The video version of this podcast can be found here:
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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 the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below.
The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will cover 4 clinical groups and the remaining groups were covered in last week’s episode.
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.
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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
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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 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 are going to review the draft NICE guideline on type 2 diabetes, focusing on the main changes as applied to 7 specific groups of patients. In the previous episode we covered the first 3 groups so today we will cover the rest.
Right, let’s jump into it.
And, as you know, the draft guideline is open for consultation until October, and the final guidance is due in February 2026, so let’s not forget that it is only a draft, and we should not be making clinical decisions based on it yet.
Today’s episode is based on the visual summary created by NICE and the link to it is in the episode description.
The visual summary includes specific guidance for 7 different groups of patients:
1. The group of patients with no relevant comorbidities, then
2. Obesity
3. Frailty
4. CKD
5. Heart failure
6. Atherosclerotic cardiovascular disease and
7. Early onset type 2 diabetes
And today we will look at the last 4 groups that we did not cover last time.
So let’s start with the CKD group.
For people with CKD, like for many of the other groups. the draft guideline recommends starting treatment with metformin plus an SGLT-2 inhibitor. Because of licensing reasons, we are advised to choose either empagliflozin or dapagliflozin in this group. If metformin is contraindicated or not tolerated, the SGLT-2 inhibitor can be offered on its own.
Treatment will also depend on kidney function, measured by eGFR. As we know, metformin in contraindicated if eGFR is less than 30, and, given that SGLT-2 efficacy decreases with advancing renal impairment, NICE recommends not using empagliflozin or dapagliflozin is eGFR is less than 20.
Therefore, the first line treatment on this basis is as follows:
- If eGFR is above 30 mL/min/1.73 m², in principle we will offer metformin plus dapagliflozin or empagliflozin, although, if metformin is not tolerated the SGLT-2 inhibitor can be given by itself.
- If eGFR is between 20 and 30, we will offer either dapagliflozin or empagliflozin alone.
- And, if eGFR is below 20, we will then go for a DPP-4 inhibitor in preference. If that is contraindicated or not tolerated, we will consider pioglitazone or insulin, given that sulfonylureas should not be given if the eGFR is below 30. This is because sulfonylureas accumulate in renal impairment and increase the hypoglycaemia risk.
If further glycaemic lowering is needed after first line treatment, we can use other options including DPP-4 inhibitors (if not already used), sulfonylureas or insulin depending on renal function and safety profile.
How does this differ from the previous guidance?
Like in other groups, the big change here is the earlier, more proactive use of SGLT-2 inhibitors specifically for renal protection, not just glucose lowering. Previously, SGLT-2 inhibitors were used after metformin for people with established albuminuria or heart failure. Now, the draft guidance recognises the trial evidence showing that, apart from the cardiovascular benefits, SGLT2 inhibitors also reduce progression of CKD, and this benefit occurs even in people with moderately reduced eGFR and independently of albuminuria. The slower progression of CKD is because SGLT2 inhibitors reduce albuminuria, intraglomerular pressure and protect against hyperfiltration.
Another nuance is that the draft now pushes dapagliflozin and empagliflozin explicitly into first-line therapy alongside metformin or alone if necessary, with thresholds set according to kidney function. And it also sets out a clear sequence for treatment as eGFR declines, including when to use DPP-4 inhibitors or move to insulin.
What this means in practice is that:
- We will need to check eGFR early and often, as it will determine the choice of treatment.
- Metformin + SGLT-2 inhibitor is the default down to eGFR 30; SGLT-2 inhibitor alone is preferred between 20 and 30, and below 20, we will switch to a DPP-4 inhibitor, and only after that will we consider pioglitazone or insulin if needed.
- And, practically, the bigger focus on protecting kidney function means that more patients will be started on dapagliflozin or empagliflozin earlier, so we will need to familiarise ourselves with renal thresholds and side effect monitoring.
Now, let’s move to the heart failure group.
For adults with type 2 diabetes and heart failure, NICE also recommends that the initial therapy should be metformin plus an SGLT-2 inhibitor. If metformin is contraindicated or not tolerated, then an SGLT-2 inhibitor alone is advised. If additional therapy is needed to help with weight management, then a GLP-1 receptor agonist (specifically subcutaneous semaglutide) can be considered provided there is no frailty and the patient has a preserved ejection fraction. After that, for further glycaemic lowering, we can add a sulfonylurea or insulin, remembering that pioglitazone is contraindicated in heart failure
The difference with the old guideline is that the draft makes metformin + SGLT-2 inhibitor the standard, aiming to get heart failure-related benefits earlier. As we know, trial data show that SGLT2 inhibitors reduce hospitalization for heart failure, improve symptoms, slow progression, and improve cardiovascular mortality, independent of glycaemic control. So, using them early helps not just glucose but also cardiac outcomes.
