Type 2 diabetes treatment updates: putting NICE into practice

Diabetes advanced nurse practitioner Molly Mckeown discusses the latest updates to NICE type 2 diabetes treatment recommendations, and explains how nurses in primary care can implement the changes safely and effectively

What are the key changes to the treatment recommendations, and how does this advance more ‘personalised’ care?

For decades, pharmacological management of type 2 diabetes has followed a predominantly glycaemia-driven escalation model – a graduated progression of glucose-lowering therapy based largely on HbA1c thresholds.

The recently updated NICE guidance marks a clear shift away from this reactive, blanket glucose-lowering approach towards a proactive, personalised strategy that prioritises the individual and their wider cardio-renal-metabolic risk.¹

Treatment with medication is now stratified according to key clinical characteristics rather than HbA1c alone.

Specifically, NICE states that we should assess each patient for the following prior to initiating treatment:

• Established atherosclerotic cardiovascular disease (ASCVD).
• Heart failure.
• Chronic kidney disease (CKD).
• Obesity.
• Early-onset type 2 diabetes (diagnosed before age 40).
• Frailty.

In practice, this means that the patient’s comorbidity profile, not just glycaemic level, increasingly determines medicine choice.¹ Recommendations for initial therapy depending on the patient’s clinical characteristics or comorbidities are summarised in Box 1 below and NICE provides a helpful visual summary of all treatment recommendations in each scenario.

A major development is the earlier use of sodium–glucose cotransporter (SGLT)-2 inhibitors. NICE now recommends these agents as part of initial dual therapy, along with modified-release (MR) metformin for most people, or as monotherapy where metformin is unsuitable.

It remains advisable to titrate metformin MR to the maximum tolerated dose before introducing SGLT2 inhibitors, ensuring tolerability is established. In clinical practice, treatments are typically introduced sequentially, with each agent optimised and assessed for tolerability before adding the next.

Earlier introduction of SGLT2 inhibitors reflects clinical trial evidence demonstrating reductions in heart failure hospitalisation and slower progression of CKD, with benefits that extend beyond glycaemic control.^2,3

The guidance also elevates glucagon-like peptide-1 (GLP-1) receptor agonists like semaglutide (Ozempic) and the dual GLP-1 / glucose-dependent insulinotropic peptide (GIP) receptor antagonist tirzepatide within the treatment pathway. Earlier use of these medications, often alongside metformin and SGLT-2 inhibitors, is now recommended for people with ASCVD, obesity, or early-onset type 2 diabetes, where weight reduction and cardiovascular risk modification are priorities.

Importantly, these are no longer restricted to use only after triple therapy or if the patient has a BMI >35kg/m². In addition, these agents are continued unless the person becomes underweight (BMI <18.5 kg/m²) or fails to meet their individualised glycaemic targets (when not prescribed for cardiovascular benefit).

As in the previous guideline, GLP-1 or GLP-1/GIP receptor agonists should not be used in combination with a DPP‑4 inhibitor.¹

How can nurses start making these new prescribing choices and counsel patients?

Primary care and community nurses play a central role in helping people with type 2 diabetes start and adjust medication safely, whether or not they prescribe themselves.

Their contribution is less about choosing a drug in isolation and more about ensuring the chosen treatment fits the person’s clinical risks, priorities and lifestyle.

In practice, this begins with assessing factors that now drive treatment choice in the NICE pathway – such as comorbid ASCVD, heart failure, CKD, obesity or frailty and early-onset type 2 diabetes. Nurses often identify these risks first, during review or routine monitoring.

Equally as important is the nurse’s role in translating prescribing decisions into meaningful, patient-centred conversations.

NICE visual tools, including the HbA1c decision aid and medicines pathway diagrams, help patients understand why a particular treatment is recommended and how it relates to their individual targets and comorbidities.^4,5

Nurses can use these visuals during consultations to link HbA1c goals with treatment effects and broader benefits in a clear, patient-friendly way. Using both the HbA1c decision aid and medicines pathway shifts the conversation from adding ‘another diabetes drug’ to choosing the most appropriate treatment to reach agreed goals in a way that matches the person’s preferences and individual health needs.

With the expanding use of newer agents, drug-specific knowledge also becomes increasingly important.

