Update information

July 2016: Recommendation 1.15.1 has been reworded to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen.

November 2015: A footnote has been added to recommendation 1.7.14, to state that metformin does not have a UK marketing authorisation for the recommended indication. A link to the NICE guideline on coeliac disease has been added to recommendation 1.12.1.

September 2015: 'that is' has been added to the wording of recommendation 1.7.2, to clarify that these regimens should not be offered.

August 2015: This guidance is an update of NICE guideline CG15 (published July 2004) and replaces the guidance for adults. It also updates and replaces NICE technology appraisal guidance 53 and NICE technology appraisal guidance 60.

It has not been possible to update all recommendations in this update of the guideline. Areas for review and update were identified and prioritised through the scoping process and stakeholder feedback. Areas that have not been reviewed in this update may be addressed in 2 years' time when NICE next considers updating this guideline. NICE is currently considering setting up a standing update committee for diabetes, which would enable more rapid update of discrete areas of the diabetes guidelines, as and when new and relevant evidence is published.

Recommendations are marked as [new 2015], [2015], [2004] or [2004, amended 2015]:

  • [new 2015] indicates that the evidence has been reviewed and the recommendation has been added or updated

  • [2015] indicates that the evidence has been reviewed but no change has been made to the recommended action

  • [2004] indicates that the evidence has not been reviewed since 2004

  • [2004, amended 2015] or [2004, amended 2016] indicates that the evidence has not been reviewed since 2004, but either changes have been made to the recommendation wording that change the meaning or NICE has made editorial changes to the original wording to clarify the action to be taken (see below).

Recommendations from NICE guideline CG15 that have been amended

Recommendations are labelled [2004, amended 2015] or [2004, amended 2016] if the evidence has not been reviewed but either:

  • changes have been made to the recommendation wording (indicated by highlighted text) that change the meaning or

  • NICE has made editorial changes to the original wording to clarify the action to be taken.

Recommendation in 2004 guideline

Recommendation in current guideline

Reason for change

Elements of an individualised and culturally appropriate plan will include:

  • sites and timescales of diabetes education including nutritional advice (see 'Approach to education', Section 1.8.1, and 'Dietary management', Section 1.8.3)

  • initial treatment modalities (see 'Insulin regimens', Section 1.9.3, and 'Insulin delivery', Section 1.9.4)

  • means of self‑monitoring (see 'Self‑monitoring of glucose level', Section 1.8.2)

  • means and frequency of communication with the professional team

  • follow‑up consultations including surveillance at annual review (see individual late complications recommendations)

  • management of arterial risk factors (see 'Control of arterial risk', Section 1.10). (1.12.1.2)

Elements of an individualised and culturally appropriate plan will include:

  • sites and timescales of diabetes education, including nutritional advice (see sections 1.3 and 1.4)

  • initial treatment modalities, including guidance on insulin injection and insulin regimens (see sections 1.7 and 1.8)

  • means of self‑monitoring and targets (see section 1.6)

  • symptoms, risk and treatment of hypoglycaemia

  • management of special situations, such as driving

  • means and frequency of communication with the diabetes professional team

  • management of cardiovascular risk factors (see section 1.13)

  • for women of childbearing potential, implications for pregnancy and family planning advice (see the NICE guideline on diabetes in pregnancy)

  • frequency and content of follow‑up consultations, including review of HbA1c levels and experience of hypoglycaemia, and annual review [2004, amended 2015] (1.1.7)

Additional elements have been included to make this recommendation comprehensive.

An individual care plan should be set up and reviewed annually, modified according to changes in wishes, circumstances and medical findings, and the details recorded. The plan should include aspects of:

  • diabetes education including nutritional advice (see 'Approach to education', Section 1.8.1, and 'Dietary management', Section 1.8.3)

  • insulin therapy (see 'Insulin regimens', Section 1.9.3, and 'Insulin delivery', Section 1.9.4)

  • self‑monitoring (see 'Self‑monitoring of glucose', Section 1.8.2)

  • arterial risk factor surveillance and management (see 'Control of arterial risk', Section 1.10)

  • late complications surveillance and management (see 'Identification and management of complications', Section 1.11)

  • means and frequency of communication with the professional care team

  • follow‑up consultations including next annual review. (1.7.1.4)