But another big change is that the draft also acknowledges that weight loss (from GLP-1 RAs) can help reduce cardiac workload, reduce fluid overload, and improve quality of life in heart failure. Combining SGLT-2 inhibitors with semaglutide in patients for whom weight is an issue, is intended to deliver a dual benefit: cardiorenal protection and weight reduction. Previously, GLP-1 RAs were less likely to be used early in heart failure, and semaglutide had stricter criteria; now, semaglutide is explicitly considered earlier in heart failure when weight benefit is also a goal. Any limitations? Well, semaglutide will be limited to patients with obesity, preserved EF and no frailty. Frailty and ejection fraction matter because the benefits and risks of semaglutide vary (e.g. risk of dehydration and hypotension,) depending on heart function and overall general state.
What the changes mean in practice is that:
- We will start more patients on both metformin and an SGLT-2 inhibitor upfront. This also means that we will need to discuss SGLT-2 inhibitor side effects like the risk of genital infections, volume depletion, sick-day rules, and renal monitoring from the start.
- Patients will need assessment of heart failure subtype (especially ejection fraction) and frailty to decide who is eligible for early semaglutide.
- Monitoring will need to include not only HbA1c, but also cardiac function, kidney function, and watch for adverse events.
- And finally, when adding semaglutide, the expectation would be that it's for weight benefit, so obesity must be present.
Now, let’s look at the atherosclerotic cardiovascular disease group.
For them, we will offer triple therapy with metformin plus an SGLT-2 inhibitor and the GLP-1 receptor agonist, semaglutide, for additional risk reduction and weight benefit. And it is worth mentioning that we should also consider semaglutide for any other group if at any stage, ASCVD develops after treatment has already been started. If extra glycaemic lowering is needed, we will add a sulfonylurea, pioglitazone, or insulin. As we know, we should not combine a GLP1 receptor agonist and a DPP4 inhibitor, but if a GLP-1 RA isn’t appropriate, we will add a DPP-4 inhibitor instead and before considering the other options of a sulfonylurea, pioglitazone, or insulin.
This is different from the previous version because before GLP-1 RAs were not used for their cardiovascular benefit but their use was rather tied to glycaemic and BMI thresholds. The draft moves to routine early triple therapy with metformin, an SGLT-2 inhibitor, and semaglutide when ASCVD is present or develops, bringing GLP-1 therapy forward in the pathway.
This change is due to trial evidence showing that GLP-1 receptor agonists not only improve weight, blood pressure and post-prandial glycaemia, but they also reduce atherosclerotic cardiovascular events, with semaglutide having one of the strongest evidence for this reduction within the class. Combining semaglutide with metformin and an SGLT-2 inhibitor early is designed to achieve both cardio renal benefits as well as a lower atherothrombotic risk.
What it means in practice is that:
- We will treat ASCVD earlier with SGLT-2 inhibitors and semaglutide and, in principle, we will continue these therapies long term even if HbA1c or weight targets aren’t fully met.
Finally, let’s move to the early-onset type 2 diabetes group. For NICE this group refers to type 2 diabetes diagnosed in people under the age of 40.
First-line treatment here is metformin plus an SGLT-2 inhibitor like everybody else but, on top of that, the draft says that we should consider adding a GLP-1 receptor agonist early. If metformin is contraindicated or not tolerated, we will offer an SGLT-2 inhibitor and still consider adding a GLP-1 RA. If more glycaemic lowering is needed, the add-on choices are, again, a GLP 1 receptor agonist if not already prescribed, a sulfonylurea, pioglitazone, or insulin. If a GLP-1 RA isn’t appropriate we will add a DPP-4 inhibitor instead before considering a sulfonylurea, pioglitazone, or insulin.
This is different from the previous guidance because before early-onset type 2 diabetes did not have its own explicit guidance. NICE is changing this because it has been shown that early-onset type 2 diabetes carries disproportionately higher lifetime risk. In fact, large reviews show that early-onset T2D is linked to higher rates of complications and premature mortality at any given age compared with later-onset disease, due to the additional years exposed to hyperglycaemia, faster β-cell decline, and earlier cardio-renal and microvascular complications. So this is why NICE now favours earlier, multi-mechanism therapy in this group, including GLP-1 receptor agonists for their cardiovascular benefits.
What this means in practice is that we will start combination therapy sooner in the form of metformin + SGLT-2 inhibitor while, proactively considering a GLP-1 RA early, in many cases resulting in early triple therapy.
We will also need to assess tolerance and to monitor side effects as well as reviewing targets explicitly, while being aware that in early-onset T2D, continuing GLP-1 RAs may be appropriate even when targets aren’t met.
So that is it, an review of the draft NICE guideline on type 2 diabetes focusing on the visual summary.
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.
