Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice.
Continuous glucose monitoring
Recommendations 1.7.1 to 1.7.10
Why the committee made the recommendations
The committee discussed how continuous glucose monitoring (CGM) could potentially be useful for many people with type 2 diabetes. They were aware of examples from current practice in which adults who have insulin-treated type 2 diabetes and use intermittently scanned CGM (isCGM) have had good outcomes. Because of the additional cost associated with CGM and the large number of adults with type 2 diabetes, the committee used both the evidence and their clinical experience to decide who would gain the most benefit from using CGM.
There was evidence that isCGM was cost effective for adults with type 2 diabetes using insulin, but no evidence for populations not using insulin, so the committee agreed to restrict their recommendations to adults using insulin.
People who have recurrent or severe hypoglycaemic events were identified as one of the groups likely to benefit most from isCGM, because hypoglycaemic events were considered to be one of the most important and concerning outcomes for adults with type 2 diabetes who are using insulin. The committee decided that the number of hypoglycaemic events was a more effective indicator of someone who would benefit from isCGM than specific HbA1c target values, because target values can vary between people. The evidence also indicated minimal effects of isCGM on HbA1c values.
The committee agreed that people with impaired hypoglycaemic awareness would also benefit from isCGM. However, they did not recommend specific methods for assessing impaired hypoglycaemic awareness. This is because validated methods for assessing impaired hypoglycaemic awareness in people with type 2 diabetes (such as the GOLD or Clarke scores) are not always available in primary care.
People who use insulin and have a condition or disability that restricts their ability to self-monitor blood glucose levels should also be offered isCGM. This is because having access to isCGM means they will no longer have to rely on others to monitor their diabetes, potentially increasing their independence.
People who need help from a care worker or other healthcare professional to administer their insulin injections should also be offered isCGM, even if they only use once-daily insulin injections. isCGM will help care workers to record a person's blood glucose levels quickly. And for people who have multiple home care visits per day, blood glucose levels can be recorded at each visit. This will help them to adjust their insulin levels to reduce the risk of hypoglycaemic events between home visits. It may also reduce the number of hospital admissions for this group.
The committee discussed how short-term use of isCGM may still be useful for some people. It may help people to understand when they have hypoglycaemic episodes, which would help them to develop a more effective treatment plan.
There was no evidence that rtCGM was cost effective for people with type 2 diabetes, so the committee agreed it could not be recommended for all adults with type 2 diabetes (whether or not they used insulin). They noted, however, that prices of rtCGM have reduced over the past few years, and if this continues to happen there may come a time when it is no more expensive than isCGM. At this point, rtCGM would be an appropriate alternative for people who meet the criteria for isCGM.
The committee did not make a recommendation on using specific devices because CGM technologies are changing very quickly and this recommendation would soon be out of date. Local healthcare services are better placed to assess which devices are evidence-based and suitable for use at any given time.
The committee discussed how self-monitoring of blood glucose should still take place, albeit less frequently, even when a person is using CGM. The ability to self-monitor blood glucose levels allows people to ensure the accuracy of the CGM device. The committee also recommended keeping capillary blood glucose monitoring as a back-up for situations such as when the technology fails.
The committee decided to highlight that CGM should be provided by a team who have expertise in its use. To ensure that CGM is effective, healthcare professionals need to have the skills to interpret and communicate the data effectively. As well as healthcare professionals having a clear understanding of CGM, it is also crucial that people with type 2 diabetes who are using CGM have education about the technology. This will increase the likelihood that people will scan and report the results frequently, allowing people to understand and manage their diabetes effectively.
Although many people will choose CGM if offered, there are some people who either cannot be offered it or do not want to use it. Because it is still important for these people to monitor their blood glucose levels, the committee made a recommendation to reinforce the importance of offering capillary blood glucose monitoring instead.
The committee did not make a recommendation on how long CGM should be used because there was no evidence on this, and they did not want to stop people accessing CGM for short periods if they and their healthcare professional thought they could benefit from this. Using CGM for a short period of time may help some people to understand when they have hypoglycaemic episodes, thereby helping them to develop a more effective treatment plan.
Despite the positive recommendations on CGM, the committee were concerned that existing health inequalities may still lead to lower uptake of CGM in some groups of people. To address this, the committee made a recommendation outlining actions for commissioners, providers and healthcare professionals.
The committee highlighted the importance of routinely reviewing a person's use of CGM. This will establish whether it is providing clinical benefits and whether the monitor is being used correctly. Making people aware that their use of CGM will be continually reviewed is important so they know it is not a guaranteed long-term option.
The committee also made a recommendation for research on using routinely collected real-world data to assess the effectiveness and cost effectiveness of CGM. They agreed that this has the potential to show the direct effects of the technology used by people with type 2 diabetes instead of interpreting it through the results of clinical trials. Increased monitoring of routine healthcare data including registries and audits would ensure that findings from a broader population are captured.
How the recommendations might affect practice
The recommendations are likely to increase the number of adults with type 2 diabetes who are offered CGM, particularly those who have issues with hypoglycaemia. This will have associated cost implications:
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It may save the NHS time, because healthcare professionals do not have to meet people who are using CGM as often as people who use capillary blood glucose monitoring.
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There should be fewer hypoglycaemic events to manage.
The committee did not expect a significant resource impact related to education and monitoring for the CGM devices.
Involving people in medicine discussions
Recommendations 1.9.1 to 1.9.5
Why the committee made the recommendations
Continuing care is critical to ensuring good outcomes for people with type 2 diabetes. Therefore, the committee made a recommendation about advice on healthy living, including physical activity, losing weight, quitting smoking and drinking less alcohol. It also includes a link to the NHS Path to Remission programme, which is of great importance. While the committee did not find any evidence of using medicines to support remission, considering how to use medicines alongside the programme to support remission is key to preventing long-term adverse events.
The committee agreed that discussing the effects of each medicine ahead of time was important. They agreed the discussion should include the effectiveness of the medicine on glycaemic and cardiometabolic response, whether it has cardiovascular and renal protection benefits and any adverse effects or other problems that someone could experience and that could be a barrier to adherence. The committee agreed that working together in this way would help to promote concordance and improve long-term adherence, leading to better outcomes.
Guidance was agreed for when people have more than one comorbidity. For most people, initial therapy should consist of an SGLT‑2 inhibitor combined with modified‑release metformin, although metformin alone may be used when frailty makes SGLT‑2 inhibitors unsuitable. People with chronic kidney disease require kidney‑specific prescribing adjustments, which may involve dose changes, choosing SGLT‑2 inhibitors licensed for renal impairment or substituting metformin with a DPP‑4 inhibitor if appropriate. Early treatment with GLP‑1 receptor agonists may be appropriate for those at high cardiovascular or renal risk, with subcutaneous semaglutide (Ozempic), up to 1 mg once a week, recommended for people with atherosclerotic cardiovascular disease. Any GLP-1 receptor agonist or tirzepatide can be considered for early onset type 2 diabetes, with tirzepatide being considered for the glycaemic benefits.
The committee noted that there is a particular risk for women, trans men and non-binary people of childbearing potential in this group who take GLP-1 receptor agonists or tirzepatide. The committee agreed that the effects of such a medicine can lead to improved fertility. MHRA guidance on GLP-1 medicines recommends that GLP-1 receptor agonists and tirzepatide should not be taken during pregnancy and breastfeeding because there is not enough safety data to know whether doing this can cause harm. It also recommended that all people of childbearing potential should take steps to ensure they do not become pregnant while taking a GLP-1 receptor agonist or tirzepatide and for a duration after taking it (this duration depends on the specific medicine the person takes). The committee noted this was particularly important for people with early onset type 2 diabetes because of their age and this guideline's recommendations to consider GLP-1 receptor agonists or tirzepatide for this group.
The language healthcare professionals use can have an impact. People with type 2 diabetes can experience a lot of stigma in discussions about medications, even when healthcare professionals are not doing this intentionally. People can also struggle with stereotypes about diabetes and weight. This can lead to them feeling blame, shame and guilt, which can have a significant impact on their wellbeing. Stigma and stereotypes can also make it difficult for people to start or continue taking medication. The committee's experience was that this is quite common. So, it's important that particular efforts are being made to get the words right in conversations about medication. More guidance on communication for healthcare professionals can be found in NHS England's guide to language and diabetes.
How the recommendations might affect practice
Improvements in long-term adherence lead to better outcomes. They are more likely if medicine options are discussed with the person using non-judgemental language. The person should feel involved in decisions made regarding their cardiometabolic targets and comorbidities.
Sick day rules
Why the committee made the recommendation
Sick day rules are common in diabetes care, but in the committee's experience there are inconsistencies in practice. In particular, the committee have seen issues with people having medications stopped but not started again. The recommendation will improve consistency and quality of care in this area.
How the recommendation might affect practice
Including sick day rules in people's treatment plans may help avoid delays in providing the right medication and treating any underlying illness. This may reduce the chance of adverse events or shorten hospital stays (or avoid the need for a stay altogether), which would reduce costs.
Assessing risk before starting medicines
Recommendations 1.11.1 and 1.11.2
Why the committee made the recommendations
Assessing cardiovascular status
The committee agreed it was important to assess people's cardiovascular status and risk to help determine which treatments are suitable for them. The definition they used for the established cardiovascular disease groups (adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease) reflects the people included in all the clinical trials and modelled as a subgroup in the economic model.
Assessing frailty
Adverse treatment effects and polypharmacy are a particular concern for people with frailty. The committee did not review the evidence on specific criteria that should trigger a frailty assessment, so healthcare professionals will need to use clinical judgement for this.