Set up an individual care plan jointly agreed with the adult with type 1 diabetes, review it annually and modify it taking into account changes in the person's wishes, circumstances and medical findings, and record the details. The plan should include aspects of:

  • diabetes education, including nutritional advice (see sections 1.3 and 1.4)

  • insulin therapy, including dose adjustment (see sections 1.8 and 1.9)

  • self‑monitoring (see section 1.6)

  • avoiding hypoglycaemia and maintaining awareness of hypoglycaemia

  • for women of childbearing potential, family planning, contraception and pregnancy planning (see the NICE guideline on diabetes in pregnancy)

  • cardiovascular risk factor monitoring and management (see section 1.13)

  • complications monitoring and management (see section 1.15)

  • means and frequency of communicating with the diabetes professional team

  • frequency and content of follow‑up consultations, including review of HbA1c levels and experience of hypoglycaemia, and next annual review. [2004, amended 2015] (1.2.5)

The word 'late' has been deleted (with respect to complications) because it implies advanced complications and takes the focus away from prevention. Some crucial aspects of a care plan have been added for completeness as they were not covered in the 2004 recommendation.

Information should also be made available on:

  • effects of different alcohol‑containing drinks on blood glucose excursions and calorie intake

  • use of high‑calorie and high‑sugar 'treats'

  • use of foods of high glycaemic index. (1.8.3.6)

Make information available on:

  • effects of different alcohol‑containing drinks on blood glucose excursions and calorie intake

  • use of high‑calorie and high‑sugar 'treats'. [2004, amended 2015] (1.4.10)

There is no evidence of benefit for a low glycaemic index diet (see recommendation 1.4.3), so the reference to giving information about foods of high glycaemic index has been deleted.

Information about the benefits of healthy eating in reducing arterial risk should be made available as part of dietary education in the period after diagnosis, and according to need and interest at intervals thereafter. This should include information about low glycaemic index foods, fruit and vegetables, and types and amounts of fat, and ways of making the appropriate nutritional changes. (1.8.3.7)

Make information available about the benefits of healthy eating in reducing cardiovascular risk as part of dietary education in the period after diagnosis, and according to need and interest at intervals thereafter. Include information about fruit and vegetables, types and amounts of fat, and ways of making the appropriate nutritional changes. [2004, amended 2015] (1.4.11)

There is no evidence of benefit for a low glycaemic index diet (see recommendation 1.4.3), so the reference about giving information about foods of low glycaemic index has been deleted.

All healthcare professionals providing advice on the management of type 1 diabetes should be aware of appropriate nutritional advice on common topics of concern and interest to adults living with type 1 diabetes, and should be prepared to seek advice from colleagues with more specialised knowledge. Suggested common topics include:

  • glycaemic index of specific foods

  • body weight, energy balance and obesity management

  • cultural and religious diets, feasts and fasts

  • foods sold as 'diabetic'

  • sweeteners

  • dietary fibre intake

  • protein intake

  • vitamin and mineral supplements

  • alcohol

  • matching carbohydrate, insulin and physical activity

  • salt intake in hypertension

  • co‑morbidities including nephropathy and renal failure,

  • coeliac disease, cystic fibrosis or eating disorders

  • use of peer support groups. (1.8.3.9)

Be aware of appropriate nutritional advice on common topics of concern and interest to adults living with type 1 diabetes, and be prepared to seek advice from colleagues with more specialised knowledge. Suggested common topics include:

  • body weight, energy balance and obesity management

  • cultural and religious diets, feasts and fasts

  • foods sold as 'diabetic'

  • sweeteners

  • dietary fibre intake

  • protein intake

  • vitamin and mineral supplements

  • alcohol

  • matching carbohydrate, insulin and physical activity

  • salt intake in hypertension

  • comorbidities, including nephropathy and renal failure, coeliac disease, cystic fibrosis or eating disorders

  • use of peer support groups. [2004, amended 2015] (1.4.13)

There is no evidence of benefit for a low glycaemic index diet (see recommendation 1.4.3), so the reference about giving information about the glycaemic index of foods has been deleted.

Self‑monitoring skills should be taught close to the time of diagnosis and initiation of insulin therapy. (1.8.2.2)

Teach self‑monitoring skills at the time of diagnosis and initiation of insulin therapy. [2004, amended 2015] (1.6.16)

The GDG stated that it is important that self‑monitoring skills are taught as soon as type 1 diabetes is diagnosed.

