Major changes to type 2 diabetes treatment could save thousands of lives
New guidance means millions of people will get access to medicines that protect the heart and kidneys, while NHS savings of £560 million from using generic dapagliflozin can be reinvested elsewhere in NHS care.
Millions of people with type 2 diabetes could live longer, healthier lives under new NICE recommendations that put individual needs at the heart of treatment decisions.
In final guidance published by NICE today (Wednesday, 18 February), people with type 2 diabetes will be offered a type of medicine called an SGLT-2 inhibitor, known as ‘flozins’, much earlier in their treatment.
The NHS is set to save millions of pounds because one of the most commonly prescribed SGLT-2 medicines, dapagliflozin, is now available as a clinically equivalent generic version. The estimated cumulative savings in total for 2025/26 and 2026/27 from generic dapagliflozin would be £560m. This money could be reinvested in other areas of diabetes care, such as education programmes and community support services or other parts of the NHS.
Analysis by NICE suggests using SGLT-2 medicines earlier in the treatment pathway, and the introduction of GLP-1 receptor agonists and tirzepatide for some people, could prevent around 17,000 deaths over a three-year period across the UK by reducing the risk of heart attacks, strokes and kidney problems.
What's changing
Until now, most people newly diagnosed with type 2 diabetes were started on a medicine called metformin. The new NICE guidance recommends that most people should now be offered metformin along with an SGLT-2 inhibitor from the start. But this isn't one-size-fits-all approach as people will work with their healthcare professional to decide the best treatment for them, based on their own circumstances and preferences.
SGLT-2 inhibitors work by helping the kidneys remove excess sugar from the body. But research shows they do much more than control blood sugar by also protecting the heart and kidneys. This is particularly important because heart disease is the leading cause of death in people with type 2 diabetes.
The guidance also recommends that people should be given a slow-release form of metformin. Many people experience stomach upsets with the standard-release form, which can put them off taking their medicine. The slow-release version is easier on the stomach and helps people stay on their treatment particularly if they experience side effects.
Making sure everyone benefits
NICE looked at the anonymised records of almost 590,000 people and found that SGLT-2 inhibitors are not being prescribed fairly in all populations as not all people access the care they need. They are often under prescribed to women, older people, and Black people. The new guidance includes recommendations to monitor who is getting these treatments and take action to close these gaps.
This is a landmark moment for diabetes care. Our independent committee conducted a rigorous review of the evidence and concluded that by offering certain medicines earlier, we can prevent thousands of heart attacks, strokes and cases of kidney failure — keeping people healthier for longer while reducing pressure on NHS services.
Eric added, "But we also found something troubling: these life-saving medicines are currently under-prescribed to women, older people and Black patients. Tackling health inequalities is at the heart of what NICE does, and these recommendations will help ensure everyone with type 2 diabetes gets fair access to the best available treatments.
"By recommending generic dapagliflozin where clinically appropriate, we're also freeing up hundreds of millions of pounds that can be reinvested elsewhere in NHS care. This is evidence-based guidance that saves lives and delivers value for the taxpayer."
Your diabetes, your treatment
Everyone with type 2 diabetes is different. The guidance asks healthcare professionals to work with each person to find the right treatment for them, based on their other health conditions, the medicines they already take, and what matters most to them. Decisions should be made together, with regular check-ups to make sure treatments are still working.
Safety comes first. While newer medicines offer real benefits, they are not right for everyone. Healthcare professionals will check each person's heart and kidney health before starting treatment, and new medicines should be introduced one at a time to make sure they are well tolerated. A new prescribing guide published alongside this guidance will help healthcare professionals have these conversations and prescribe safely.
As a GP, I see first-hand how type 2 diabetes affects my patients' lives. Right now, only around 1 in 5 people with type 2 diabetes and heart disease are receiving the medicines that could protect them from heart attacks, strokes and kidney failure.
Waqaar continues, "By recommending these treatments earlier, we have a real opportunity to prevent thousands of serious complications.
“But every person is different, and the decision about which medicine is right should always be made together with the patient, taking into account their individual circumstances, preferences and what matters most to them."
Tailored treatment for different needs
The new guidance moves away from a 'one-size-fits-all' approach. Instead, it sets out different recommendations depending on each person's circumstances:
People diagnosed with type 2 diabetes before age 40 face a higher lifetime risk of heart and kidney problems, so may benefit from adding another type of medicine called a GLP-1 receptor agonist (such as semaglutide, dulaglutide and liraglutide) or tirzepatide.
People living with obesity have specific recommendations that take account of their needs.
People who already have kidney disease or heart failure have tailored recommendations, with SGLT-2 inhibitors offering particular benefits for protecting their kidneys and heart.
This welcome guidance will transform treatment for people living with type 2 diabetes across the UK. Providing earlier access to vital drugs that protect the heart and kidneys from serious diabetes-related complications is a major step towards reducing the harm caused by this relentless condition.
Douglas adds, "The shift towards a more personalised approach will help more people get the right treatment for them, at the right time. Monitoring the uptake of medicines, to ensure that those who could benefit receive them, will help address the unacceptable inequities in type 2 diabetes treatments and outcomes that still persist."
Newer medicines for specific groups
The guidance also expands access to a group of medicines called GLP-1 receptor agonists (such as semaglutide, dulaglutide and liraglutide) and tirzepatide. Semaglutide will now be recommended for people with type 2 diabetes who also have cardiovascular disease caused by blocked arteries (such as previous heart attacks or strokes). GLP-1 receptor agonists and tirzepatide will be recommended for people who were diagnosed before age 40, or who are living with obesity. Around 810,000 more people could benefit from these medicines.
These medicines help manage blood sugar levels while also protecting the heart and kidneys. While some of these medicines are also prescribed separately for weight loss, the recommendations here focus specifically on treating type 2 diabetes.
Healthy living still matters
The guidelines make clear that medicines are just one part of managing type 2 diabetes. Doctors and nurses should discuss diet, physical activity and other healthy changes alongside any medicines. Some people may be able to put their diabetes into remission through changes to their diet and weight – the NHS Type 2 Diabetes Path to Remission Programme can help with this.
People with type 2 diabetes should speak to their healthcare provider at their next diabetes follow up appointment to discuss what these changes might mean for them.