How the recommendations might affect practice
Assessing for cardiovascular risk and frailty before initiating medicines may reduce the need for additional appointments further down the treatment pathway for:
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cardiovascular and renal comorbidities or
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concerns regarding frailty and adverse events.
This is because it will ensure that a person takes medicines most suited to their personal situation from the start.
Addressing inequalities in use of SGLT-2 inhibitors
Why the committee made the recommendation
Analysis showed that, for people with type 2 diabetes who are eligible to receive SGLT-2 inhibitors, the uptake was low considering it was recommended by NICE since 2022. This was associated with age, gender, ethnicity and areas of deprivation. To address this issue, the committee made a recommendation outlining actions for commissioners, providers and healthcare professionals to identify those who are eligible to receive SGLT-2 inhibitors but who are currently not taking them, and to encourage them to do so. Achieving higher and more equal uptake of SGLT-2 inhibitors will mean that people living in the most deprived areas will experience greater net benefits.
This, combined with the recommendation for research to assess how prescribing and access to SGLT-2 inhibitors can be improved for people with type 2 diabetes from the most deprived groups, may help to address health inequalities.
How the recommendation might affect practice
The recommendation will encourage the assessment of SGLT-2 inhibitor uptake in different groups of people to ensure universal access to treatment. This would increase the number of people taking SGLT-2 inhibitors and help to address health inequalities. This may require additional resources to make interventions to support people in more deprived areas. However, this is more likely to reduce poor outcomes in the long term by supporting people who are more likely to experience adverse health outcomes.
Initial medicines: people with type 2 diabetes and no relevant comorbidities
Recommendations 1.13.1 and 1.13.2
Why the committee made the recommendations
Metformin and SGLT-2 inhibitors
There is good evidence that managing type 2 diabetes should aim to improve health holistically (in particular, cardiovascular and renal protection), rather than just aim to meet HbA1c targets.
The evidence on antidiabetic therapies covered a diverse patient group, including, in varying proportions, people:
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with multiple cardiovascular risk factors
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with atherosclerotic cardiovascular disease, heart failure or chronic kidney disease
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who likely had a lower cardiovascular risk.
The committee agreed that this population likely reflected the population that will be seen most often in general practice.
Overall, network and pairwise meta-analyses comparing antidiabetic therapies showed that treatment combining metformin with an SGLT-2-inhibitor was more clinically effective at reducing HbA1c, weight and cardiovascular events than:
-
any other therapy combining metformin with 1 other medicine, and
-
metformin alone.
Cardiovascular events covered by the evidence included cardiovascular mortality, myocardial infarction, non-fatal stroke and hospitalisation for heart failure.
The evidence also showed that canagliflozin and dapagliflozin reduced the risk of end-stage renal failure.
Benefits outweigh the risk of adverse events
The committee weighed the greater likelihood of cardiovascular and renal benefits against the risk of volume depletion and genital mycotic infections. The evidence found that, in people taking metformin combined with an SGLT-2 inhibitor, compared with those who did not take an SGLT-2 inhibitor, there were reductions in the number of:
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deaths from cardiovascular disease
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heart attack or stroke 3-item MACE
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hospitalisation for heart failure.
The evidence found, for example, that:
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123 out of 1,000 people who did not take an SGLT-2 inhibitor had a major adverse cardiovascular event, known as a 3-item MACE event, over 3 years (that is, a non-fatal myocardial infarction, non-fatal stroke or death from a cardiovascular cause), compared with 107 to 115 people out of 1,000 people who were taking an SGLT-2 inhibitor for 3 years
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54 out of 1,000 people who did not take an SGLT-2 inhibitor were hospitalised with heart failure over 3 years, compared with 26 to 40 people out of 1,000 people who were taking an SGLT-2 inhibitor for 3 years.
These clinically important reductions were weighed against the chance that:
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between 10 and 100 in 1,000 people would experience genital infections
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1 in 1,000 or fewer people would experience rarer events like diabetic ketoacidosis or Fournier's gangrene or other severe infections.
Given this, the committee agreed that, for most people, the benefits outweighed the risks. They agreed that the risk of volume depletion is manageable, and that it would be uncommon for it to lead to diabetic ketoacidosis. They agreed that these risks should be discussed with the person ahead of starting treatment.
Wider access to SGLT-2 inhibitors is likely to reduce health inequalities
The committee also agreed that providing SGLT-2 inhibitors and metformin as a part of standard therapy for most people with type 2 diabetes could reduce inequality. Evidence indicated that interventions to reduce socioeconomic inequalities, including health inequalities, often include actions that address the population or health system level which requires limited voluntary behaviour change on the part of an individual person. Evidence shows that SGLT-2 inhibitors provide net health benefits for people with type 2 diabetes living in the most deprived areas. The committee agreed that this is an important reason for ensuring universal access to SGLT-2 inhibitors.
Choosing a specific medicine
For the 2026 update, the committee was aware of the large reduction in price of dapagliflozin because generic versions were becoming available. They did not make a recommendation for dapagliflozin, acknowledging that other medicines in the same class were as effective and may become cheaper in the future. However, they support its use while it is the least expensive of the SGLT-2 inhibitors that may be suitable, because it is likely to reduce the cost of implementing the recommendation without negatively affecting quality of care.
People with a relatively lower risk of cardiovascular disease
People with type 2 diabetes have a higher risk of cardiovascular disease than people with the same health-related characteristics and no diabetes. The committee acknowledged that people with type 2 diabetes have an inherent increased lifetime risk of cardiovascular disease before accounting for any other cardiovascular risk factors that are more commonly associated with the condition, such as hypertension and dyslipidaemia. Therefore, in the absence of direct evidence, the committee agreed that even people with a relatively lower cardiovascular risk should be offered an SGLT-2 inhibitor and metformin, because it is important to reduce this risk, including for those without comorbidities or other cardiovascular risk factors. They also noted that, compared with groups who have a higher risk of cardiovascular disease, including people with early onset type 2 diabetes, the population that these recommendations cover is small. This population includes people likely to be 41 to 59 years old, who have no cardiovascular risk factors other than type 2 diabetes (who would otherwise be identified to have a QRISK score below 10%).
Because of their age, they may share similarities with people with early onset type 2 diabetes, for whom earlier intensive treatment is recommended.
Conclusion
Taking the evidence into account, the committee agreed that combining metformin with an SGLT-2 inhibitor is the most clinically effective therapy option, and that this should be the standard initial treatment for people with no relevant comorbidities.
Modified compared to standard-release metformin
There was limited evidence comparing standard-release and modified-release metformin for people with type 2 diabetes and no relevant comorbidities, and the committee agreed that there are benefits to recommending modified-release metformin first. This is because, when compared with standard-release metformin, modified-release metformin:
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has similar clinical effectiveness on HbA1c and weight reduction
-
has similar safety results for hypoglycaemia
-
is associated, in evidence outside of the protocol for the review, with reductions in gastrointestinal adverse events
-
is likely to be better adhered to, and the committee was aware of the downstream costs of non-adherence (for example, cardiovascular and renal adverse events, further appointments and investigations), and
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can fluctuate in price but, in December 2025, cost less than standard-release metformin.
The committee noted that standard-release metformin may be preferable for people with difficulty swallowing because unlike modified-release metformin, it can be crushed and is available in a liquid form. This may be appropriate for people with dementia or with learning disabilities in whom dysphagia is more common. The committee did not make a recommendation about this because they were aware that NEWT guidelines provide further information to support decision making for people with swallowing difficulties.
The committee agreed that this should be addressed in a conversation between the person and the healthcare professional when prescribing the medication.
GLP-1 receptor agonists and tirzepatide
GLP-1 receptor agonists and tirzepatide were not found to be or did not have evidence for clinical or cost effectiveness for this population, so were not recommended.
Medicines for people who cannot take metformin
The evidence showed that SGLT-2 inhibitors reduced cardiovascular events compared with placebo when metformin is the background therapy. The committee agreed that even though the evidence was limited for people with no relevant comorbidities, this benefit would also be seen in people for whom metformin is contraindicated. Therefore, because the committee wanted people with type 2 diabetes to continue to gain the cardiovascular benefits seen in the evidence, they recommended monotherapy with an SGLT-2 inhibitor when metformin is contraindicated.
Recommendation for research
The committee reviewed real-world evidence that SGLT-2 inhibitors are under-prescribed, particularly to women and older people, people from some ethnic backgrounds, and people who have experienced higher levels of deprivation when sex and age are accounted for. They agreed that further research is needed to understand the reasons behind this so made a recommendation for research on improving access to SGLT-2 inhibitors.
How the recommendations might affect practice
Metformin
The recommendations may lead to a change in current practice but should not lead to a significant cost or resource impact. The price of modified-release metformin can fluctuate but, in December 2025, was lower than the cost of standard-release metformin.
SGLT-2 inhibitors
SGLT-2 inhibitors were recommended by NICE in 2022 for:
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all people with chronic heart failure
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all people with atherosclerotic cardiovascular disease
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some people at high risk of developing cardiovascular disease.
Recommendations for SGLT-2 inhibitors for people with chronic kidney disease were previously made through different guidance but are not expected to reflect a significant change in practice.
However, real-world evidence (2026) shows that SGLT-2 inhibitors are under-prescribed throughout the UK. The 2026 recommendations may increase the number of people who are offered SGLT-2 inhibitors, which will increase prescribing costs. But broader access to SGLT-2 inhibitors may also result in long-term medicine costs being partially offset by fewer people needing treatment for atherosclerotic cardiovascular disease.