Monitoring using sites other than the fingertips (often the forearm, using meters that require small volumes of blood and devices to obtain those small volumes) cannot be recommended as a routine alternative to conventional self‑blood glucose monitoring. (1.8.2.8)

Monitoring blood glucose using sites other than the fingertips cannot be recommended as a routine alternative to conventional self‑monitoring of blood glucose. [2004, amended 2015] (1.6.20)

Blood glucose has been stated for clarity. The statements about small volumes and special devices for alternative site monitoring have been removed because (1) the 2015 guideline supports the 2004 view that alternative site monitoring is not recommended, so the comment is redundant and (2) all meters now use small volumes.

For adults with erratic and unpredictable blood glucose control (hyper‑ and hypoglycaemia at no consistent times), rather than a change in a previously optimised insulin regimen, the following should be considered:

  • resuspension of insulin and injection technique

  • injection sites

  • self‑monitoring skills

  • knowledge and self‑management skills

  • nature of lifestyle

  • psychological and psychosocial difficulties

  • possible organic causes such as gastroparesis. (1.9.3.12)

For adults with erratic and unpredictable blood glucose control (hyperglycaemia and hypoglycaemia at no consistent times), rather than a change in a previously optimised insulin regimen, the following should be considered:

  • injection technique

  • injection sites

  • self‑monitoring skills

  • knowledge and self‑management skills

  • nature of lifestyle

  • psychological and psychosocial difficulties

  • possible organic causes such as gastroparesis. [2004, amended 2015] (1.7.12)

Reference to resuspension of insulin is out of date and so has been deleted.

Adults with diabetes should be provided with suitable containers for the collection of used needles. Arrangements should be available for the suitable disposal of these containers. (1.9.4.7)

Provide adults with type 1 diabetes with suitable containers for collecting used needles and other sharps. Arrangements should be available for the suitable disposal of these containers. See also section 1.1.4 of the NICE guideline on infection control. [2004, amended 2015] (1.8.6)

Mention of other sharps and cross‑reference to the NICE guideline on infection control added to the recommendation.

The injection‑site condition should be checked annually and if new problems with blood glucose control occur. (1.9.4.8)

Check injection site condition at least annually and if new problems with blood glucose control occur. [2004, amended 2015] (1.8.7)

The GDG clarified that injection site condition can be checked more frequently than annually if appropriate.

Adults with type 1 diabetes should be informed that any available glucose/sucrose‑containing fluid is suitable for the management of hypoglycaemic symptoms or signs in people who are able to swallow. Glucose‑containing tablets or gels are also suitable for those able to dissolve or disperse these in the mouth and swallow the products. (1.9.5.1)

Explain to adults with type 1 diabetes that a fast‑acting form of glucose is needed for the management of hypoglycaemic symptoms or signs in people who are able to swallow. [2004, amended 2015] (1.10.10)

The GDG clarified that a fast‑acting form of glucose can be used for managing hypoglycaemia. The text specifying tablets or gels has been deleted. Glucogel is no longer listed in the BNF. The BNF also advises that other suitable forms of glucose can be used and therefore we did not want to state that only gels and tablets are appropriate..

Adults with decreased level of consciousness due to hypoglycaemia who are unable to take oral treatment safely should be:

  • given intramuscular glucagon by a trained user (intravenous glucose may be used by professionals skilled in obtaining intravenous access)

  • monitored for response at 10 minutes, and then given intravenous glucose if the level of consciousness is not improving significantly

  • then given oral carbohydrate when it is safe to administer it, and placed under continued observation by a third party who has been warned of the risk of relapse. (1.9.5.3)

Adults with type 1 diabetes with a decreased level of consciousness as a result of hypoglycaemia and so are unable to take oral treatment safely should be:

  • given intramuscular glucagon by a family member or friend who has been shown how to use it (intravenous glucose may be used by healthcare professionals skilled in obtaining intravenous access)

  • monitored for response at 10 minutes, and then given intravenous glucose if their level of consciousness is not improving significantly

  • then given oral carbohydrate when it is safe to administer it, and placed under continued observation by a third party who has been warned of the risk of relapse. [2004, amended 2015] (1.10.11)

The GDG clarified that this recommendation relates to people who are unable to protect their airway because of a decreased level of consciousness.