Nurses need confidence in initiation criteria, dosing, contraindications and adverse-effect profiles of SGLT-2 inhibitors and GLP-1 receptor agonists, alongside competence in metformin use, renal dose adjustment and managing hypoglycaemia risk with sulfonylureas and insulin.

This pharmacological understanding underpins effective counselling at treatment initiation, the early recognition of adverse effects and the ability to provide patients with clear, confident explanations about their treatment options.

Explaining the benefits of a medicine, its mechanism of action and potential adverse effects can be challenging without provoking unnecessary anxiety; using clear, balanced and reassuring language helps patients feel informed, supported and confident in their treatment.

Explaining the mechanism of action for a SGLT-2 inhibitor

With SGLT2 inhibitors it may be helpful to use a statement including a recycling metaphor such as: ‘Your kidneys normally act like a recycling system: they filter sugar out of your blood and then pull it back in so the body can reuse it.

‘SGLT‑2 inhibitors work by turning down that “sugar‑recycling pump”. As a result, more sugar is allowed to pass out through your urine. This not only lowers blood sugar but also reduces strain on the heart and kidneys.’

Explaining how a GLP-1 works

Similarly for patients starting a GLP-1 receptor agonist like semaglutide you might use the following:

‘Think of your hunger signals like the volume on a radio. These medicines turn the volume down, so you feel satisfied with smaller meals and your blood sugar stays more stable.

‘They slow down your stomach’s emptying so you feel fuller for longer and also help your pancreas make insulin more effectively when you eat, reduce the liver’s sugar output and slow the rise in blood sugar after meals.’

Other considerations with SGLT-2 inhibitors and GLP-1 based drugs – side effects and interactions

With the increasing use of SGLT-2 inhibitors and GLP-1 or dual GLP-1/GIP receptor agonists, nurses should be aware of the key adverse effects associated with each class, alongside evolving safety guidance.

SGLT-2 inhibitors are associated with genital and urinary infections and may increase the risk of volume depletion, hypotension, and, rarely, diabetic ketoacidosis – particularly during acute illness. Patients should be advised on-sick day management, including ketone monitoring where appropriate (see more details on sick-day rules below).

GLP-1 (like semaglutide) and dual GLP-1/GIP receptor agonists (like tirzepatide) most frequently cause gastrointestinal side effects, including nausea, vomiting, and diarrhoea, which are usually transient. Less common but important risks include acute pancreatitis and potential worsening of diabetic retinopathy associated with rapid reductions in HbA1c.

Nurses should be familiar with current Medicines and Healthcare products Regulatory Agency (MHRA) guidance, including advice on GLP-1 use in contraception, pregnancy and breastfeeding, ketone monitoring with SGLT2 inhibitors during acute illness, and strengthened warnings regarding pancreatitis with GLP-1-based therapies.^6-9

Rare cases of non-arteritic anterior ischaemic optic neuropathy (NAION) have also been reported with semaglutide;¹⁰ patients should be advised to seek urgent assessment if they experience sudden vision loss.

Clinical judgement remains essential where contraindications or higher risks of adverse effects exist, such as previous pancreatitis with GLP-1based therapies or risk of dehydration, hypotension or diabetic ketoacidosis in frail individuals using SGLT-2 inhibitors.

How can nurses explain side effects safely and effectively?

1. Put likelihood into perspective

Patients often assume listed side effects are common unless told otherwise. It can be helpful to reassure patients that, for example, ‘Most people tolerate this very well,’ and ‘Serious problems are rare’.

Also, when introducing risks, add context, such as ‘We mention this so you know what to look out for’.

2. Start with normalising and reassurance

Avoid overly definitive language such as: ‘This drug causes…’

Instead, frame side effects as possible, not inevitable: ‘Some people notice…’, ‘You might experience…’ and ‘These are usually mild and settle…’

Some specific, pertinent examples here might be:

• SGLT-2 inhibitors: ‘Some people notice they need to pass urine more often, especially at the start.’
• GLP-1 receptor agonists: ‘Some people notice nausea or a reduced appetite when they begin treatment.’

3. Pair every side effect with an action

Link each symptom to clear advice so patients know what to do.