Based on these recommendations, people at lower risk of developing cardiovascular disease, who previously would not have had access to SGLT-2 inhibitors, can now access them. The committee did not believe this to be a large group and so the impact of this is likely to be minimal.
Initial medicines: people with heart failure (any ejection fraction, unless specified)
Recommendations 1.14.1 and 1.14.2
Why the committee made the recommendations
Metformin and SGLT-2 inhibitors
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.
Overall, network and pairwise meta-analyses comparing antidiabetic therapies showed that therapy combining metformin with an SGLT-2 inhibitor was more clinically effective at reducing HbA1c, weight and cardiovascular events than:
-
any other therapy combining metformin with 1 other medicine, and
-
metformin alone.
Cardiovascular events covered included cardiovascular mortality, myocardial infarction, non-fatal stroke and hospitalisation for heart failure. Evidence showed that canagliflozin and dapagliflozin also reduced the risk of end-stage renal failure.
The committee agreed that therapy combining metformin with an SGLT-2 inhibitor is the most clinically effective option for people with heart failure and recommended this as the standard initial treatment.
There was limited evidence for people with type 2 diabetes and heart failure. However, for people with type 2 diabetes who are at high risk of developing cardiovascular disease, there was strong evidence that SGLT-2 inhibitors reduced the number of hospitalisations due to heart failure.
During the 2026 update of the guideline, the committee was aware of the large reduction in price of dapagliflozin because generic versions of the medicine were becoming available. They did not make a recommendation for this specific medicine, acknowledging that other medicines in the same class were as effective and may become cheaper in the future. However, they support its use while it is the least expensive of the SGLT-2 inhibitors that may be suitable, because it is likely to reduce the cost of implementing the recommendation without impacting the quality of care for most people with type 2 diabetes.
Modified compared to standard-release metformin
There was limited evidence comparing standard-release and modified-release metformin. On weighing up the evidence, the committee agreed that there were benefits to recommending modified-release metformin first. This was because, when compared with standard-release metformin, modified-release metformin:
-
has similar clinical effectiveness on HbA1c and weight reduction
-
has similar safety results for hypoglycaemia
-
was associated, in evidence outside of the protocol for the review, with reductions in gastrointestinal adverse events
-
is likely to be better adhered to, and the committee was aware of the downstream costs of non-adherence (for example, cardiovascular and renal adverse events, further appointments and investigations)
-
can fluctuate in price but, in December 2025, cost less than standard-release metformin.
The committee noted that standard-release metformin can be preferable for people with difficulty swallowing because it can be crushed and is available in a liquid form while modified-release metformin cannot. This may be more useful for some people with dementia and some people with learning disabilities in whom dysphagia is more common. The committee did not make a recommendation about this because they were aware that NEWT guidelines provide further information to support decision making for people with swallowing difficulties.
The committee agreed that this should be addressed in a conversation between the person and the healthcare professional when prescribing the medication.
Medicines for people who cannot take metformin
The trial evidence showed that SGLT-2 inhibitors reduced cardiovascular events compared with placebo when metformin was the background therapy. The committee agreed that this benefit of using SGLT-2 inhibitors would also be seen in people with contraindications to metformin, even though the evidence was limited for this group. Therefore, as the committee wanted people with type 2 diabetes to continue to gain the cardiovascular benefits seen in the evidence, they recommended that when people have a contraindication to metformin, they should have monotherapy with an SGLT-2 inhibitor.
How the recommendations might affect practice
Metformin
The recommendations about the use of metformin may lead to a change in current practice but should not lead to a significant cost or resource impact. The price of modified-release metformin can fluctuate but, in December 2025, was lower than the cost of standard-release metformin.
SGLT-2 inhibitors
SGLT-2 inhibitors were recommended by NICE in 2022. They were recommended for:
-
all people with chronic heart failure
-
some people at high risk of developing cardiovascular disease.
However, real-world evidence shows that SGLT-2 inhibitors are under-prescribed throughout the UK. The recommendations may increase the number of people who are offered SGLT-2 inhibitors, which will increase prescribing costs. But the long-term medicine cost associated with broader access to SGLT-2 inhibitors may be partially offset if it results in fewer people needing treatment for atherosclerotic cardiovascular disease or hospitalisation for heart failure.
Initial medicines: people with atherosclerotic cardiovascular disease
Recommendations 1.15.1 and 1.15.2
Why the committee made the recommendations
Metformin and SGLT-2 inhibitors
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.
Overall, network and pairwise meta-analyses comparing antidiabetic therapies showed that therapy combining metformin with an SGLT-2 inhibitor was more clinically effective at reducing HbA1c, weight and cardiovascular events than:
-
any other therapy combining metformin with 1 other medicine, and
-
metformin alone.
Cardiovascular events covered included cardiovascular mortality, myocardial infarction, non-fatal stroke and hospitalisation for heart failure. Evidence showed that canagliflozin and dapagliflozin reduced the risk of end-stage renal failure.
The committee agreed that therapy combining metformin with an SGLT-2 inhibitor is the most clinically effective option for people with atherosclerotic cardiovascular disease and recommended this as the standard initial treatment.
Data on health inequalities showed that people living in the most deprived areas experience the greatest benefits for their health from SGLT-2 inhibitors. The committee believe this is an important reason for ensuring universal access to SGLT-2 inhibitors.
During the 2026 update of the guideline, the committee was aware of the large reduction in price of dapagliflozin because generic versions of the medicine were becoming available. They did not make a recommendation for this specific medicine, acknowledging that other medicines in the same class were as effective and may become cheaper in the future. However, they support its use while it is the least expensive of the SGLT-2 inhibitors that may be suitable, because it is likely to reduce the cost of implementing the recommendation without impacting the quality of care for most people with type 2 diabetes.
Modified compared to standard-release metformin
There was limited evidence comparing standard-release and modified-release metformin. On weighing up the evidence, the committee agreed that there were benefits to recommending modified-release metformin first. This was because, when compared with standard-release metformin, modified-release metformin:
-
has similar clinical effectiveness on HbA1c and weight reduction
-
has similar safety results for hypoglycaemia
-
was associated, in evidence outside of the protocol for the review, with reductions in gastrointestinal adverse events
-
is likely to be better adhered to, and the committee was aware the downstream costs of non-adherence (for example: cardiovascular and renal adverse events, further appointments and investigations)
-
can fluctuate in price but, in December 2025, cost less than standard-release metformin.
The committee noted that standard-release metformin can be preferable for people with difficulty swallowing because it can be crushed and is available in a liquid form while modified-release metformin cannot. This may be more useful for some people with dementia and some people with learning disabilities in whom dysphagia is more common. The committee did not make a recommendation about this because they were aware that the NEWT guidelines provide further information to support decision making for people with swallowing difficulties.
The committee agreed that this should be addressed in a conversation between the person and the healthcare professional when prescribing the medication.
Medicines for people who cannot take metformin
The trial evidence showed that SGLT-2 inhibitors reduced cardiovascular events compared with placebo when metformin was the background therapy. The committee agreed that this benefit of using SGLT-2 inhibitors would also be seen in people with contraindications to metformin, even though the evidence was limited for this group. Therefore, as the committee wanted people with type 2 diabetes to continue to gain the cardiovascular benefits seen in the evidence, they recommended that when people have a contraindication to metformin, they should have monotherapy with an SGLT-2 inhibitor.
Subcutaneous semaglutide
Evidence showed that subcutaneous semaglutide (Ozempic) was the most cost-effective GLP-1 receptor agonist. This evidence was based on clinical benefits identified in a population that included a large proportion of people with atherosclerotic cardiovascular disease but also some people who did not have atherosclerotic cardiovascular disease but were at high risk of it (because they had type 2 diabetes). Evidence was only identified for doses up to 1 mg of subcutaneous semaglutide once a week. The committee agreed that evidence from this mixed population indirectly applied because of the large proportion of people in the group who did have atherosclerotic cardiovascular disease.
Subcutaneous semaglutide (Ozempic), up to 1 mg once a week, also had the best clinical results. Evidence showed that it made a clinically important reduction to the person's:
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risk of major adverse cardiovascular events and
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HbA1c and
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weight.
The results for these outcomes were precise, which means that there is very little uncertainty about them. Other GLP-1 receptor agonists did not achieve this. Liraglutide was cost effective in a sensitivity analysis taking into account projected price reductions after the generic version became available. But the committee agreed that it was not sufficiently clinically effective to justify adding it to the recommendation. In addition, evidence was not available to the committee to evaluate tirzepatide for this population at this time. As a result, the committee agreed to specifically recommend subcutaneous semaglutide (Ozempic), up to 1 mg once a week, rather than any other GLP-1 receptor agonist or tirzepatide.
The committee noted that there are potential serious side effects with GLP-1 receptor agonists and tirzepatide, and a potential for misuse. However, they did not make a recommendation on monitoring because it is covered by MHRA drug safety updates. See MHRA guidance on GLP-1 receptor agonists: reminder of the potential side effects and to be aware of the potential for misuse, GLP-1 receptor agonists and dual GLP-1/GIP receptor agonists: strengthened warnings on acute pancreatitis, including necrotising and fatal cases and semaglutide (Wegovy, Ozempic and Rybelsus): risk of non-arteritic anterior ischemic optic neuropathy (NAION) for more details.
The committee made the decision to recommend this medicine in combination with metformin and an SGLT-2 inhibitor based on:
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evidence they had from a pooled analysis
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their own clinical experience.
