What's new?

NICE has made major changes to the management of type 2 diabetes in its 2026 guideline. The new guidance focuses on achieving and maintaining good glycaemic control while reducing cardiovascular complications, among other risks. Key components are:

• Healthy living such as healthy eating (e.g. high fibre foods, oily fish and foods with a low glycaemic index), regular physical activity (aerobic plus resistance training) and weight management
• Glucose-lowering pharmacological treatment with metformin first-line, glucagon-like peptide (GLP-1) receptor agonists or sodium-glucose co-transporter-2 (SGLT-2) inhibitors where there is established CVD, heart failure or chronic kidney disease, and others such as dipeptidyl peptidase-4 (DPP-4) inhibitors, pioglitazone, sulfonylureas and insulin
• Managing comorbidities such as effective blood pressure and lipid management to reduce cardiovascular risks and complications.

Alongside education and dietary management, the previous NICE guideline recommended metformin monotherapy as first‑line treatment. Other glucose-lowering medicines were then advised if metformin was not tolerated, or ineffective. There was specific guidance for those with established CVD, or those at high risk of CVD, as well as chronic heart failure and obesity. Dual therapy was the first stage of treatment escalation and if this was inadequate, treatment with insulin also considered. The new recommendations now emphasise the need for individualised care, considering comorbidities, preferences, frailty and polypharmacy. The need for regular review and deprescribing where appropriate is also highlighted.

These recommendations align with international recommendations and the NHS 10 Year Health Plan for England, shifting from a one-size-fits-all approach to treatment based on personal characteristics and comorbidities.

Advice on healthy living remains the same, as do recommendations on blood glucose monitoring through three to six monthly HbA1c measurements, with targets relaxed for older or frail adults, as appropriate.

The first-line treatment option for most people with type 2 diabetes is now modified-release metformin plus an SGLT-2 inhibitor (dapagliflozin, empagliflozin, canagliflozin or ertugliflozin). This now means SGLT-2 inhibitors are a joint first-choice treatment. They can also be used instead of metformin if it is contraindicated or not tolerated.

SGLT-2 inhibitors improve cardiovascular outcomes in adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease (ASCVD). They also reduce the risk of progression of chronic kidney disease (CKD), and the risk of cardiovascular events in adults with type 2 diabetes and CKD.

Those with comorbid heart failure or ASCVD should be prescribed a SGLT-2 inhibitor alongside metformin MR at diagnosis.

Subcutaneous (SC) semaglutide (a GLP-1 receptor agonist) should be added as a third medicine (i.e. triple therapy) for people with ASCVD at a dose not exceeding 1mg once weekly.

With more widespread use of SGLT-2 inhibitors expected, key safety considerations must be considered before they are prescribed. Such considerations include low carbohydrate or ketogenic diets. There is increased risk of diabetic ketoacidosis (DKA) with SGLT-2 inhibitors in people on such diets.