Some examples here include:

• SGLT-2 inhibitors:
  • ‘You may feel thirstier or pass more urine – try to stay well hydrated.’
  • ‘If you develop itching or soreness in the genital area, this could be a common infection – let us know as it’s easily treated.’
  • ‘If you feel unwell with nausea, vomiting or stomach pain, especially if you’re not eating normally, seek advice promptly as we may need to check for ketoacidosis.’
• GLP-1 receptor agonists:
  • ‘If you feel nauseous, eating smaller, lower-fat meals can help.’
  • ‘If vomiting or diarrhoea persists, contact us as we may need to adjust the dose.’
  • ‘If you develop severe, persistent abdominal pain, seek urgent advice as this could indicate pancreatitis.’

4. Separate common and serious effects clearly

Patients cope better when risks are grouped and contextualised.

Some key examples here include:

• SGLT-2 inhibitors:
  • ‘Common effects include passing urine more often, feeling thirsty or mild genital infections.’
  • ‘Rarely, more serious problems like ketoacidosis can occur – we’ll explain what symptoms to watch for, but this is uncommon.’
• GLP-1 receptor agonists:
  • ‘Common effects include nausea, reduced appetite, or diarrhoea, which usually improve over time.’
  • ‘Rarely, more serious effects such as pancreatitis or changes in vision can occur – seek advice if you experience severe abdominal pain or sudden visual changes.’

What should nurses consider after initiating treatment and at subsequent review?

Ongoing review in type 2 diabetes requires a structured and proactive approach to address concerns and optimise long-term outcomes.

As ever, nurses should assess for early changes in clinical status, including deterioration in renal function, emerging cardiovascular symptoms (such as breathlessness or oedema) and weight changes, and escalate concerns appropriately.

Monitoring should be individualised according to treatment regimen, comorbidities and overall risk, with increased monitoring for higher-risk groups such as older adults and those with frailty.

During review, education should support patients to recognise and report potential adverse effects, reinforce sick-day guidance (see below) and promote adherence to lifestyle and pharmacological therapies.

Integrating clinical assessment, patient-reported information and routine investigations (HbA1c, renal function, liver function, lipids and blood pressure) enable timely treatment optimisation, to help prevent complications and support safe, person-centred long-term diabetes management.

NICE treatment pathways provide specific, evidence-based recommendations for treatment intensification in different patient groups and should be used to guide decisions about further therapy. Before escalating treatment, nurses should confirm medication adherence, ensure current medication has been optimised, review HbA1c trends, check renal function and assess hypoglycaemia risk. They should also identify the presence of cardiovascular disease, heart failure, CKD, obesity or frailty and consider individualised HbA1c targets, as these factors guide drug choice and help ensure treatment escalation is appropriate, safe and person-centred.

Explaining sick-day rules

During acute illness (e.g., vomiting, diarrhoea, fever, or reduced oral intake), some diabetes medications should be temporarily stopped to reduce the risk of dehydration and complications.

Of note:

• Metformin: Should be withheld if there is risk of dehydration, acute kidney injury, or vomiting/diarrhoea, as this increases the risk of lactic acidosis. Restart once the person is eating and drinking normally and renal function is stable.
• SGLT-2 inhibitors: Should be stopped during acute illness due to the risk of dehydration and euglycaemic diabetic ketoacidosis. Restart once oral intake is adequate for 24–48 hours.
• GLP-1 receptor agonists: Should be withheld if there is significant nausea, vomiting or reduced oral intake, as these can worsen dehydration and gastrointestinal symptoms. Restart once symptoms resolve and normal intake resumes.

Patients should maintain fluid intake, monitor blood glucose and seek medical advice if they are unable to keep fluids down, have persistent hyperglycaemia, or develop symptoms of diabetic ketoacidosis, such as abdominal pain, nausea, vomiting, rapid breathing or drowsiness.

Should we be switching treatments in our existing patients with type 2 diabetes?

Managing existing patients who are already on medication for their type 2 diabetes but whose treatment no longer aligns with updated NICE guidance requires a structured, person-centred approach.

Systematic searches of clinical records can identify individuals with type 2 diabetes whose therapy may not reflect current recommendations, prioritising those with established ASCVD, CKD, obesity, early-onset diabetes or frailty.