The evidence in the pooled network meta-analysis came from a review that looked at the cost and clinical effectiveness of adding subsequent therapies to previous treatment. It showed clinical benefits from GLP-1 receptor agonists, but most studies in the evidence review did not give separate results based on the number or type of other treatments received. A small number of studies specifically included triple therapy combining GLP-1 receptor agonists, SGLT-2 inhibitors and metformin. When compared in health economic evaluation, adding subcutaneous semaglutide to an SGLT-2 inhibitor and metformin was cost effective.
The evidence for combination therapy with metformin and SGLT-2 inhibitors showed that the cardiovascular benefits came from the SGLT-2 inhibitors alone. This was clear because people receiving metformin and placebo did not get the same benefits. When compared with placebo in clinical trials, GLP-1 receptor agonists, including semaglutide also showed cardiovascular benefits, regardless of other treatment received. Because of this, the committee agreed that people with atherosclerotic cardiovascular disease should receive therapy combining an SGLT-2 inhibitor and subcutaneous semaglutide if metformin is contraindicated or not tolerated.
How the recommendations might affect practice
Metformin
The recommendations about the use of metformin may lead to a change in current practice but should not lead to a significant cost or resource impact. The price of modified-release metformin can fluctuate but, in December 2025, was lower than the cost of standard-release metformin.
SGLT-2 inhibitors were recommended by NICE in 2022. They were recommended for:
-
all people with atherosclerotic cardiovascular disease
-
some people at high risk of developing cardiovascular disease.
However, real-world evidence shows that SGLT-2 inhibitors are under-prescribed throughout the UK. The recommendations may increase the number of people who are offered SGLT-2 inhibitors, which will increase prescribing costs. But broader access to SGLT-2 inhibitors may also result in long-term medicine costs being partially offset by fewer people needing treatment for atherosclerotic cardiovascular disease.
Subcutaneous semaglutide
Subcutaneous semaglutide is a GLP-1 receptor agonist. GLP-1 receptor agonists were previously reserved for later treatment phases. Recommending subcutaneous semaglutide (Ozempic), up to 1 mg once a week, for some people as part of initial therapy will increase costs. Taking subcutaneous semaglutide will mean that DPP-4 inhibitor use will reduce. Early intervention could lead to weight loss as a beneficial side effect that may result in better long-term prognoses. If maintained, this will reduce needs for both long-term treatment and later stage treatments (such as insulin).
Initial medicines: people with early onset type 2 diabetes
Recommendations 1.16.1 and 1.16.2
Why the committee made the recommendations
Metformin and SGLT-2 inhibitors
There is good evidence that managing type 2 diabetes should aim to improve health holistically (in particular, cardiovascular and renal protection), rather than just HbA1c. Based on their experience, the committee agreed that people with early onset type 2 diabetes:
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have a very high lifetime risk of cardiovascular and renal complications, and of dying from them, and
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are more likely to be living with obesity.
Early intensive treatment can provide benefits by preventing these future negative outcomes.
Though there were no clinical trials focusing solely on people with early onset diabetes, there was good evidence in the wider population of people with type 2 diabetes, which the committee agreed could be extrapolated to people with early onset type 2 diabetes. It showed that:
-
both SGLT-2 inhibitors and GLP-1 receptor agonists reduce the risk of cardiovascular events (cardiovascular mortality, myocardial infarctions, non-fatal strokes and hospitalisation for heart failure) and of developing end-stage renal disease
-
SGLT-2 inhibitors, GLP-1 receptor agonists and tirzepatide reduce HbA1c, and lead to weight loss as a beneficial side effect.
The committee agreed that the benefits could be increased with long-term use.
The health economic evidence for this population was highly uncertain. The committee concluded that this was because:
-
there were no clinical trials focusing solely on early onset diabetes,
-
the trial informing the model only included a small number of people with early onset type 2 diabetes, and
-
the short time horizon for evaluating treatment benefits may have underestimated long-term advantages for this group.
Data on health inequalities showed that people living in the most deprived areas experience the greatest health benefits from SGLT-2 inhibitors. The committee agreed that this is an important reason for ensuring universal access to SGLT-2 inhibitors.
During the 2026 update of the guideline, the committee was aware of the large reduction in price of dapagliflozin because generic versions of the medicine were becoming available. They did not make a recommendation for this specific medicine, acknowledging that other medicines in the same class were as effective and may become cheaper in the future. However, they support its use while it is the least expensive of the SGLT-2 inhibitors that may be suitable, because it is likely to reduce the cost of implementing the recommendation without impacting the quality of care for most people with type 2 diabetes.
Modified-release compared to standard-release metformin
There was limited evidence comparing standard-release and modified-release metformin, and the committee agreed that there are benefits to recommending modified-release metformin first. This is because, when compared with standard-release metformin, modified-release metformin:
-
has similar clinical effectiveness on HbA1c and weight reduction
-
has similar safety results for hypoglycaemia
-
is associated, in evidence outside of the protocol for the review, with reductions in gastrointestinal adverse events
-
is likely to be better adhered to, and the committee was aware of the downstream costs of non-adherence (for example, cardiovascular and renal adverse events, further appointments and investigations), and
-
can fluctuate in price but, in December 2025, cost less than standard-release metformin.
The committee noted that standard-release metformin may be preferable for people with difficulty swallowing because unlike modified-release metformin, it can be crushed and is available in a liquid form. This may be appropriate for people with dementia or learning disabilities in whom dysphagia is more common. The committee did not make a recommendation about this because they were aware that the NEWT guidelines provide further information to support decision making for people with swallowing difficulties.
The committee agreed that this should be addressed in a conversation between the person and the healthcare professional when prescribing the medication.
GLP-1 receptor agonists and tirzepatide
The committee recommended combining a GLP-1 agonist or tirzepatide with metformin and an SGLT-2 inhibitor based on evidence from a pooled network meta-analysis and their clinical experience.
The evidence in the pooled network meta-analysis used in the health economic modelling came from a review of people at higher risk of developing cardiovascular disease or people with existing atherosclerotic cardiovascular disease adding subsequent therapies to previous treatment. It showed benefits from GLP-1 receptor agonists, but most studies did not give separate results based on the number or type of other treatments received. A small number of studies included triple therapy combining GLP-1 receptor agonists, SGLT-2 inhibitors and metformin. When compared in health economic evaluation, adding most GLP-1 receptor agonists was not cost effective, while adding liraglutide to an SGLT-2 inhibitor and metformin reported an incremental cost-effectiveness ratio (ICER) approaching £20,000 per quality-adjusted life year (QALY) gained. Tirzepatide was not analysed for this population.
The evidence for combination therapy with metformin and SGLT-2 inhibitors showed that the cardiovascular benefits came from the SGLT-2 inhibitors alone. This was clear because the people receiving metformin and placebo did not get the same benefits. When compared with placebo in clinical trials, GLP-1 receptor agonists also showed cardiovascular benefits regardless of other treatment received. The evidence evaluated for tirzepatide did not show cardiovascular benefits, which leaves some uncertainty about its use for this purpose. However, the committee acknowledged the benefits in reducing HbA1c and weight, and how this could lead to beneficial cardiovascular outcomes in the long term.
The committee agreed that GLP-1 receptor agonists and tirzepatide should be considered in addition to metformin and SGLT-2 inhibitors, given the:
-
relatively small size of this group
-
health inequalities that this group would face if they did not receive treatment early, and
-
challenges in identifying appropriate data.
The committee also made a recommendation for research on treatments for people with early onset diabetes.
The committee noted potential serious side effects with GLP-1 receptor agonists and tirzepatide, and a potential for misuse. However, they did not make a recommendation for monitoring because it is covered by MHRA drug safety updates. See MHRA guidance on GLP-1 receptor agonists: reminder of the potential side effects and to be aware of the potential for misuse, GLP-1 receptor agonists and dual GLP-1/GIP receptor agonists: strengthened warnings on acute pancreatitis, including necrotising and fatal cases and semaglutide (Wegovy, Ozempic and Rybelsus): risk of non-arteritic anterior ischemic optic neuropathy (NAION) for more details.
Medicines for people who cannot take metformin
The evidence showed that SGLT-2 inhibitors reduce cardiovascular events compared with placebo when metformin is the background therapy. The committee agreed that even though the evidence was limited for this group, this benefit would also be seen in people for whom metformin is contraindicated. Therefore, given that the committee wanted people with type 2 diabetes to continue to gain the cardiovascular benefits seen in the evidence, they recommended monotherapy with an SGLT-2 inhibitor when metformin is contraindicated.
They agreed that people with early onset diabetes should receive an SGLT-2 inhibitor, and that adding a GLP-1 receptor agonist or tirzepatide could be considered if metformin is contraindicated or not tolerated.
How the recommendations might affect practice
Metformin
The recommendations may lead to a change in current practice but should not lead to a significant cost or resource impact. The price of modified-release metformin can fluctuate but, in December 2025, was lower than the cost of standard-release metformin.
SGLT-2 inhibitors
SGLT-2 inhibitors were recommended by NICE in 2022 for some people at high risk of developing cardiovascular disease.
However, real-world evidence shows that SGLT-2 inhibitors are under-prescribed throughout the UK. The recommendations may increase the number of people who are offered SGLT-2 inhibitors, which will increase prescribing costs. But broader access to SGLT-2 inhibitors may also result in long-term medicine costs being partially offset by fewer people needing treatment for atherosclerotic cardiovascular disease, especially in this population, when taking a long-term perspective.
GLP-1 receptor agonists and tirzepatide
GLP-1 receptor agonists and tirzepatide were previously reserved for later treatment phases. Recommending these for some people as part of initial therapy will increase costs. Increased GLP-1 receptor agonists or tirzepatide use will reduce DPP-4 inhibitor use. Early intervention could lead to weight loss as a beneficial side effect that may result in better long-term prognoses. If maintained, this will reduce needs for both long-term treatment and later stage treatments (such as insulin).
