Draft NICE guidelines propose upgrading Sodium-Glucose Transport Protein 2 (SGLT2) inhibitors from second choice to first-choice treatments for type 2 diabetes.
The updated draft guideline, ‘Type 2 diabetes in adults: management (medicines update) NG28’, opened for consultation today.
It recommends that SGLT2 inhibitors – including canagliflozin, dapagliflozin, empagliflozin and ertugliflozin – should be offered alongside metformin as an initial treatment option for people with type 2 diabetes.
The draft guidance also recommends that certain groups of people with type 2 diabetes should be offered glucagon-like peptide-1 (GLP-1) receptor agonists as part of their initial treatment.
GLP-1 receptor agonists, including semaglutide and liraglutide, would be prescribed alongside SGLT2 inhibitors and metformin as first-line therapy for adults with type 2 diabetes and established cardiovascular disease.
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People with early-onset type 2 diabetes would be offered dual therapy before a GLP-1 receptor agonist is considered.
For people who cannot tolerate metformin, 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 per cent 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.
Professor Jonathan Benger, Deputy Chief Executive and Chief Medical Officer at NICE, said: “This guidance means more people will be offered medicines where it is right to do so to reduce their future risk of ill 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.”
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He added: “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.
The 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.
Dr Waqaar Shah, Chairman of the Guideline Committee, said: “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.”
Beth Kelly, Director of the DSN Forum UK, said: “This new guidance out today is a real change to how NICE has previously encouraged clinicians to care for people living with type 2 diabetes.
“Diabetes specialist nurses and other healthcare professionals have long complained that NICE was out of touch with European and international guidance that is out there, so this is welcome.”
She added: “The new guidance today moves away from a one size fits all approach and really allows clinicians to personalise treatment plans to subsets of specific groups of people, for example those diagnosed with type 2 diabetes under the age of 40.
“It is great to have something more amenable to clinical care that is in line with the rest of the world.”
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. If metformin does not 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 per cent 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, October 2. NICE’s guideline committee will consider all feedback received before publishing the final recommendations.
To access the draft guideline, click here.
