NICE draft guideline on Type 2 diabetes marks shift to personalized care with stronger role for real-world data 

The National Institute for Health and Care Excellence (NICE) has issued draft guidance on Type 2 diabetes that expands early use of SGLT-2 inhibitors and GLP-1 receptor agonists, while drawing on real-world data (RWD) to address inequalities in access and outcomes. Described as the “biggest shake-up in Type 2 diabetes care in a decade,” the update aligns with the NHS 10-Year Health Plan.  

Moving beyond “one-size-fits-all” treatment 

The recommendations mark a move away from a standardized prescribing pathway towards more personalized care that takes cardiovascular, renal, and metabolic health into account. 

As explained by Professor Jonathan Benger, deputy chief executive and chief medical officer at NICE:  

“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.” 

Under the draft guidance, SGLT-2 inhibitors such as dapagliflozin and empagliflozin would be prescribed as joint first-line therapy with metformin, while GLP-1 receptor agonists like semaglutide could be introduced earlier. Triple therapy with metformin, an SGLT-2 inhibitor, and semaglutide is recommended for people with cardiovascular disease, and new tailored pathways are proposed for those with obesity, early-onset diabetes, chronic kidney disease, and frailty. 

Using RWD to address inequalities 

A central feature of the draft guideline is its reliance on RWD to highlight prescribing gaps and inform new recommendations. An analysis of almost 590,000 patient records revealed that SGLT-2 inhibitors are under-prescribed, particularly to women, older people, and Black or Black British patients. 

Dr Waqaar Shah, chair 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.” 

Commenting on the broader policy shift, Neil Grubert observed:  

“The “biggest shake-up in Type 2 diabetes care in a decade” reveals much about how England’s NHS 10-Year Plan, real-world data and addressing inequality in access to care will influence NICE. The agency describes the overhaul of its guidance as a move away from a “one-size-fits-all” approach to more personalized care.” 

Cost-effectiveness and practice changes 

Although earlier use of GLP-1 receptor agonists is expected to raise initial treatment costs, NICE modeling suggests long-term savings from reduced cardiovascular events, weight loss benefits, and less reliance on later-stage therapies such as insulin. SGLT-2 inhibitors were also shown to be cost-effective in preventing cardiovascular complications even when used more widely. 

The guidance additionally updates recommendations on insulin prescribing, encouraging greater use of lower-cost biosimilars and emphasizing shared decision-making when considering switches for existing patients. 

Prevention and management of complications  

Beyond medicines, the guideline places greater emphasis on prevention and early management of complications. Updated recommendations cover periodontitis, gastroparesis, neuropathy, erectile dysfunction, and eye disease. Non-surgical periodontal treatment, for example, was found to improve glycemic control and be cost-effective if improvements are sustained. 

Aligning with the NHS 10-Year Health Plan 

The proposals are designed to reflect the NHS 10-Year Health Plan’s, focus on prevention, early intervention, and data-driven improvement. NICE estimates that nearly 22,000 lives could be saved if uptake of SGLT-2 inhibitors as joint first-line therapy with metformin reached 90%. 

Highlighting the scale of the challenge, Neil Grubert noted: 

“The NHS spends £1mn per hour—10% of its budget—on diabetes, with 60% of that expenditure on managing complications.” 

The draft guideline is open for consultation until October 2, 2025, with final recommendations due later this year.