Initial medicines: people living with obesity
Recommendations 1.17.1 and 1.17.2
Why the committee made the recommendations
The evidence comparing antidiabetic therapies for people with no relevant comorbidities included people living with obesity. However, in most studies it was not possible to separate out this group from the larger study population and identify specific effects for people living with obesity. Given the limitations of the evidence, the committee recommended the same medicines for this group as for other people with type 2 diabetes and no other specific comorbidities.
The committee recommended these therapies for people living with obesity because of their glycaemic reduction properties, and cardiovascular and renal benefits. Weight reduction may be a side effect of some medicines (including GLP-1 receptor agonists and tirzepatide, SGLT-2 inhibitors, and metformin), which may be important to the person with type 2 diabetes and their healthcare professionals. However, if weight reduction is the primary aim of the treatment, the committee agreed that healthcare professionals should follow NICE's guideline on overweight and obesity management instead of this guideline.
For the wider population, therapy with metformin and an SGLT-2 inhibitor was more clinically effective at reducing HbA1c, weight and cardiovascular events than:
-
any other therapy combining metformin with 1 other medicine, and
-
metformin alone.
Cardiovascular events covered included cardiovascular mortality, myocardial infarction, non-fatal stroke and hospitalisation for heart failure. Evidence showed that canagliflozin and dapagliflozin reduced the risk of end-stage renal failure.
The committee agreed that therapy combining metformin with an SGLT-2 inhibitor is the most clinically effective option for people living with obesity and recommended this as the standard initial treatment.
SGLT-2 inhibitors were cost effective for people living with obesity. Data on health inequalities also showed that people living in the most deprived areas experience the greatest benefits for their health from SGLT-2 inhibitors. The committee believe this is an important reason for ensuring universal access to SGLT-2 inhibitors.
During the 2026 update of the guideline, the committee was aware of the large reduction in price of dapagliflozin because generic versions of the medicine were becoming available. They did not make a recommendation for this specific medicine, acknowledging that other medicines in the same class were as effective and may become cheaper in the future. However, they support its use while it is the least expensive of the SGLT-2 inhibitors that may be suitable, because it is likely to reduce the cost of implementing the recommendation without impacting the quality of care for most people with type 2 diabetes.
GLP-1 receptor agonists were not cost effective in the health economic modelling for this population. Compared to people with early onset type 2 diabetes, the lifetime risk of cardiovascular disease is lower. Bearing in mind the cardiovascular protection already being provided by SGLT-2 inhibitors and metformin, GLP-1 receptor agonists and tirzepatide were not recommended as initial medicines and were instead recommended as treatment options if further medicines are needed.
How the recommendations might affect practice
Metformin
The recommendations about the use of metformin may lead to a change in current practice but should not lead to a significant cost or resource impact. The price of modified-release metformin can fluctuate but, in December 2025, was lower than the cost of standard-release metformin.
SGLT-2 inhibitors
SGLT-2 inhibitors were recommended by NICE in 2022. They were recommended for some people at high risk of developing cardiovascular disease.
However, real-world evidence shows that SGLT-2 inhibitors are under-prescribed throughout the UK. The recommendations may increase the number of people who are offered SGLT-2 inhibitors, which will increase prescribing costs. But broader access to SGLT-2 inhibitors may also result in long-term medicine costs being partially offset by fewer people needing treatment for atherosclerotic cardiovascular disease.
Initial medicines: people with chronic kidney disease
Recommendations 1.18.1 to 1.18.5
Why the committee made the recommendations
eGFR above 30 ml/min/1.73 m2
Little evidence was identified specifically for people with chronic kidney disease. However, the committee agreed that people with an eGFR above 30 ml/min/1.73 m2 should see the same benefits from diabetes medicines as people without chronic kidney disease. In the health economic analysis, metformin and SGLT-2 inhibitors were less costly and more effective than other medicines. The committee noted that while the cardiovascular and renal protection provided by SGLT-2 inhibitors are retained at eGFR values below 45 ml/min/1.73 m2, the glycaemic benefits may reduce. Glycaemic benefits can come from metformin, but there may be a need to add further therapy to provide these. Options for this are provided in the section on treatment options if further medicines are needed.
Data on health inequalities showed that people living in the most deprived areas experience the greatest benefits for their health from SGLT-2 inhibitors. The committee believe this is an important reason for ensuring universal access to SGLT-2 inhibitors.
The committee examined evidence from the FLOW trial. While the trial identified clinically important benefits in terms of renal protection and glycaemia, subcutaneous semaglutide was not cost effective in the economic model. Therefore, the committee did not recommend semaglutide, any other GLP-1 receptor agonists or tirzepatide for this population.
eGFR above 20 ml/min/1.73 m2 and up to 30 ml/min/1.73 m2
People with an eGFR below 30 ml/min/1.73 m2 cannot take metformin. However, the committee agreed that people with an eGFR above 20 ml/min/1.73 m2 could still be offered an SGLT-2 inhibitor to reduce the risk of end-stage renal events and cardiovascular events (including cardiovascular mortality, myocardial infarctions, non-fatal strokes and hospitalisations for heart failure) from type 2 diabetes. The committee recommended dapagliflozin and empagliflozin because these are the 2 SGLT-2 inhibitors that are licensed for use in this population. The committee noted that while the cardiovascular and renal protection provided by SGLT-2 inhibitors are retained at eGFR values below 30 ml/min/1.73 m2, the glycaemic benefits may reduce or be absent. Therefore, adding a DPP-4 inhibitor was recommended, because it is effective at reducing HbA1c and relatively safe for people with an eGFR between 20 ml/min/1.73 m2 and 30 ml/min/1.73 m2.
Data on health inequalities showed that people living in the most deprived areas experience the greatest benefits for their health from SGLT-2 inhibitors. The committee believe this is an important reason for ensuring universal access to SGLT-2 inhibitors.
eGFR below 20 ml/min/1.73 m2
DPP-4 inhibitors are effective at reducing HbA1c and have fewer adverse effects than other comparable options. If DPP-4 inhibitors are contraindicated, not tolerated or not effective for people with an eGFR below 20 ml/min/1.73 m2, then in the committee's experience the best option is either pioglitazone or an insulin-based treatment. The committee acknowledged that a sulfonylurea could increase the risk of hypoglycaemia as renal impairment increases, so would not be a good option for this group. Pioglitazone might worsen cardiovascular outcomes and should be avoided for people with heart failure.
How the recommendations might affect practice
Metformin
The recommendations about the use of metformin may lead to a change in current practice but should not lead to a significant cost or resource impact. The price of modified-release metformin can fluctuate but, in December 2025, was lower than the cost of standard-release metformin.
SGLT-2 inhibitors
The recommendations about the use of SGLT-2 inhibitors should not lead to a change in current practice.
DPP-4 inhibitors, pioglitazone and insulin
The recommendation about the use of DPP-4 inhibitors, pioglitazone and insulin should not reflect a change in current practice.
Initial medicines: people with frailty
Recommendations 1.19.1 to 1.19.3
Why the committee made the recommendations
Because of concerns about adverse effects and polypharmacy, the committee agreed that SGLT-2 inhibitors may not be appropriate for some people with frailty and type 2 diabetes.
There was no specific evidence for people with frailty, so the committee could not recommend a particular method of assessment or cutoff for prescribing SGLT-2 inhibitors. The decision would need to be made based on clinical judgement, taking into account the needs of each person.
The committee recommended medicines for this group based on:
-
their own expertise
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common medicine contraindications in this group
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their knowledge of which medicines were likely to have the most manageable side effects.
The committee did not recommend GLP-1 receptor agonists and tirzepatide for people with frailty. However, they agreed that there is no additional safety risk for this population. Therefore, if a person has a relevant indication and frailty, they can still be offered a GLP-1 receptor agonists or tirzepatide.
How the recommendations might affect practice
Metformin
The recommendations about the use of metformin may lead to a change in current practice but should not lead to a significant cost or resource impact. The price of modified-release metformin can fluctuate but, in December 2025, was lower than the cost of standard-release metformin.
DPP-4 inhibitors
The recommendations about the use of DPP-4 inhibitors should not reflect a change in current practice.
How to introduce medicines
Recommendations 1.20.2 to 1.21.3
Why the committee made the recommendations
When starting first-line therapy with metformin and other medicines, the committee noted the importance of introducing the medicines sequentially. This enables any side effects and intolerances from the first medicine to be identified before the second is introduced. In line with current practice, the committee recommended starting with metformin and then adding the SGLT-2 inhibitor without delay once metformin tolerability at the highest achievable dose is established, to avoid people remaining on metformin alone for prolonged periods.
The committee agreed that sudden reductions in HbA1c can increase the risk of diabetic retinopathy and ischaemic maculopathy, especially with GLP-1 receptor agonists and tirzepatide. Given this safety concern, they highlighted relevant recommendations in NICE's guideline on diabetic retinopathy for further guidance for anyone starting these medicines.
Preventing diabetic ketoacidosis when taking SGLT-2 inhibitors
The committee noted some particularly important safety considerations to take into account before an adult with type 2 diabetes starts on an SGLT-2 inhibitor. In the committee's experience there have been multiple instances of avoidable diabetes ketoacidosis (DKA) resulting in hospital admission. The committee highlighted some factors that might put someone at higher risk of DKA, but the list is not intended to be exhaustive. Addressing modifiable risk factors before starting an SGLT-2 inhibitor could reduce the risk of DKA and make the medicine safer for the person with type 2 diabetes. The committee agreed that taking these factors into account was more important than providing a specific HbA1c threshold from which to avoid prescribing SGLT-2 inhibitors.