Glucagon can be administered in an emergency situation. The Human Medicines Regulations 2012 schedule 19 lists glucagon as a medicine that can be administered in an emergency without a prescription. The MHRA states that 'Regulation 238 of the Human Medicines Regulations 2012 allows for certain prescription only medicines to be administered by anyone for the purpose of saving life in an emergency. The medicines this concerns are covered in Schedule 19 and are listed below.' Therefore the recommendation has been changed to reflect that intramuscular glucagon does not have to be given by a trained user.

Nocturnal hypoglycaemia (symptomatic or detected on monitoring) should be managed by:

  • reviewing knowledge and self‑management skills

  • reviewing current insulin regimen and evening eating habits and previous physical activity.

  • choosing an insulin type and regimen with less propensity to induce low glucose levels in the night hours, such as:

    • isophane (NPH) insulin at bedtime

    • rapid‑acting analogue with the evening meal

    • long‑acting insulin analogues (insulin glargine)

    • insulin pump. (1.9.5.8)

Manage nocturnal hypoglycaemia (symptomatic or detected on monitoring) by:

  • reviewing knowledge and self‑management skills

  • reviewing current insulin regimen, evening eating habits and previous physical activity

  • choosing an insulin type and regimen that is less likely to induce low glucose levels at night. [2004, amended 2015] (1.10.14)

Details about insulin types have been deleted because the information is out of date and inconsistent with other recommendations in this guideline.

In adults with type 1 diabetes who have a low body mass index or unexplained weight loss, markers of coeliac disease, should be assessed. (1.12.4.1)

In adults with type 1 diabetes who have a low BMI or unexplained weight loss, assess markers of coeliac disease. For guidance on testing for coeliac disease, see the NICE guideline on coeliac disease. [2004, amended 2015] (1.12.1)

Cross‑reference to relevant NICE guideline added.

Healthcare professionals should be alert to the possibility of the development of other autoimmune disease in adults with type 1 diabetes (including Addison's disease, pernicious anaemia and thyroid disorders). (1.12.4.2)

Be alert to the possibility of the development of other autoimmune disease in adults with type 1 diabetes (including Addison's disease and pernicious anaemia). For advice on monitoring for thyroid disease, see recommendation 1.15.40. [2004, amended 2015] (1.12.2)

Mention of thyroid disorders has been deleted because thyroid disease is now covered by a separate recommendation to measure TSH levels at annual review.

Adults who have had myocardial infarction or stroke should be managed intensively, according to relevant non‑diabetes guidelines. In the presence of angina or other ischaemic heart disease, beta‑adrenergic blockers should be considered. (For use of insulin in these circumstances, see 'Hospital administration and intercurrent disease', Section 1.12.3.) (1.10.2.8)

Provide intensive management for adults who have had myocardial infarction or stroke, according to relevant non‑diabetes guidelines. In the presence of angina or other ischaemic heart disease, beta‑adrenergic blockers should be considered. (For use of insulin in these circumstances, see section 1.14). For guidance on secondary prevention of myocardial infarction, see the NICE guideline on MI – secondary prevention. [2004, amended 2015] (1.13.7)

Cross‑reference to relevant NICE guideline added.

A trial of a low‑dose thiazide diuretic should be started as first‑line therapy for raised blood pressure, unless the person with type 1 diabetes is already taking a renin‑angiotensin system blocking drug for nephropathy (see 'Nephropathy', Section 1.1 1.2). Multiple drug therapy will often be required. (1.10.3.3)

Start a trial of a renin–angiotensin system blocking drug as first‑line therapy for hypertension in adults with type 1 diabetes. [2004, amended 2015] (1.13.10)

The GDG did not review the evidence for this recommendation. However, the NICE guidance on hypertension has changed since CG15 was published in 2004, and thiazides are no longer first‑line therapy for any age group. Thiazides can elevate blood glucose. The GDG recommend renin–angiotensin system blockers as first‑line therapy. They are recommended in NICE's hypertension guideline as first‑line therapy for people under 55 years, which accounts for most adults with type 1 diabetes and hypertension. For people over 55 years who do not have renal impairment, the NICE hypertension guideline recommends calcium channel blockers. As soon as renal impairment or albuminuria is detected, a renin–angiotensin system blocker is recommended for renal protection. Therefore it is sensible to recommend a renin–angiotensin blocker as first‑line therapy for all adults with type 1 diabetes if they have hypertension. Mention of nephropathy has been removed; guidance on nephropathy is given in recommendation 1.15.19.

