Learning Objectives
By the end of this module you will be able to:
- Apply the updated NICE treatment algorithm for type 2 diabetes
- Select appropriate GLP-1RA or SGLT2 inhibitor based on patient profile
- Understand the cardiovascular and renal protection benefits of newer agents
- Know when to refer to specialist diabetes services
Background
NICE guideline NG28 was updated in 2024 to reflect accumulating evidence from large cardiovascular outcome trials (CVOTs). The key changes affect the choice of second-line therapy and the targets for HbA1c in different patient groups.
First-line Therapy
Metformin remains first-line for most patients with type 2 diabetes unless contraindicated. For patients with eGFR below 30, dose adjustment or cessation is required.
Second-line Therapy — Key NICE Recommendations
For patients with established cardiovascular disease, heart failure, or chronic kidney disease:
- SGLT2 inhibitor (empagliflozin, dapagliflozin, or canagliflozin) is recommended regardless of HbA1c level
- GLP-1 receptor agonist (semaglutide, dulaglutide, liraglutide) if SGLT2 inhibitor not tolerated or contraindicated
For patients without established CVD/HF/CKD — add a second agent based on individual patient factors including weight, hypoglycaemia risk, and patient preference.
HbA1c Targets
NICE recommends:
- 48 mmol/mol (6.5%) for newly diagnosed or drug-naive patients
- 53 mmol/mol (7.0%) on one drug
- 58 mmol/mol (7.5%) if hypoglycaemia risk or frailty
Key Clinical Points
- Review all type 2 diabetes patients on sulfonylureas — consider switch to SGLT2i or GLP-1RA where appropriate
- SGLT2 inhibitors have evidence for heart failure and CKD regardless of diabetes control
- Weight management should be discussed at every appointment — semaglutide 2.4mg licensed for obesity