The committee was aware that adults with type 2 diabetes who are living with overweight or obesity may wish to try a ketogenic diet to reverse or reduce the severity of their diabetes or induce remission. However, the committee agreed, based on their experience, that there may be an increased risk of DKA associated with SGLT-2 inhibitors and such diets. It is important to tell people about these risks and to advise them to discuss any planned change to a very low carbohydrate or ketogenic diet with their healthcare professional first.
How the recommendations might affect practice
The recommendations are not expected to significantly increase consultation time or be a change in practice because these should already form part of the prescribing process. Checking that the person is not at increased risk of DKA when they are prescribed an SGLT-2 inhibitor should help reduce the number of people who experience DKA and thereby reduce unnecessary hospital admissions.
Reviewing medicines
Recommendations 1.23.1, 1.24.1 to 1.24.6
Why the committee made the recommendations
The committee agreed that, when changes to treatment are being considered, it is important to review existing treatment options first. Stopping medications that have not worked, for example, in controlling blood glucose, and optimising current treatments may remove the need to prescribe additional medicines. In particular, there might be factors, such as problems with adherence or adverse effects, that might make existing treatments less effective or ineffective. Addressing these might mean that adding a new medicine is unnecessary.
In the committee's experience, some people have their medications stopped after they reach their glycaemic targets. This can lead to their HbA1c levels and weight rising again. Often, it would be better for the person to keep taking medications that have helped them reach their individualised glycaemic targets, to prevent future problems. There was no evidence on which groups would most benefit from this, so the decision would need to be based on clinical judgement and the preferences of the person with type 2 diabetes.
SGLT-2 inhibitors are a good treatment option for most people and provide cardiovascular and renal protection that cannot be measured by tests. Therefore, the committee agreed that these should be continued even if they do not help the person reach their individualised glycaemic targets.
However, the committee acknowledged that the decision is more complicated for GLP-1 receptor agonists and tirzepatide. For people with atherosclerotic cardiovascular disease or early onset type 2 diabetes, GLP-1 receptor agonists and SGLT-2 inhibitors are being used to prevent cardiovascular events. For these groups, continuing GLP-1 receptor agonists can provide benefits even if they do not help the person reach their glycaemic targets. For people who do not have atherosclerotic cardiovascular disease or early onset type 2 diabetes, GLP-1 receptor agonists and tirzepatide are being used to reach individualised glycaemic targets, so they should be treated like any other medication and stopped if they are not effective for this purpose.
The list of factors to think about as part of optimisation is not exhaustive but includes those that the committee thought were particularly important. The committee agreed that it is important to revisit advice about diet and healthy living. This is because part of this discussion is to ensure the person is supported with both non-pharmacological and pharmacological interventions to improve their current health and prognosis.
The committee agreed that there are cases where treatment with certain medicines highlights diagnostic uncertainty (for example: absence of response to treatments other than insulin, sudden unexpected weight loss). Therefore, the committee highlighted guidance regarding type 1 diabetes and revisiting other diagnoses.
People already on standard-release metformin
There was no evidence identified in the review to show that modified-release metformin was more effective than standard-release metformin, and no evidence that it would be more cost effective for people for whom it works. However, the committee agreed that, in their clinical experience, people can experience fewer gastrointestinal adverse events with modified-release metformin compared to standard-release metformin. Additionally, a person may want to reduce the number of times they take metformin each day. Therefore, the option of switching from standard-release to modified-release metformin should be available.
Not combining a DPP-4 inhibitor and a GLP-1 agonist
Based on their own experience, the committee agreed that combining a GLP-1 receptor agonist or tirzepatide and a DPP-4 inhibitor would not add value. The 2 medicines have a similar mechanism of action, as they act on different parts of the GLP-1 pathway. Because of this, it is unlikely that combining the medications provides any additional effect and so it is unlikely to be clinically or cost effective.
How the recommendations might affect practice
The recommendations will lead to people taking SGLT-2 inhibitors and GLP-1 receptor agonists or tirzepatide for longer. This will initially increase costs. However, the long-term protective benefits of these medicines will reduce the need to treat future cardiovascular and renal problems, which will lead to cost savings. Otherwise, the recommendations are not expected to change current practice significantly.
The 2022 recommendations about reviewing medicines are not expected to be a change in practice or to need substantial additional resources because these conversations should already take place.
Further treatment: people with type 2 diabetes and no relevant comorbidities
Why the committee made the recommendations
Most of the evidence used an additive strategy (where additional treatment was provided) rather than a switching strategy (where 1 treatment was stopped and another was started). This appeared to provide effective results. The committee agreed that this is likely to be effective for most people.
DPP-4 inhibitors
Evidence was available for individual population groups: people with heart failure, chronic kidney disease and at higher risk of developing cardiovascular disease. The evidence for all groups showed similar results; that DPP-4 inhibitors were effective at reducing HbA1c and relatively safe. Based on the evidence, and their own experience, the committee recommended that a DPP-4 inhibitor should be the first choice for people who need further medicines. DPP-4 inhibitors all have similar clinical efficacy, and no particular medicine was more cost effective than the others.
Sulfonylureas or pioglitazone
If a DPP-4 inhibitor is not effective or tolerated, a sulfonylurea or pioglitazone should be considered. The evidence showed that both reduced HbA1c. However, there was also limited evidence, indicating that they both had a potential for adverse effects:
-
sulfonylureas might increase hypoglycaemic events and weight gain
-
pioglitazone might worsen cardiovascular outcomes and should be avoided for people with heart failure.
The committee acknowledged that pioglitazone increases the risk of fractures and weight gain, as stated in the BNF. As with each medicine listed in this section, they agreed that healthcare professionals should consider the benefits and risks of each treatment when deciding if a treatment is appropriate, on a case-by-case basis. This information should be discussed with the person with diabetes so that they and their healthcare professional can come to an informed decision together about their treatment plan.
Insulin-based treatments
Evidence showed that insulin-based treatments are less effective than most other antidiabetic therapies at reducing harm from adverse events because it can increase the risk of hypoglycaemic events and weight gain. There are 2 main scenarios when insulin is an effective treatment:
-
managing acute hyperglycaemia
-
managing long-term worsening hyperglycaemia that does not respond to other treatments.
However, in the committee's experience, insulin may also be a good option for people who cannot tolerate more effective medicines. Therefore, they recommended insulin alongside other options for people who cannot tolerate DPP-4 inhibitors.
How the recommendations might affect practice
These recommendations are likely to be a change from current practice, with wider access to therapies with more recent evidence of clinical and cost effectiveness.
The recommendations on DPP-4 inhibitors, sulfonylureas, pioglitazone and insulin do not reflect a significant change in current practice and are unlikely to increase resource use. DPP-4 inhibitors vary in price, but the default assumption is that services will use the medicine with the lowest acquisition cost (in the absence of patient-specific factors).
Further treatment: people with heart failure (any ejection fraction unless specified)
Why the committee made the recommendations
DPP-4 inhibitors
Evidence was available for individual population groups: people with heart failure, chronic kidney disease and at higher risk of developing cardiovascular disease. The evidence for all groups showed similar results, that DPP-4 inhibitors were effective at reducing HbA1c and relatively safe. Based on this evidence, and their own clinical and lived experience, the committee recommended that a DPP-4 inhibitor should be the first choice for people with heart failure who need further medicines. DPP-4 inhibitors all have similar clinical efficacy, and no particular medicine was more cost effective than the others.
Sulfonylureas
Sulfonylureas are recommended for people who need further treatment because the evidence showed that they reduced HbA1c based on the evidence for people at high risk of cardiovascular disease. However, there was also limited evidence indicating that they had a potential for adverse effects, given that sulfonylureas and insulin-based therapies might increase hypoglycaemic events and weight gain. Healthcare professionals are advised to consider this when choosing treatments.
Insulin-based treatments
Evidence showed that insulin-based treatments are less effective than most other antidiabetic therapies at reducing harm from adverse events because it can increase the risk of hypoglycaemic events and weight gain. There are 2 main scenarios for which insulin is an effective treatment:
-
managing acute hyperglycaemia
-
managing long-term worsening hyperglycaemia that does not respond to other treatments.
However, in the committee's experience, insulin may also be a good option for people who cannot tolerate other medicines. Therefore, they recommended insulin alongside sulfonylureas for people who need further medicines to reach their individualised glycaemic targets.
How the recommendations might affect practice
These recommendations are likely to be a change from current practice, with wider access to therapies with more recent evidence of clinical and cost effectiveness.
Sulfonylureas and insulin
The recommendations on sulfonylureas and insulin do not reflect a significant change in current practice and are unlikely to increase resource use. The use of more intensive earlier treatment may lead to a reduction in the use of insulin, which may offset costs in the long term.
Further treatment: people with atherosclerotic cardiovascular disease
Recommendations 1.27.1 and 1.27.2
Why the committee made the recommendations
Subcutaneous semaglutide
Subcutaneous semaglutide (Ozempic), up to 1 mg once a week, was recommended for people who develop atherosclerotic cardiovascular disease after starting initial treatment because evidence showed that this medicine:
-
reduces the risk of cardiovascular events
-
helps with weight loss as a side effect
-
is cost effective.
The evidence showed subcutaneous semaglutide (Ozempic), up to 1 mg once a week, was the most cost effective and clinically effective GLP-1 receptor agonist in terms of cardiovascular and renal protection, and weight reduction.
