Introduction

Recommendations that represent a change to current practice:

• Offer initial modified-release metformin and SGLT-2 inhibitor treatment for people with type 2 diabetes and:
  • no relevant comorbidity
  • heart failure (with any ejection fraction, unless specified)
  • atherosclerotic cardiovascular disease (ASCVD)
  • early onset type 2 diabetes
  • obesity
  • chronic kidney disease.
• Offer initial subcutaneous semaglutide (up to 1 mg once a week) treatment for people with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD).
• Consider initial GLP-1 receptor agonist or tirzepatide treatment for people with early onset type 2 diabetes.

A resource impact template has been developed and published alongside this report.

The key areas of impact are:

• an increase in the cost of treatments in primary care
• a reduction in heart failure hospitalisations
• a reduction in strokes
• a reduction in angina events
• a reduction in myocardial infarctions
• a reduction in established kidney disease
• an increase in GP appointments (initiation of GLP-1 receptor agonist or tirzepatide)
• an increase in pharmacy time (SGLT-2 inhibitor and GLP-1 receptor agonist or tirzepatide)
• a reduction in GP appointments (switching to modified-release metformin)
• a reduction in mortality.

Resource impact (cash and capacity items)

Table 1 highlights for every additional 10,000 people being treated the increase in treatment costs and the savings from a reduction in events for the following 3 groups:

• SGLT-2 inhibitors for patients with type 2 diabetes
• semaglutide (subcutaneous) for patients with type 2 diabetes and ASCVD
• GLP-1 receptor agonist or tirzepatide for patients with early onset type 2 diabetes.

These costs and savings are over a short period of time (3 years). In clinical practice, people are likely to remain on these medicines (where clinically appropriate) for many years and further events avoided are likely to be realised over this period. Based on committee experience 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. Early intensive treatment can provide benefits by preventing these future negative outcomes.

Note: the table does not include any impact on primary care appointments, however these can be modelled in the template.

Note: the table does not include any impact on primary care appointments, however these can be modelled in the template.

These costs are based on the profile of market shares in the future practice remaining the same as current practice, and assumes that in current practice people have generic dapagliflozin. The cost of treatment may reduce if the price of dapagliflozin generics reduce further or there is a market share shift from comparators to generic dapagliflozin.

The health economics underpinning the guidance calculated the benefits associated (events avoided) with the use of an SGLT-2 inhibitor and GLP-1 receptor agonist over a 3-year period, hence the cost of the medicines is also reported over the same period.

The change in events avoided for SGLT-2 inhibitors is based on the health economic modelling, which compared people treated with SGLT-2 inhibitors and metformin to being treated with metformin alone. For GLP-1 receptor agonists, the comparison was made between people treated with GLP-1 receptor agonists, SGLT-2 inhibitors and metformin compared with being treated with SGLT-2 inhibitors and metformin.

The event rates and cost of the event is based on the economic model. Tirzepatide was not included in the economic model, so no events avoided have been included for tirzepatide in the calculations.

The template has inputted percentages for current and future market share for metformin, SGLT-2 inhibitors, GLP-1 receptor agonists and tirzepatide treatments for all population groups under consideration. Users are advised to adjust these for their local expected change in practice.

The 'Unit costs' worksheet should be reviewed to ensure costs used represent local cost profiles. This should include confidential prices for tirzepatide and any generic products.

The template assumes people initiating GLP-1s or tirzepatide will require two 20-minute appointments with a band 6 nurse; users can amend the number and time of appointments on the capacity tab in the resource impact template. Users can also amend the nursing or pharmacy time to reflect any additional requirements for prescribing SGLT-2, GLP-1s or tirzepatide.

Please refer to the rationale and impact section in the guideline, which explains why the committee made the recommendations and how they might affect practice.

Population covered

Table 2 shows the number of adults eligible for metformin and SGLT-2s in England. The prevalence of diabetes is based on Department of Health and Social Care Fingertips data. There is a tab within the template that shows the prevalence of diabetes by integrated care board if users wish to use these instead. The proportion of people with type 2 diabetes is based on Diabetes UK’s statistics, and the proportion of people receiving pharmacological treatment is based on Clinical Practice Research Datalink December 2023 dataset.

Table 3 shows the number of adults with type 2 diabetes and ASCVD who are eligible for subcutaneous semaglutide in England. The proportion of people with ASCVD and the proportion of people receiving pharmacological treatment is based on Clinical Practice Research Datalink December 2023 dataset.

Table 4 shows the number of adults with early onset type 2 diabetes who are eligible for a GLP-1 or tirzepatide in England. The proportion of people with early onset diabetes is based on the young people with Type 2 diabetes report 2023/24 from NHS Digital, and the proportion of people receiving pharmacological treatment is based on Clinical Practice Research Datalink December 2023 dataset.

Key information

About this resource impact summary report

This resource impact summary report accompanies NICE’s guideline on Type 2 diabetes in adults and should be read with it.