These patients should be proactively invited for review, with additional time built into annual or opportunistic consultations to discuss potential treatment optimisation.

Addressing inequalities in SGLT-2 inhibitor uptake is also essential. Evidence suggests lower uptake among women, older adults, some minority ethnic groups and people living in socioeconomically deprived areas.¹⁰ Practices should monitor prescribing data to identify patients who are clinically eligible but not receiving SGLT-2 inhibitors. Targeted engagement strategies including culturally appropriate education, shared decision-making and proactive medication reviews can help overcome barriers and improve access to SGLT-2 inhibitor therapy.

For higher-risk individuals, such as those with frailty, high HbA1c, advanced age, multiple comorbidities (e.g., cardiovascular disease, heart failure, chronic kidney disease), history of severe hypoglycaemia, or frequent hospital admissions, additional follow-up appointments may be needed rather than waiting for the next routine review. Treatment adjustments may include initiating SGLT-2 inhibitors or GLP-1 receptor agonists, with careful consideration of safety, comorbidities and patient preference.

Embedding this proactive, data-driven approach within routine care supports personalised, evidence-based management, ensures therapies remain aligned with current guidance, and promotes consistent, high-quality care for people living with diabetes.

Key points

• Nurses in primary care play a central role in translating updated NICE guidance into safe, personalised care for people with type 2 diabetes.
• A key focus is on identifying individuals with comorbidities and proactively supporting therapy optimisation in particular where SGLT-2 inhibitors or GLP-1 receptor agonists are now recommended.
• It is important to continue to provide clear, balanced patient education: explaining mechanisms, benefits and side effects in understandable terms, reinforcing sick-day guidance and using visual aids to support shared decision-making.
• Maintaining up-to-date pharmacological knowledge and engaging in ongoing professional development ensures nurses can counsel confidently, recognise adverse effects early and help patients manage their diabetes safely and effectively.

Molly Mckeown is a diabetes advanced nurse practitioner at North Uttlesford PCN and Diabetes Specialist Nurse Forum Affiliate

References

1. NICE. Type 2 diabetes in adults: management. [NG28] 2026
2. Herrington W et al. Empagliflozin in patients with chronic kidney disease. N Engl J Med 2023;388:117-27
3. Vaduganathan M et al. SGLT2 inhibitors in patients with heart failure: a comprehensive meta-analysis of five randomised controlled trials. Lancet 2022;400(10354):757-67
4. NICE. Patient decision aid on type 2 diabetes: agreeing my blood glucose (HbA1c) target. 2022
5. NICE. Type 2 diabetes in adults: management. Visual summary: Choosing medicines for first-line and further treatment. [NG28] 2026
6. MHRA. GLP-1 medicines for weight loss and diabetes: what you need to know: GLP-1 medicines, contraception and pregnancy. February 2026
7. MHRA. GLP-1 medicines for weight loss and diabetes: what you need to know: GLP-1 medicines and breastfeeding. February 2026
8. MHRA. SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness. March 2020
9. MHRA. GLP-1 receptor agonists and dual GLP-1/GIP receptor agonists: strengthened warnings on acute pancreatitis, including necrotising and fatal cases. January 2026
10. MHRA. Semaglutide (Wegovy, Ozempic and Rybelsus): risk of Non-arteritic Anterior Ischemic Optic Neuropathy (NAION). February 2026
11. Jack G. Overcoming Disparities in Using SGLT2 Inhibitors for Cardiorenal Protection in Persons With and Without Type 2 Diabetes. J Clin Endocrinol Metab 2025;110(9): e2852–63

Further reading and resources

• Diabetes UK resources – including e-learning, competency frameworks and professional development materials.
• Certificate Diabetes Education Programme – an online portal offering modules, webinars, and resources on oral therapies, GLP-1 receptor agonists, and injectable therapies.
• PITstop for diabetes: educational programmes
• Diabetes Specialist Nurse Forum UK. People living with diabetes.
• TREND Diabetes. Managing diabetes during intercurrent illness. 2025
• TREND Diabetes. Kidney disease and type 2 diabetes. 2020
• TREND Diabetes. Hypoglycaemia and type 2 diabetes. 2025
• TREND Diabetes. Patient leaflet: How to reduce your risk of genital fungal infection. 2022