Sulfonylureas and pioglitazone
Sulfonylureas and pioglitazone are recommended for people who need further treatment because the evidence showed that these both reduced HbA1c. However, there was also limited evidence indicating that they both had a potential for adverse effects:
-
sulfonylureas and insulin-based therapies might increase hypoglycaemic events and weight gain
-
pioglitazone might worsen cardiovascular outcomes and should be avoided for people with heart failure.
The committee acknowledged that pioglitazone increases the risk of fractures and weight gain, as stated in the BNF. As with each medicine listed in this section, they agreed that healthcare professionals should consider the benefits and risks of each treatment when deciding if a treatment is appropriate, on a case-by-case basis. This information should be discussed with the person with diabetes so that they and their healthcare professional can come to an informed decision together about their treatment plan.
Insulin-based treatments
Evidence showed that insulin-based treatments are less effective than most other antidiabetic therapies at reducing harm from adverse events because it can increase the risk of hypoglycaemic events and weight gain. There are 2 main scenarios in which insulin is an effective treatment:
-
managing acute hyperglycaemia
-
managing long-term worsening hyperglycaemia that does not respond to other treatments.
However, in the committee's experience, insulin may also be a good option for people who cannot tolerate other medicines. Therefore, they recommended insulin alongside other options for people who need further medicines to reach their individualised glycaemic targets.
How the recommendations might affect practice
These recommendations are likely to be a change from current practice, with wider access to therapies with more recent evidence of clinical and cost effectiveness.
Subcutaneous semaglutide
Subcutaneous semaglutide is a GLP-1 receptor agonist. GLP-1 receptor agonists were previously recommended after triple therapy with metformin and 2 other oral medicines was not effective, tolerated or contraindicated. Therefore, recommending the treatment as triple therapy after taking metformin and 1 oral medicine (an SGLT-2 inhibitor) may lead to increases in costs. The committee agreed this will likely reduce over time, because the cardiovascular benefits and weight loss side effect of subcutaneous semaglutide will reduce the number of appointments needed to treat atherosclerotic cardiovascular disease. An increase in subcutaneous semaglutide use will reduce DPP-4 inhibitor use. Early intervention could lead to weight loss as a beneficial side effect and so to a better long-term prognosis, which, if maintained, will reduce:
-
long-term treatment requirements and
-
the need for later stage treatments (such as insulin) and
-
downstream treatment costs.
Sulfonylureas, pioglitazone and insulin
The recommendations on sulfonylureas, pioglitazone and insulin do not reflect a significant change in current practice and are unlikely to increase resource use. The use of more intensive earlier treatment may lead to a reduction in the use of insulin, which may offset costs in the long term.
Further treatment: people with early onset type 2 diabetes
Recommendations 1.28.1 to 1.28.3
Why the committee made the recommendations
GLP-1 receptor agonists and tirzepatide
Though there were no clinical trials focusing solely on people with early onset diabetes, there was good evidence in the wider population of people with type 2 diabetes, which the committee agreed could be extrapolated to people with early onset type 2 diabetes. It showed that GLP-1 receptor agonists reduce the risk of cardiovascular events and lead to weight loss as a side effect. Based on their experience, the committee agreed that people with early onset type 2 diabetes:
-
have a very high lifetime risk of cardiovascular and renal complications, and of dying from them, and
-
are more likely to be living with obesity.
Taking this into account, they agreed that, if not started as initial therapy, starting a GLP-1 receptor agonist or tirzepatide as subsequent therapy was likely the most appropriate treatment because it could help to reduce long-term cardiovascular, renal and glycaemic complications better than other medications, while also reducing weight as a side effect.
DPP-4 inhibitors (for people not taking a GLP-1 receptor agonist or tirzepatide)
Evidence was not available for people with early onset type 2 diabetes. The evidence for groups who did not have early onset type 2 diabetes, including people at higher risk of cardiovascular disease, showed that DPP-4 inhibitors were effective at reducing HbA1c and relatively safe. Based on this evidence, and their experience, the committee recommended that a DPP-4 inhibitor should be a choice for people with early onset type 2 diabetes who need further medicines when a GLP-1 receptor agonist or tirzepatide is not appropriate. DPP-4 inhibitors all have similar clinical efficacy, and no particular medicine was more cost effective than the others.
Sulfonylureas and pioglitazone
The committee recommended sulfonylureas and pioglitazone in this group based on their own experience, and by extrapolating the evidence from other groups covered in this guideline (which showed that these medicines reduced HbA1c). However, there was also limited evidence for these other groups that showed a potential for adverse effects:
-
sulfonylureas might increase hypoglycaemic events and weight gain
-
pioglitazone might worsen cardiovascular outcomes and should be avoided for people with heart failure.
The committee acknowledged that pioglitazone increases the risk of fractures and weight gain, as stated in the BNF. As with each medicine listed in this section, they agreed that healthcare professionals should consider the benefits and risks of each treatment when deciding if a treatment is appropriate, on a case-by-case basis. This information should be discussed with the person with diabetes so that they and their healthcare professional can come to an informed decision together about their treatment plan.
Insulin-based treatments
For insulin-based treatments, the evidence for other populations showed that they are less effective than most other antidiabetic therapies at reducing harm from adverse events because it can increase the risk of hypoglycaemic events and weight gain. There are 2 main scenarios when insulin is an effective treatment:
-
managing acute hyperglycaemia
-
managing long-term worsening hyperglycaemia that does not respond to other treatments.
However, in the committee's experience, insulin may also be a good option for people who cannot tolerate other medicines. Therefore, they recommended insulin alongside other options for people who need further medicines to reach their individualised glycaemic targets.
How the recommendations might affect practice
These recommendations are likely to be a change from current practice, enabling wider access to therapies supported by recent evidence of clinical and cost effectiveness.
GLP-1 receptor agonists or tirzepatide
GLP-1 receptor agonists and tirzepatide were previously recommended after triple therapy with metformin and 2 other oral medicines was not effective, tolerated or contraindicated. Therefore, recommending the treatment as triple therapy after taking metformin and 1 oral medicine (an SGLT-2 inhibitor) may lead to increases in costs. The committee agreed that this will likely reduce over time, because the cardiovascular benefits and weight loss side effect of GLP-1 receptor agonists will reduce the number of appointments needed to treat atherosclerotic cardiovascular disease. Increased use of GLP-1 receptor agonists or tirzepatide will reduce DPP-4 inhibitor use. Early intervention could lead to weight loss as a beneficial side effect and so to a better long-term prognosis, which, if maintained, will reduce:
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long-term treatment requirements and
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the need for later stage treatments (such as insulin).
DPP-4 inhibitors, sulfonylureas, pioglitazone and insulin
The recommendations on DPP-4 inhibitors, sulfonylureas, pioglitazone and insulin do not reflect a significant change in current practice and are unlikely to increase resource use. There may be cost savings if people are no longer prescribed GLP-1 receptor agonists and DPP-4 inhibitors together. DPP-4 inhibitors vary in price, but the default assumption is that services will use the medicine with the lowest acquisition cost (in the absence of patient-specific factors). The use of more intensive earlier treatment may lead to a reduction in the use of insulin, which may offset costs in the long term.
Further treatment: people living with obesity
Recommendations 1.29.1 to 1.29.4
Why the committee made the recommendations
GLP-1 receptor agonists or tirzepatide
The committee agreed GLP-1 receptor agonists and tirzepatide should be considered for people living with obesity because of the medicines' glycaemic reduction properties. GLP-1 receptor agonists also have the cardiovascular and renal benefits. These may also reduce weight, which may be an important side effect for the person with type 2 diabetes and their healthcare professionals. However, if weight reduction is the primary aim of the treatment, the committee agreed that guidance should be sought within NICE's guideline on overweight and obesity management instead of this guideline.
Evidence showed that out of the GLP-1 receptor agonists, only liraglutide reached the cost-effectiveness threshold in the base-case analysis for people living with obesity. The committee agreed that while liraglutide was cost effective, it was less clinically effective than other GLP-1 receptor agonists, for example semaglutide. Semaglutide was cost effective when more favourable assumptions around weight loss¸ such as it being maintained for a longer period, were used in the economic model. Given this, the committee agreed that it was plausible for both liraglutide and semaglutide to be cost effective. The committee therefore made the recommendation to consider more clinically effective GLP-1 receptor agonists dependent on the needs of the person.
Tirzepatide is a glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 dual-receptor agonist. The committee looked at the evidence from NICE's technology appraisal guidance for tirzepatide for people with type 2 diabetes, which recommends tirzepatide as an alternative to GLP-1 receptor agonists. In October 2023, the technology appraisal guidance recommended that it should be offered alongside diet and exercise to adults for whom type 2 diabetes is insufficiently controlled and only if triple therapy with metformin and 2 other oral antidiabetic medicines is ineffective, not tolerated or contraindicated (among other criteria). Given that the evidence supporting the technology appraisal guidance found tirzepatide was clinically and cost effective for reducing HbA1c and weight for people with type 2 diabetes, the committee for this guideline agreed to recommend it as an alternative to GLP-1 receptor agonists.
A GLP-1 receptor agonist or tirzepatide should only be added after at least 3 months of initial therapy, so that the effect of the initial therapy on the person's glycaemic targets can be assessed and taken into account when deciding whether additional treatment is needed. The committee agreed that the medicine should be continued as long as it has benefits in reducing HbA1c for the person.
