Type 2 diabetes draft guideline pledges earlier access to newer treatments

New draft NICE guidelines have proposed patients be given earlier access to newer type 2 diabetes treatments to help reduce health inequalities and provide better outcomes.

The move will likely see a significant increase in prescribing and monitoring workloads for nurse prescribers and nurses involved in diabetes care in general practice and has been described as the ‘biggest shake-up in care for a decade’.

Published today and out to consultation until 2 October, the draft guidelines suggest SGLT-2 inhibitors become a first-line treatment for most people with diabetes, along with metformin or alone if metformin is not tolerated or contraindicated.

SGLT-2 inhibitors work to protect the heart and kidneys while lowering blood sugar levels, and include drugs canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. They are currently recommended for those with heart failure, cardiovascular disease or high cardiovascular risk.

In addition, the draft guidelines propose that GLP-1receptor agonists, such as semaglutide, are offered as initial therapy for people with atherosclerotic cardiovascular disease (ASCVD) and considered for people with early onset type 2 diabetes.

NICE said ‘millions’ of people were set to benefit from the changes.

It added that its recommendations came as part of a move away from a ‘one-size-fits-all’ approach and towards personalised care that supports treatment for diabetes alongside cardiovascular and kidney disease, rather than in isolation.

NICE said people with type 2 diabetes should speak with their diabetes team at their next annual review meeting to discuss what treatment option is right for them.

The body recognised that putting recommendations into practice ‘can take time’ and that when exercising their judgement, health professionals are ‘expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service’. It is not however mandatory to apply the recommendations.

Professor Jonathan Benger, deputy chief executive and chief medical officer at NICE, said the draft recommendations supported commitments within the government’s recently published 10-year health plan, including its focus on shifting from treatment to prevention.

‘This guidance means more people will be offered medicines where it is right to do so to reduce their future risk of ill health,’ he said.

‘This represents a significant evolution in how we approach type 2 diabetes treatment.

‘We’re moving beyond simply managing blood sugar to taking a holistic view of a person’s health, particularly their cardiovascular and kidney health.’

The guidelines also aim to address concerns about under-prescribing of SGLT-2 inhibitors and that these medicines are not being offered equitably across the UK.

According to NICE analysis of almost 590,000 patient records in 2024, SGLT-2 inhibitors were particularly under-prescribed to women, older people and Black or Black British individuals.

Among people with ASCVD, 32% of those aged 50-59 with ASCVD received SGLT-2 prescriptions compared to just 13% of those aged 80-89.

Black or Black British people with ASCVD and those in deprived areas with ASCVD had 22% and 15% lower odds of receiving prescriptions respectively, the study found.

Meanwhile, men (35%) were more likely to receive prescriptions than women (23%) among people with heart failure.

Professor Benger added: ‘There are prescribing gaps that need to be addressed. The guideline update published today will help to increase equitable uptake of SGLT-2 inhibitors, which we know can prevent serious health complications.’

Dr Waqaar Shah, a GP partner at Chatfield Health Care in London and committee chair, said the recommendations could ‘help reduce health inequalities while providing better outcomes for everyone’.

‘There is some urgency to find ways to increase the uptake of SGLT-2 inhibitors because if we were to achieve perfect uptake the nation would be significantly healthier,’ he said.

‘That has benefits primarily for the patient but also for the healthcare system, potentially reducing the use of resources associated with health complications.’

Professor Azeem Majeed, professor of primary care and public health at Imperial College London and a GP in London, said the draft guidelines represented an ‘important step forward’ in managing type 2 diabetes.

But he added that implementation would be ‘challenging and will require careful planning’.

‘Cost is a key issue: SGLT-2 inhibitors and GLP-1 receptor agonists are substantially more expensive than older diabetes drugs, and the NHS will need to weigh these higher upfront costs against the long-term savings from preventing heart disease, kidney failure and hospital admissions,’ he said.

‘Capacity is another concern. Primary care teams already carry a heavy workload, and wider use of newer medicines will require more time, resources, and training to support patients effectively.’

He added that ‘clinician confidence will be crucial’.

‘Most GPs, practice nurses and pharmacists are very familiar with prescribing or dispensing metformin, but many will feel less confident about when and how to use newer agents,’ he said.

‘Clear guidance, straightforward prescribing pathways, and ongoing education will be essential to ensure these medicines are used safely, equitably, and to best effect.’

Head of clinical at Diabetes UK Douglas Twenefour said the announcement from NICE today ‘propels type 2 diabetes treatment into the 21st century’ and that increasing access to newer treatments ‘will be transformative for people with type 2 diabetes’.

‘These guidelines could go a long way to easing the burden of living with this relentless condition, as well as helping to address inequities in type 2 diabetes treatments and outcomes,’ he added.

The draft guideline is open for public consultation until 2 October. NICE’s guideline committee will consider all feedback received before publishing the final recommendations.