hypoglycaemia, for example, if they are at risk of falling, they have impaired awareness of hypoglycaemia, or they drive or operate machinery as part of their job
intensive management would not be appropriate, for example if they have significant comorbidities. [2015, amended 2022]
If adults with type 2 diabetes reach an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example deteriorating renal function or sudden weight loss. [2015]
For guidance on HbA1c targets in pregnancy, see NICE's guideline on diabetes in pregnancy. [2015]
These recommendations relate to self-monitoring by capillary blood glucose monitoring.
Take the Driver and Vehicle Licensing Agency (DVLA)'s Assessing fitness to drive: a guide for medical professionals into account when offering self‑monitoring of capillary blood glucose levels for adults with type 2 diabetes. [2015, amended 2022]
Do not routinely offer self-monitoring of capillary blood glucose levels for adults with type 2 diabetes unless:
the person is on insulin or
there is evidence of hypoglycaemic episodes or
the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery or
they are pregnant or are planning to become pregnant (see NICE's guideline on diabetes in pregnancy). [2015, amended 2022]
Consider short-term self-monitoring of capillary blood glucose levels in adults with type 2 diabetes, reviewing treatment as necessary:
when starting treatment with oral or intravenous corticosteroids or
to confirm suspected hypoglycaemia. [2015, amended 2022]
Be aware that adults with type 2 diabetes who have acute intercurrent illness are at risk of worsening hyperglycaemia. Review treatment as necessary. [2015]
If adults with type 2 diabetes are self-monitoring their capillary blood glucose levels, carry out a structured assessment at least annually. The assessment should include:
the person's self-monitoring skills
the quality and frequency of testing
checking that the person knows how to interpret the blood glucose results and what action to take
the impact on the person's quality of life
the continued benefit to the person
the equipment used. [2015, amended 2022]
Offer intermittently scanned continuous glucose monitoring (isCGM, commonly referred to as 'flash') to adults with type 2 diabetes on multiple daily insulin injections if any of the following apply:
they have recurrent hypoglycaemia or severe hypoglycaemia
they have impaired hypoglycaemia awareness
they have a condition or disability (including a learning disability or cognitive impairment) that means they cannot self-monitor their blood glucose by capillary blood glucose monitoring but could use an isCGM device (or have it scanned for them)
they would otherwise be advised to self-measure at least 8 times a day.
For guidance on continuous glucose monitoring (CGM) in pregnancy, see NICE's guideline on diabetes in pregnancy. [2022]
Offer isCGM to adults with insulin-treated type 2 diabetes who would otherwise need help from a care worker or healthcare professional to monitor their blood glucose. [2022]
Consider real-time continuous glucose monitoring (rtCGM) as an alternative to isCGM for adults with insulin-treated type 2 diabetes if it is available for the same or lower cost. [2022]
CGM should be provided by a team with expertise in its use, as part of supporting people to self-manage their diabetes. [2022]
Advise adults with type 2 diabetes who are using CGM that they will still need to take capillary blood glucose measurements (although they can do this less often). Explain that is because:
they will need to use capillary blood glucose measurements to check the accuracy of their CGM device
they will need capillary blood glucose monitoring as a back-up (for example when their blood glucose levels are changing quickly or if the device stops working).
Provide them with enough test strips to take capillary blood glucose measurements as needed. [2022]
If a person is offered rtCGM or isCGM but cannot or does not want to use any of these devices, offer capillary blood glucose monitoring. [2022]
Ensure CGM is part of the education provided to adults with type 2 diabetes who are using it (see the section on education). [2022]
Monitor and review the person's use of CGM as part of reviewing their diabetes care plan (see the section on individualised care). [2022]
If there are concerns about the way a person is using the CGM device:
ask if they are having problems using their device
look at ways to address any problems and concerns to improve their use of the device, including further education and emotional and psychological support. [2022]
Commissioners, providers and healthcare professionals should address inequalities in CGM access and uptake by:
monitoring who is using CGM
identifying groups who are eligible but who have a lower uptake
making plans to engage with these groups to encourage them to use CGM. [2022]
For a short explanation of why the committee made these 2022 recommendations and how they might affect practice, see the rationale and impact section on continuous glucose monitoring.
Full details of the evidence and the committee's discussion are in evidence review C: continuous glucose monitoring in adults with type 2 diabetes.
If an adult with type 2 diabetes has symptoms of hyperglycaemia, consider insulin (see the section on insulin-based treatments) or a sulfonylurea, and review treatment when blood glucose is within the targets set for the person. [2015]