The video version of this podcast can be found here:

·      https://youtu.be/mHyDaVHtb58

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in August 2025 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only. I also give an overview of the draft NICE guideline on type 2 diabetes open for consultation until October 2025 and due for publication in February 2026.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] 

• Music provided by Audio Library Plus 
• Watch: https://youtu.be/aBGk6aJM3IU 
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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for August 2025 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2025-08-01&to=2025-08-31&ndt=Guidance&ndt=Quality+standard

The updated quality standard Overweight and obesity management [QS212] can be found here:

·      https://www.nice.org.uk/guidance/qs212

The NICE announcement on Type 2 diabetes management can be found here:

·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced

The NICE draft guideline on Type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450

The visual summary of the NICE draft guideline on type 2 diabetes can be found here:

·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in August 2025, focusing on what is relevant in Primary Care only.

Today there’s just one updated clinical area to cover, overweight and obesity. But I will also mention that the draft NICE guideline on type 2 diabetes has now been made public, so we will discuss that too.

Right, let’s jump into it.

And I know most of you will be keen to hear about the new diabetes guidance, and understandably so. But before we get to that, I would like to spend the first minute and a half on an area that’s often neglected: overweight and obesity. NICE has just released a new quality standard that replaces three separate guidelines, those on children, adults, and general clinical management, and brings them together into a single standard, reflecting new priorities and evidence.

There are eight quality statements on obesity.

In the first two statements, the focus is on better identification. For adults with long-term conditions, BMI should be recorded at least annually, and if BMI is under 35, waist-to-height ratio should also be measured. This represent a change from previous guidance where BMI alone was the main focus. Also, for children over the age of two, BMI should be recorded opportunistically. putting greater emphasis on early recognition.

Statements three, four, and five are all about improving access to services, including people with learning disabilities. Local authorities and commissioners need to maintain an up-to-date list of services to offer patients, which should reduce barriers and ensure equity of access.

Statements six, seven, and eight deal with clinical management. People prescribed weight management medicines should receive holistic care, covering diet, nutrition, and physical activity. Those who stop medicines or finish behavioural interventions should get long term follow up support, which recognises the importance of relapse prevention. And finally, adults discharged after bariatric surgery should be followed up at least annually within a shared-care model. This is also new because the need for ongoing shared care was not explicit before.

And that is it in respect of overweight and obesity. Now let’s move to the real headline, the draft new NICE guideline on type 2 diabetes. This is the one everyone’s been talking about. The draft is open for public consultation until October, and the final guidance is due in February 2026.

Today I’ll just give you a quick overview. But in a future episode, we’ll look at the proposed changes in slightly more detail, so stay tuned. Just remember, for now it’s only a draft, which means it could still change, and we should not be making clinical decisions based on it yet.

First, the biggest shift: Treatment no longer starts with just metformin. Instead, the new draft guideline recommends combination therapy from day one—metformin plus an SGLT-2 inhibitor for almost all adults with type 2 diabetes. This is a major departure from monotherapy and reflects the fact that type 2 diabetes is not only about sugar control. SGLT-2 inhibitors confer cardiac and renal protection, reducing cardiovascular events and slowing kidney disease progression, benefits that metformin alone can’t offer. NICE has been clear that SGLT2 inhibitors remain underutilised in practice. Why? In many cases, clinicians have stuck with the traditional stepwise model of adding medicines only when HbA1c goes up. Others may be concerned about cost, side effects, or uncertainty over who exactly should benefit. The new guideline cuts through that by saying: everyone with type 2 diabetes will benefit, so we need to make SGLT-2 inhibitors part of the standard starting treatment. The message is that we should be thinking beyond blood glucose from the very beginning, and treating cardiovascular and renal risk right from the start.

Second, we move away from risk-based prescribing. In the past, SGLT-2 inhibitors were reserved only for people with heart failure or at high cardiovascular risk, so their use was much more limited. As we have just said, the new draft guideline takes a completely different approach: now, SGLT-2 inhibitors are recommended for everyone with type 2 diabetes, regardless of their cardiovascular risk profile. The thinking here is simple — we know these drugs consistently reduce hospitalisations for heart failure and slow the progression of kidney disease, and those benefits apply across the board, not just in the highest-risk patients. On top of that, for people who already have established atherosclerotic cardiovascular disease, the guidance goes further by recommending that a GLP-1 receptor agonist, semaglutide, is added as well, creating a triple-therapy regimen right from the start. This combination gives comprehensive coverage: metformin for glucose control, SGLT-2 inhibitors for renal and heart protection, and GLP-1 agonists for both cardiovascular benefit and weight management. It’s simply a move towards using the right drug in the right place earlier, instead of holding them back as late-stage rescue therapies.

