The National Institute for Health and Care Excellence (NICE) has announced draft guidelines representing the most significant transformation in type 2 diabetes care in a decade, moving from standardised treatment protocols to personalised therapeutic approaches.

The guidelines elevate SGLT-2 inhibitors from second line to first-line therapy options, recognising their cardioprotective and nephroprotective benefits beyond glucose lowering, in a bid to address the leading causes of morbidity and mortality in diabetic patients.

This represents a move away from a one-size-fits-all approach to “take a holistic view of a person's health, particularly their cardiovascular and kidney health” (Professor Jonathan Benger, deputy chief executive and chief medical officer at NICE) which is in line with the aims of the 10-Year Health Plan and its shift from treatment to prevention.

The guidelines introduce stratified treatment approaches based on patient characteristics and comorbidities. These include adults with established cardiovascular disease, those with early-onset diabetes diagnosed before age 40, those with chronic kidney disease, and frail patient cohorts. Evidence suggests implementing these recommendations around SGLT-2 inhibitors could prevent approximately 22,000 deaths annually, once 90% uptake is achieved across eligible populations.

The guidance also addresses the latest real-world data analysis of nearly 590,000 patient records which revealed significant under-prescribing of SGLT-2 inhibitors, particularly affecting women, elderly patients, and Black or Black British individuals. As a result, the guidance aims to repair these stark inequalities, while supporting the NHS preventative care objectives outlined in the 10-Year Health Plan.

This was summarised by Dr Waqaar Shah, chairman of the guideline committee, who explained that “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.”

As well as expanding access for patients, earlier use of these treatments would bring the UK in line with international guidance, as Hannah Beba, consultant pharmacist for diabetes at West Yorkshire Health and Care Partnership, explains: “This update from NICE will free us to align with our international colleagues already adopting this evidence-based practice. Thousands of poor outcomes for people living with diabetes will be prevented.”

However, challenges remain. Implementation will incur substantial costs, as SGLT-2 inhibitors and GLP-1 receptor agonists represent significantly higher upfront expenditure compared to traditional diabetes medications. Although, potential long-term savings in the prevention of cardiovascular and renal complications may offset initial costs. Primary care capacity constraints present additional concerns, with expanded prescribing and monitoring requirements potentially increasing workloads substantially. Clinician confidence in prescribing newer agents remains variable, so comprehensive training programmes and clear prescribing pathways will also be required to ensure safe, equitable implementation across different care settings.

The draft guidance remains open for public consultation until 2 October 2025, with final implementation contingent upon NHS adoption and Department of Health and Social Care support to ensure equitable access across all diabetes services nationwide.