Update information

August 2019: Section 1.4 on blood pressure management was updated and replaced by recommendations in the NICE guideline on hypertension in adults.

May 2017: Text on sodium–glucose cotransporter 2 (SGLT-2) inhibitors was added to the section on initial drug treatment. The algorithm for blood glucose lowering therapy in adults with type 2 diabetes was also updated to revise footnote b with links to relevant NICE guidance on SGLT-2 inhibitors, and new information on SGLT-2 inhibitors was also added to the box on action to take if metformin is contraindicated or not tolerated.

December 2016: The text following recommendation 1.6.31 and the algorithm for blood glucose lowering therapy in adults with type 2 diabetes were updated to include reference to NICE TA418 on dapagliflozin in triple therapy for treating type 2 diabetes.

July 2016: Recommendation 1.7.17 has been reworded to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen.

December 2015: This guidance updates and replaces NICE guideline CG87 (published May 2009). It also updates and replaces NICE technology appraisal guidance 203 and NICE technology appraisal guidance 248.

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

Recommendations are marked as [new 2015], [2015], [2009] or [2009, amended 2015]:

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

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

  • [2009] indicates that the evidence has not been reviewed since 2009.

  • [2009, amended 2015] or [2009, amended 2016] indicates that the evidence has not been reviewed since 2009, but either changes have been made to the recommendation wording that change the meaning or NICE has made editorial changes to the original wording to clarify the action to be taken (see below).

Recommendations from NICE clinical guideline 87 (2009) that have been amended

Recommendations are labelled [2009, amended 2015] if the evidence has not been reviewed but either:

  • changes have been made to the recommendation wording that change the meaning or

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

Recommendation in 2009 guideline

Recommendation in current guideline

Reason for change

For a person with continuing intolerance to an ACE inhibitor (other than renal deterioration or hyperkalaemia), substitute an angiotensin II‑receptor antagonist for the ACE inhibitor. [1.8.10]

Do not combine an ACE inhibitor with an angiotensin II‑receptor antagonist to treat hypertension. [new 2015] (1.4.11)

The Guideline Development Group noted that there was no recommendation highlighting the importance of not combining an ACE inhibitor with an angiotensin II‑receptor antagonist to treat hypertension. The Guideline Development Group agreed that recommendation 1.6.7 from the NICE hypertension guideline CG127 should be added, as although the hypertension guideline does not specifically include people with type 2 diabetes, the principle also applies in this population.

If the person's blood pressure is not reduced to the individually agreed target with first‑line therapy, add a calcium‑channel blocker or a diuretic (usually bendroflumethiazide, 2.5 mg daily). Add the other drug (that is, the calcium‑channel blocker or diuretic) if the target is not reached with dual therapy. [1.8.11]

If the person's blood pressure is not reduced to the individually agreed target with first‑line therapy, add a calcium‑channel blocker or a diuretic (usually a thiazide or thiazide‑related diuretic). Add the other drug (that is, the calcium‑channel blocker or diuretic) if the target is not reached with dual therapy. [2009, amended 2015] (1.4.12)

The Guideline Development Group noted that there are other thiazides and related diuretics which are used in standard clinical practice, and agreed that reference should be made to the drug group rather than restricting the recommendation to a specific drug, in line with NICE hypertension guideline CG127. Therefore, the Guideline Development Group wanted to change this recommendation to allow healthcare professionals greater flexibility in prescribing.

Refer to an ophthalmologist in accordance with the National Screening Committee criteria and timelines if any of these features is present:

  • referable maculopathy:

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

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

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

  • referable pre‑proliferative retinopathy (if cotton wool spots are present, look carefully for the following features, but cotton wool spots themselves do not define pre‑proliferative retinopathy):

    • any venous beading

    • any venous loop or reduplication

    • any intraretinal microvascular abnormalities

    • multiple deep, round or blot haemorrhages

  • any unexplained drop in visual acuity. [1.13.9]

Refer to an ophthalmologist in accordance with the National Screening Committee criteria and timelines if any of these features is present:

  • referable maculopathy:

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

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

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

  • referable pre‑proliferative retinopathy (if cotton wool spots are present, look carefully for the following features, but cotton wool spots themselves do not define pre‑proliferative retinopathy):

    • any venous beading

    • any venous reduplication

    • any intraretinal microvascular abnormalities

    • multiple deep, round or blot haemorrhages

  • any large, sudden, unexplained drop in visual acuity. [2009, amended 2015] (1.7.25)

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

Consider a trial of metoclopramide, domperidone or erythromycin for an adult with gastroparesis. [1.14.3.2]

For adults with type 2 diabetes who have vomiting caused by gastroparesis explain that:

• there is not strong evidence that any available antiemetic therapy is effective

• some people have had benefit with domperidone, erythromycin or metoclopramide.

• The strongest evidence for effectiveness is for domperidone, but prescribers must take into account its safety profile, in particular its cardiac risk and potential interactions with other medicines. [new 2015] (1.7.2)

For treating vomiting caused by gastroparesis in adults with type 2 diabetes:

• consider alternating use of erythomycin and metoclopramide

• consider domperidone only in exceptional circumstances (if domperidone is the only effective treatment) and in accordance with MHRA guidance. [new 2015] (1.7.3)

The recommendation on the treatment of gastroparesis from clinical guideline 87 has been replaced by recommendations from the guideline update of type 1 diabetes which undertook a new evidence review on the management of gastroparesis in type 1 diabetes. It was agreed by the guideline committees for type 1 and type 2 diabetes that the management of gastroparesis would be similar for people with diabetes. It was considered important to highlight the MHRA warning around the use of domperidone.

1.7.1, 1.7.5, 1.7.6, 1.7.17

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

Minor changes since publication

June 2018: Recommendation 1.3.11 was added to provide a link to NICE's advice on bariatric surgery.

January 2018: Footnotes were added with links to MHRA warnings about sodium–glucose cotransporter 2 (SGLT-2) inhibitors.

ISBN: 978-1-4731-1477-7

  • National Institute for Health and Care Excellence (NICE)