Throughout the course of an inpatient admission, the personal expertise of adults with type 1 diabetes (in managing their own diabetes) should be respected and routinely integrated into ward‑based blood glucose monitoring and insulin delivery, using the person with type 1 diabetes' own system. This should be incorporated into the nursing care plan. (1.12.3.2)

Throughout the course of an inpatient admission, respect the personal expertise of adults with type 1 diabetes (in managing their own diabetes) and routinely integrate this into ward‑based blood glucose monitoring and insulin delivery. [2004, amended 2015] (1.14.8)

The GDG advised removing 'using the person's own systems', because hospitals increasingly use monitoring systems that are quality controlled and recorded automatically into electronic patient records that can be reviewed remotely by the diabetes professional team. The updated recommendation does not preclude the person using their own system in addition to the hospital system if they wish to do so. Use of such hospital monitoring systems improves patient care.

Concerns over potential side effects should not be allowed to inhibit advising and offering the necessary use of any class of drugs, unless the side effects become symptomatic or otherwise clinically significant. In particular:

  • selective beta‑adrenergic blockers should not be avoided in adults on insulin

  • low‑dose thiazides may be combined with beta‑blockers

  • when calcium channel antagonists are prescribed, only long‑acting preparations should be used

  • direct questioning should be used to detect the potential side effects of erectile dysfunction, lethargy and orthostatic hypotension with different drug classes. [1.10.3.5]

Do not allow concerns over potential side effects to inhibit advising and offering the necessary use of any class of drugs, unless the side effects become symptomatic or otherwise clinically significant. In particular:

  • do not avoid selective beta‑adrenergic blockers where indicated in adults on insulin

  • low‑dose thiazides may be combined with beta‑blockers

  • when calcium channel antagonists are prescribed, use only long‑acting preparations

  • use direct questioning to detect the potential side effects of erectile dysfunction, lethargy and orthostatic hypotension with different drug classes. (1.13.12)

The GDG added 'where indicated' because the indications for beta blockers in pure hypertension are much more reduced now than in 2004.

Depending on the findings, structured eye surveillance should be followed by:

  • routine review in 1 year, or

  • earlier review, or

  • referral to an ophthalmologist. (1.11.1.2)

Depending on the findings, follow structured eye screening by:

  • routine review annually or

  • earlier review or

  • referral to an ophthalmologist. [2004, amended 2015] (1.15.2)

The recommendation has been amended to clarify that review should be annual.

Digital retinal photography should be implemented for eye surveillance programmes for adults with type 1 diabetes. (1.11.1.5)

Offer digital retinopathy screening annually to adults with type 1 diabetes. [2004, amended 2015] (1.15.4)

The recommendation has been amended in line with the National Screening Programme.

1.11.1.10 Referral to an ophthalmologist should occur for:

  • referable maculopathy:

  • exudate or retinal thickening within 1 disc diameter of the centre of the fovea

  • circinate or group of exudates within the macula (the macula is defined here as a circle centred on the fovea, of a diameter the distance between the temporal border of the optic disc and the fovea)

  • any microaneurysm or haemorrhage within 1 disc diameter of the centre of the fovea, only if associated with a best visual acuity of 6/12 or worse

  • referable pre‑proliferative retinopathy:

  • any venous beading

  • any venous loop or reduplication

  • any intraretinal microvascular abnormalities (IRMA)

  • multiple deep, round or blot haemorrhages (If cotton wool spots are present, look carefully for the above features, but cotton wool spots themselves do not define pre‑proliferative retinopathy)

  • any unexplained drop in visual acuity. (1.11.1.10)

Refer to an ophthalmologist for:

  • referable maculopathy:

  • exudate or retinal thickening within 1 disc diameter of the centre of the fovea

  • circinate or group of exudates within the macula (the macula is defined here as a circle centred on the fovea, of a diameter the distance between the temporal border of the optic disc and the fovea)

  • any microaneurysm or haemorrhage within 1 disc diameter of the centre of the fovea, only if associated with a best visual acuity of 6/12 or worse

  • referable pre‑proliferative retinopathy:

  • any venous beading

  • any venous reduplication

  • any intraretinal microvascular abnormalities (IRMA)

  • multiple deep, round or blot haemorrhages

(If cotton wool spots are present, look carefully for the above features, but cotton wool spots themselves do not define pre‑proliferative retinopathy)

  • any large sudden unexplained drop in visual acuity. [2004, amended 2015] (1.15.9)

The recommendations on eye disease were reviewed by the National Screening Programme and were amended to make them consistent with the current practice of the diabetes eye screening programme.

