Type 2 diabetes in adults: management

  • NICE guideline
  • NG28
  • Published: 
  • Last updated: 
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Insulin-based treatments

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.

1.32 Starting an insulin-based treatment

1.32.1

Provide a structured education programme to adults with type 2 diabetes starting insulin therapy. The programme should include:

  • injection technique, including rotating injection sites and avoiding repeated injections at the same point within sites

  • self-monitoring

  • dose titration to target levels

  • dietary advice

  • the DVLA's Assessing fitness to drive: a guide for medical professionals

  • managing hypoglycaemia

  • managing acute changes in plasma glucose

  • support from a healthcare professional trained in insulin therapy. [2015, amended 2026]

1.32.2

When initiating insulin for adults with type 2 diabetes:

  • continue to offer metformin to people already taking it

  • stop any other medicines being used solely to manage hyperglycaemia

  • discuss with the person the risks and benefits of continuing medicines for other benefits such as cardiovascular protection or weight management. [2015, amended 2026]

For a short explanation of why the committee made the 2026 amendments to the recommendations and how they might affect practice, see the rationale and impact section on insulin-based treatments.

1.33 Choosing a type of insulin

1.33.1

Offer basal insulin intended for administration once or twice a day to adults with type 2 diabetes as initial insulin therapy. [2015, amended 2026]

1.33.2

As initial insulin therapy for adults with type 2 diabetes, especially if the person's HbA1c is 75 mmol/mol (9.0%) or higher, consider combining:

  • basal insulin intended for administration once or twice a day and

  • short or rapid acting insulin.

    This should be injected either separately or as a pre-mixed (biphasic) insulin preparation. [2015, amended 2026]

For a short explanation of why the committee made the 2026 amendments to the recommendations and how they might affect practice, see the rationale and impact section on insulin-based treatments.

1.34 Choosing a preparation

1.34.1

Make a shared decision with the person on the choice of basal insulin preparation, based on considerations that are specific to them, including whether:

  • the person needs help from a carer or healthcare professional to inject insulin or

  • there is a particular concern about nocturnal hypoglycaemia or

  • the person has a strong preference for once-daily injections.

    When multiple basal insulin types (including biosimilars) and regimens are equally suitable for the person's needs, use the least expensive option. [2015, amended 2026]

1.34.2

Consider pre-mixed preparations that include insulin analogues rather than including human insulin, if:

  • the person prefers injecting insulin immediately before a meal or

  • hypoglycaemia is a problem or

  • blood glucose levels rise markedly after meals. [2015, amended 2026]

For a short explanation of why the committee made the 2026 amendments to the recommendations and how they might affect practice, see the rationale and impact section on insulin-based treatments.

1.35 Reviews

1.35.1

At each review, check whether adults with type 2 diabetes who are on a basal insulin regimen also need a short or rapid acting bolus insulin before meals (or a pre-mixed [biphasic] insulin preparation). [2015, amended 2026]

1.35.2

At each review, check whether adults with type 2 diabetes who are using a pre-mixed (biphasic) preparation and whose individualised glycaemic targets are not met, need to change to:

  • a different pre-mixed (biphasic) insulin preparation or

  • a basal-bolus regimen with basal insulin intended for administration once or twice a day. [2015, amended 2026]

For a short explanation of why the committee made the 2026 amendments to the recommendations and how they might affect practice, see the rationale and impact section on insulin-based treatments.

1.35.4

When people are already using an insulin for which a lower cost biosimilar is available:

  • Discuss with the person the possibility of switching to the biosimilar.

  • Make a shared decision about it with them. [2021]

For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale section on long-acting insulin.

1.36 Insulin delivery