Sulfonylureas and pioglitazone
The committee recommended sulfonylureas and pioglitazone in this group based on their own experience, and by extrapolating the evidence from other groups covered in this guideline (which showed that these medicines reduced HbA1c). However, there was also limited evidence for these other groups that showed a potential for adverse effects:
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sulfonylureas and insulin-based therapies might increase hypoglycaemic events and weight gain
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pioglitazone might worsen cardiovascular outcomes and should be avoided for people with heart failure.
The committee acknowledged that pioglitazone increases the risk of fractures and weight gain, as stated in the BNF. As with each medicine listed in this section, they agreed that healthcare professionals should consider the benefits and risks of each treatment when deciding if a treatment is appropriate, on a case-by-case basis. This information should be discussed with the person with diabetes so that they and their healthcare professional can come to an informed decision together about their treatment plan.
Insulin-based treatments
Evidence on insulin-based treatments for other populations showed that these treatments are less effective than most other antidiabetic therapies at reducing harm from adverse events because it can increase the risk of hypoglycaemic events and weight gain. There are 2 main scenarios when insulin is an effective treatment:
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managing acute hyperglycaemia
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managing long-term worsening hyperglycaemia that does not respond to other treatments.
However, in the committee's experience insulin may also be a good option for people who cannot tolerate other medicines. Therefore, they recommended insulin alongside other options for people who need further medicines to reach their individualised glycaemic targets.
How the recommendations might affect practice
These recommendations are likely to be a change from current practice, with wider access to therapies with more recent evidence of clinical and cost effectiveness.
GLP-1 receptor agonists and tirzepatide
GLP-1 receptor agonists and tirzepatide were previously recommended after triple therapy with metformin and 2 other oral medicines was not effective, tolerated or contraindicated. Therefore, recommending the treatment as triple therapy after taking metformin and 1 oral medicine (an SGLT-2 inhibitor) may lead to increases in costs. The committee agreed this will likely reduce over time, because the cardiovascular benefits and the weight loss side effect of GLP-1 receptor agonists will reduce the number of appointments needed to treat atherosclerotic cardiovascular disease. An increase in GLP-1 receptor agonist or tirzepatide use will mean that DPP-4 inhibitor use will reduce. Early intervention could lead to weight loss as a beneficial side effect and so to a better long-term prognosis, which, if maintained, will reduce:
-
long-term treatment requirements and
-
the need for later stage treatments (such as insulin).
DPP-4 inhibitors, sulfonylureas, pioglitazone and insulin
The recommendations on DPP-4 inhibitors, sulfonylureas, pioglitazone and insulin do not reflect a significant change in current practice and are unlikely to increase resource use. There may be cost savings if people are no longer prescribed GLP-1 receptor agonists or tirzepatide and DPP-4 inhibitors together. DPP-4 inhibitors do vary in price, but the default assumption is that services will use the medicine with the lowest acquisition cost (in the absence of patient-specific factors). The use of more intensive earlier treatment may lead to a reduction in the use of insulin, which may offset costs in the long term.
Further treatment: people with chronic kidney disease
Why the committee made the recommendation
The committee made a recommendation for this group based on their knowledge and experience, because the clinical evidence was very limited.
DPP-4 inhibitors are effective at reducing HbA1c and have fewer adverse effects than other comparable options. If DPP-4 inhibitors are contraindicated, not tolerated or not effective, then in the committee's experience the best option is either pioglitazone, a sulfonylurea, or an insulin-based treatment.
The committee acknowledged that sulfonylureas increase the risk of hypoglycaemia, pioglitazone increases the risk of heart failure, fractures and weight gain, and insulin increases the risk of hypoglycaemic events and weight gain, as recorded in the BNF. As with each medicine listed in this section, they agreed that healthcare professionals should consider the benefits and risks of each treatment when deciding if a treatment is appropriate, on a case-by-case basis. This information should be discussed with the person with diabetes so that they and their healthcare professional can come to an informed decision together about their treatment plan.
How the recommendations might affect practice
The recommendations on DPP-4 inhibitors, sulfonylureas, pioglitazone and insulin do not reflect a significant change in current practice and are unlikely to increase resource use. There may be cost savings if people are no longer prescribed GLP-1 receptor agonists or tirzepatide and DPP-4 inhibitors together. DPP-4 inhibitors do vary in price, but the default assumption is that services will use the medicine with the lowest acquisition cost (in the absence of patient-specific factors).
Further treatment: people with frailty
Recommendations 1.31.1 and 1.31.2
Why the committee made the recommendations
There was no evidence on outcomes for people with frailty. Using their knowledge from clinical practice, the committee recommended that, in this group, the aim of treatment should primarily be to control symptoms.
If initial therapy does not achieve the treatment goals, a DPP-4 inhibitor can reduce HbA1c with limited adverse effects.
Pioglitazone, sulfonylureas and insulin-based treatments are recommended as alternatives based on the committee's experience. The committee did not recommend one treatment over the other because of the lack of evidence and the diverse needs of people with frailty.
The committee acknowledged that sulfonylureas and insulin increase the risk of hypoglycaemia and falls, while pioglitazone increases the risk of fractures and weight gain, as recorded in the BNF. As with each medicine listed in this section, they agreed that healthcare professionals should consider the benefits and risks of each treatment when deciding if a treatment is appropriate, on a case-by-case basis. This information should be discussed with the person with diabetes so that they and their healthcare professional can come to an informed decision together about their treatment plan.
The committee did not recommend GLP-1 receptor agonists or tirzepatide for people with frailty. However, they agreed that there is no inherent safety risk for this population. Therefore, if a person has a relevant indication and frailty, they can still be offered a GLP-1 receptor agonist or tirzepatide.
Because of the lack of evidence, the committee made a recommendation for research on treatment strategies for people with type 2 diabetes and frailty.
How the recommendations might affect practice
The recommendations on DPP-4 inhibitors, sulfonylureas, pioglitazone and insulin do not reflect a significant change in current practice and are unlikely to increase resource use. There may be cost savings if people are no longer prescribed GLP-1 receptor agonists or tirzepatide and DPP-4 inhibitors together. DPP-4 inhibitors do vary in price, but the default assumption is that services will use the medicine with the lowest acquisition cost (in the absence of patient-specific factors).
Insulin-based treatments
Recommendations 1.32.1 to 1.35.2
Why the committee made the recommendations
In 2026, the insulin-based treatment recommendations were amended to reflect the withdrawal of insulin products and known insulin brand shortages. Based on the committee's clinical experience and consensus, this refresh acknowledges the increased use of analogue insulin. The committee agreed that:
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different insulin therapies may be more useful for different people dependent on their symptoms (for example, if there is a risk of nocturnal hypoglycaemia, a longer acting basal insulin might be more suitable) and
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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.
How the recommendations might affect practice
The effect of the 2026 recommendation updates on current practice is uncertain. There may be a general decrease in insulin use because of the use of other medications.
Biosimilar insulin
Recommendations 1.35.3 and 1.35.4
Why the committee made the recommendations
Biosimilars have the potential to offer the NHS considerable cost savings. To gain approval for use, biosimilar medicines have to be shown to be safe and as effective as the original reference medicine, and to have the same quality. Based on this, the committee noted it was appropriate, when starting a new prescription of an insulin for which a biosimilar is available, to use the one with the lowest cost.
In addition, people may be using an insulin for which a lower cost biosimilar is available. In such cases, the committee recommended discussing with people the possibility of switching to the biosimilar. This could happen at the person's routine review. They also agreed that switching to the biosimilar should be carefully planned. A shared decision should be reached about the switch, taking into consideration the dose-switching protocols, monitoring, and the person's concerns about switching from their existing regimen. Healthcare professionals should also refer to the summary of product characteristics for further information when considering switching to biosimilars.
Periodontitis
Recommendations 1.37.1 to 1.37.4
Why the committee made the recommendations
The evidence showed that people with diabetes are at increased risk of periodontitis, and that non-surgical periodontal treatment can improve diabetes control. However, in the committee's experience, people with diabetes are often unaware of this and may not be having regular oral health reviews. To address this, the committee recommended routinely discussing the risk of periodontitis at annual reviews, alongside eye disease and foot problems.
The evidence also showed that periodontal treatment is cost effective for people with type 2 diabetes, assuming improvements in HbA1c are maintained. This was tested with health economic modelling in a range of different scenarios. There were some scenarios where periodontal treatment was not cost effective, but the committee did not think these scenarios reflected real-world practice.
How the recommendations might affect practice
For oral healthcare professionals, the long-term impact of the recommendations is uncertain. The recommendations specify that people should follow existing NICE guidelines on oral health. However, the recommendations may also increase awareness of periodontitis, leading to a possible short-term increase in the number of oral health reviews. Any increase in the number of oral health reviews will potentially impact on services, as NHS dental services already have capacity issues.
A short-term increase in the number of oral health reviews will also lead to a short-term increase in costs. However, there is likely to be a larger long-term reduction in costs from the improvement to oral health and diabetes control.
Oral healthcare and dental teams will need clear advice on what they need to do for people with diabetes. They will need clear care pathways to improve quality of care and service delivery, in line with the NHS England commissioning standard on dental care for people with diabetes.
Many people do not have regular oral health reviews, even if they are eligible for free NHS dental care. People are eligible for free dental care if they are:
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pregnant
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mothers with babies under 1 year old
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on low income benefits, or under 20 and dependent on someone who is receiving low income benefits
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having treatment in an NHS hospital by the hospital dentist.
The recommendations may encourage more people with diabetes to have regular oral health reviews. Combined with proactive engagement and enhanced support for people with diabetes, this may broaden access to dental and oral healthcare and help to reduce oral health inequalities.