Third, let’s talk about GLP-1 receptor agonists a bit more, because this is another big change.

Previously, GLP-1 drugs were considered much later, often for people with obesity or those who hadn’t met glycaemic targets despite multiple therapies, and they were tied to strict BMI criteria. That’s no longer the case.

Now, semaglutide is recommended much earlier:

• It is recommended for people with type 2 diabetes and established atherosclerotic cardiovascular disease, it’s added on top of metformin and an SGLT-2 inhibitor as part of the initial treatment.
• And it is also recommended for people living with obesity or those with early-onset type 2 diabetes who still need extra glycaemic or weight management, so GLP-1 receptor agonists are also considered much sooner in the pathway for them.

And there’s another key change: continuation. In the old guideline, GLP-1 treatment was only continued if the person had lost at least 3% of body weight and dropped their HbA1c by 1% within six months. That rule is gone. Now, if semaglutide is prescribed for cardiovascular protection, it is continued long term, regardless of weight loss or HbA1c change. Only if it’s being used primarily for obesity or metabolic control do continuation decisions depend on whether agreed targets are met. In short, the focus has shifted from short-term numbers to long-term protection.

Fourth, insulin guidance has also had a major refresh.

The old guideline gave long, detailed lists of which insulin types to use in different scenarios. The new draft simplifies this into a more practical, class-based approach. Here’s what’s changed:

• We will start with basal insulin if needed. And what about short-acting and rapid-acting insulins? Well, if HbA1c remains high, then we will add short-acting insulin to basal insulin.

·      However, if someone’s HbA1c is very high, usually 75 mmol/mol or above, then basal plus short-acting insulin can be considered straight away. Rapid-acting insulin analogues are considered if someone’s lifestyle, eating patterns, or risk of hypoglycaemia makes them a better fit than human short-acting insulin. Pre-mixed short-acting analogues are also an option if appropriate. In practice, this means more flexibility while keeping the pathway simple.

• Additionally, the choice of basal insulin, whether human NPH or analogues, should be made through shared decision-making with the patient, taking into account the risk of hypoglycaemia, dosing convenience, and patient preference. If several options are suitable, we will choose the one with the lowest cost.

And this is important because these changes partly reflect a pragmatic response to insulin product withdrawals and shortages. By focusing on broader insulin classes instead of individual types, the guidance is more flexible and easier to apply, even when supply issues arise.

Importantly, GLP-1 receptor agonists can now be combined with insulin without the need for specialist approval, making access easier and quicker in primary care.

And finally, there has also been a change in how we think about escalation overall. Instead of relying on long lists of add-on options, the draft guideline now gives us a much clearer stepwise pathway. The idea is to simplify decision-making and the pathway looks like this:

• We will start most people on metformin plus an SGLT-2 inhibitor right from the beginning.
• If HbA1c isn’t controlled and more glucose lowering is needed, the first recommended add-on is a DPP-4 inhibitor, because these are well tolerated, weight neutral, and easy to use.
• If that’s not suitable or not effective, then other oral options like sulfonylureas or pioglitazone, or insulin, can be introduced depending on the person’s needs.
• For people with atherosclerotic cardiovascular disease, as we said earlier, we will add a GLP-1 receptor agonist, usually semaglutide, early in the pathway, not as a late rescue option.
• And insulin is no longer treated as a last resort — it can be integrated earlier and combined flexibly with GLP-1s when needed.

The rationale here is to avoid the old problem of incremental, reactive prescribing — waiting for one drug to fail before adding another, often leaving patients years without treatment that could protect their heart and kidneys.

So, in short: the new draft guideline is all about earlier combination therapy, universal access to SGLT-2 inhibitors, earlier and more consistent use of GLP-1 receptor agonists, a streamlined approach to insulin, simpler treatment pathways, always with a stronger focus on long-term cardiovascular and renal protection.

In the next episode, I will discuss how the draft guideline is envisaged to be used in specific groups of patients, so make sure not to miss it.

So that is it, a review of the NICE updates relevant to primary care, including an overview of the forthcoming draft guideline on Type 2 diabetes.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.