The consultation period closes on 14 October 2021, and publication of the final guideline is expected on 15 February 2022

Diabetes drugs and equipment

NICE has opened a consultation on the draft version of its update to NICE Guideline 28 (NG28), Type 2 diabetes in adults: management.

NG28 covers the care and management of adults (aged 18 years and over) with type 2 diabetes, and provides recommendations on education and dietary advice, managing cardiovascular risk, managing blood glucose levels, and identifying and managing long-term complications of the condition. The guideline is intended for use by healthcare professionals who care for adults with diabetes, commissioners and providers of diabetes services, and adults with type 2 diabetes and their families and carers.

The long-awaited update to NG28 takes into account new evidence on drug treatments for adults with type 2 diabetes. The consultation period is open until 14 October 2021, and stakeholders are invited to comment on new and updated recommendations, and recommendations that NICE proposes to delete from the 2015 guideline.

The changes in detail

Taking into account cardiovascular outcomes trials conducted since the publication of NG28 in 2015, NICE now places more emphasis on considering comorbidities, contraindications, and monitoring requirements during treatment selection, with the aim of choosing treatments that offer cardiovascular protection as well as effective diabetes control. In adults with type 2 diabetes in whom metformin is contraindicated or not tolerated, the new guidance includes sodium–glucose co-transporter-2 inhibitors (SGLT2is) as a first-line option for people who meet the criteria stated in NICE Technology Appraisals (TAs) 390 or 572

SGLT2is are also recommended as part of dual therapy for adults with type 2 diabetes when initial drug treatment with metformin has not continued to control glycated haemoglobin (HbA1c ) to below the person’s individually agreed threshold for intensification. If dual therapy with metformin and another oral drug fails to control HbA1c to below the person’s individually agreed threshold for further intervention, SGLT2is are also now an option for people who meet the criteria in NICE TAs 315, 418336, or 583.

The following recommendations from the 2015 guideline are to be deleted either because they no longer accurately reflect the relevant summaries of product characteristics (SPCs) or it is covered by the SPC:

  • 1.6.22 In adults with type 2 diabetes, review the dose of metformin if the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73 m2
    • stop metformin if the eGFR is below 30 ml/minute/1.73 m2
    • prescribe metformin with caution for those at risk of a sudden deterioration in kidney function and those at risk of eGFR falling below 45 ml/minute/1.73 m2
  • 1.6.24 In adults with type 2 diabetes, do not offer or continue pioglitazone if they have any of the following:
    • heart failure or history of heart failure
    • hepatic impairment
    • diabetic ketoacidosis
    • current, or a history of, bladder cancer
    • uninvestigated macroscopic haematuria.

These recommendations have been replaced with general references to Medicines and Healthcare products Regulatory Agency safety information, the British National Formularly, and SPCs.

Minor changes have also been made to several recommendations to update the language used—to ensure that it is easy to understand and consistent with NICE style—and to incorporate the principles of shared decision making and person-centred care.

The final guideline will update and replace NG28, and its publication is expected on 15 February 2022.


Lead image: karlevana/

Image 1: karlevana/