Millions of people are set to benefit from earlier access to newer type 2 diabetes treatments – the biggest shake-up in care for a decade – as part of NICE’s commitment to re-evaluate priority clinical pathways described in the 10-Year Health Plan for the NHS.
The announcement in draft guidelines from NICE moves away from a 'one-size-fits-all' approach, shifting from automatically starting everyone on one medicine to personalised treatment plans that aim to prevent heart failure, heart attacks and other serious medical problems.
NICE’s independent guideline committee has expanded access to newer diabetes medicines called SGLT-2 inhibitors (with names like canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin) from being second-choice treatments to first-choice treatments. And some groups of patients stand to benefit from another type of medicine called GLP-1 receptor agonists (such as liraglutide or semaglutide), rather than keeping them for later stages of treatment.
For patients who cannot tolerate metformin (the traditional first diabetes medicine), the new guidelines recommend starting with an SGLT-2 inhibitor on its own. This is because growing evidence shows these medicines protect the heart and kidneys beyond just controlling blood sugar.
New evidence also suggests that nearly 22,000 lives could be saved once uptake of the recommended changes for SGLT-2 inhibitors, as a joint first line treatment option with metformin, reaches 90% of the patient population.
People with type 2 diabetes should speak with their GP or diabetes team at their next annual review meeting to discuss what treatment option is right for them.
The draft guideline aligns with the 10-Year Health Plan for the NHS which highlights the need for a shift from treatment to prevention, through an approach that aims to prevent the future complications of diabetes. It also supports the roll out of digital care through continuous glucose monitoring and community-based care delivery.
"These draft recommendations demonstrate how NICE is already delivering on commitments within the 10-year-plan by updating guidance to drive smarter NHS spending. This guidance means more people will be offered medicines where it is right to do so to reduce their future risk of ill health," commented Professor Jonathan Benger, deputy chief executive and chief medical officer at NICE.
Professor Benger added: “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 evidence shows that certain medicines can provide important cardiovascular benefits, and by recommending them as part of initial treatment, we could help prevent heart attacks, strokes and other serious complications before they occur. This is particularly important given that cardiovascular disease is the leading cause of death in people with type 2 diabetes.”
The guidelines also address concerns about under-prescribing of SGLT-2 inhibitors, with real-world evidence showing these medicines are not being offered equitably across the UK. NICE analysed records of almost 590,000 people and found that SGLT-2 inhibitors are under-prescribed, particularly to women, older people, and Black or Black British individuals.
"We know that SGLT-2 inhibitors are currently under-prescribed, and our health economics analysis shows that people living in the most deprived areas would particularly benefit from universal access to these treatments. These recommendations could help reduce health inequalities while providing better outcomes for everyone," said Dr Waqaar Shah, chairman of the guideline committee.
The draft guideline introduces different treatment approaches based on patient characteristics and other health conditions:
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Adults with cardiovascular disease should be offered triple therapy including a GLP-1 receptor agonist.
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Adults with early onset type 2 diabetes (diagnosed before age 40) are offered dual therapy before a GLP-1 receptor agonist is considered.
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People living with obesity will receive specific treatment combinations.
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Those with chronic kidney disease have tailored recommendations based on their kidney function.
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Adults with frailty should be considered for metformin alone initially.
The new guidelines also include special recommendations for adults who may be frail or have multiple health conditions. For these people, doctors will usually start with just one medicine (metformin). If metformin doesn't work for them, they may be offered a different type of medicine instead. This recognises that more vulnerable people often do better with fewer medicines and more straightforward treatment plans.
Around 4.6 million people are diagnosed with diabetes in the UK according to Diabetes UK, with about 90% of those having type 2. Additionally, it is estimated that almost 1.3 million people in the UK are likely to have undiagnosed type 2 diabetes.
The draft guideline is open for public consultation until Thursday 2nd October. NICE’s guideline committee will consider all feedback received before publishing the final recommendations. The consultation document and details of how to respond are available on the NICE website at www.nice.org.uk.
Read the draft guideline for the management of type 2 diabetes in adults