ACE inhibitors should be started and, with the usual precautions, titrated to full dose in all adults with confirmed nephropathy (including those with microalbuminuria alone) and type 1 diabetes. (1.11.2.5)

Start angiotensin‑converting enzyme (ACE) inhibitors and, with the usual precautions, titrate to full dose in all adults with confirmed nephropathy (including those with moderately increased albuminuria ['microalbuminuria'] alone) and type 1 diabetes. [2004, amended 2015] (1.15.14)

The term 'moderately increased albuminuria' has been added, for consistency with the classification used in the NICE guideline on chronic kidney disease.

If ACE inhibitors are not tolerated, angiotensin 2 receptor antagonists should be substituted. Combination therapy is not recommended at present. (1.11.2.6)

If ACE inhibitors are not tolerated, substitute angiotensin 2 receptor antagonists. Combination therapy is not recommended. [2004, amended 2015] (1.15.15)

'at present' has been removed in view of evidence known to the GDG that the combination can be harmful, increasing risk of hyperkalaemia and acute renal injury.

The management of the symptoms of autonomic neuropathy should include standard interventions for the manifestations encountered (for example, for erectile dysfunction or abnormal sweating). (1.11.4.9)

When managing the symptoms of autonomic neuropathy, include standard interventions for the manifestations encountered (for example, for abnormal sweating and postural hypotension). [2004, amended 2015] (1.15.23)

The GDG added postural hypertension because this is an important manifestation of autonomic neuropathy. There are now separate recommendations about managing erectile dysfunction (1.15.30–1.15.32) and gastroparesis (1.15.1–1.15.4).

Diabetes professionals should ensure that they have appropriate skills in the detection and basic management of non‑severe psychological disorders in people from different cultural backgrounds. They should be familiar with appropriate counselling techniques and appropriate drug therapy, while arranging prompt referral to specialists of those people in whom psychological difficulties continue to interfere significantly with well‑being or diabetes self‑management. (1.12.5.2)

Diabetes professionals should:

  • ensure that they have appropriate skills in the detection and basic management of non‑severe psychological disorders in people from different cultural backgrounds

  • be familiar with appropriate counselling techniques and drug therapy, while arranging prompt referral to specialists of those people in whom psychological difficulties continue to interfere significantly with wellbeing or diabetes self‑management.

See also the NICE guidelines on common mental health disorders, generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults and depression in adults with a chronic health problem. [2004, amended 2015] (1.15.42)

Cross‑references to relevant NICE guidelines have been added for information.

Members of multidisciplinary professional teams should be alert to the possibility of bulimia nervosa, anorexia nervosa and insulin dose manipulation in adults with type 1 diabetes with:

• over‑concern with body shape and weight

• low body mass index

• poor overall blood glucose control. (1.12.6.1)

Members of diabetes professional teams should be alert to the possibility of bulimia nervosa, anorexia nervosa and insulin dose manipulation in adults with type 1 diabetes with:

  • over‑concern with body shape and weight

  • low BMI

  • hypoglycaemia

  • suboptimal overall blood glucose control.

See also the NICE guideline on eating disorders. [2004, amended 2015] (1.15.43)

The GDG stated that hypoglycaemia is another possible indicator of eating disorders.

Cross‑reference to the relevant NICE guideline has been added for information.

1.13.2, 1.13.9, 1.15.13

Change made from '[abnormal] albumin excretion rate' to 'albuminuria' for accuracy.

1.2.4, 1.3.8, 1.4.8, 1.11.6, 1.11.8, 1.11.10, 1.11.12, 1.13.9, 1.15.1, 1.15.6, 1.15.7, 1.15.8

NICE has made editorial changes to the original wording to clarify the action to be taken (no change to meaning): a verb has been added, the verb used has been changed or other wording has changed for clarification.

  • National Institute for Health and Care Excellence (NICE)