Type 2 diabetes in adults: management | Guidance - NICE

NICE has produced a patient decision aid on agreeing HbA1c targets, which also covers factors to weigh up when discussing HbA1c targets with ... Home NICEGuidance Conditionsanddiseases Diabetesandotherendocrinal,nutritionalandmetabolicconditions Diabetes Type2diabetesinadults:management NICEguideline[NG28] Published: 02December2015 Lastupdated: 29June2022 Guidance Toolsandresources Informationforthepublic Evidence History Overview Recommendations Recommendationsforresearch Rationaleandimpact Context Findingmoreinformationandcommitteedetails Updateinformation Downloadguidance(PDF) Guidance Next Recommendations 1.1Individualisedcare 1.2Education 1.3Dietaryadviceandbariatricsurgery 1.4Diagnosingandmanaginghypertension 1.5Antiplatelettherapy 1.6Bloodglucosemanagement 1.7Drugtreatment 1.8Managingcomplications Termsusedinthisguideline Recommendations Peoplehavetherighttobeinvolvedindiscussionsandmakeinformeddecisionsabouttheircare,asdescribedinmakingdecisionsaboutyourcare. MakingdecisionsusingNICEguidelines explainshowweusewordstoshowthestrength(orcertainty)ofourrecommendations,andhasinformationaboutprescribingmedicines(includingoff-labeluse),professionalguidelines,standardsandlaws(includingonconsentandmentalcapacity),andsafeguarding. 1.1Individualisedcare 1.1.1Adoptanindividualisedapproachtodiabetescarethatistailoredtotheneedsandcircumstancesofadultswithtype2diabetes,takingintoaccounttheirpersonalpreferences,comorbiditiesandrisksfrompolypharmacy,andtheirlikelihoodofbenefitingfromlong-terminterventions.Suchanapproachisespeciallyimportantinthecontextofmultimorbidity.[2015,amended2022] 1.1.2Reassesstheperson'sneedsandcircumstancesateachreviewandthinkaboutwhethertostopanymedicinesthatarenoteffective.[2015] 1.1.3Takeintoaccountanydisabilities,includingvisualimpairment,whenplanninganddeliveringcareforadultswithtype2diabetes.[2015] 1.2Education 1.2.1Offerstructurededucationtoadultswithtype 2diabetesandtheirfamilymembersorcarers(asappropriate)atthetimeofdiagnosis,withannualreinforcementandreview.Explaintopeoplethatstructurededucationisanintegralpartofdiabetescare.[2009] 1.2.2Ensurethatanystructurededucationprogrammeforadultswithtype 2diabetes: isevidence-based,andsuitstheneedsoftheperson hasspecificaimsandlearningobjectives,andsupportsthepersonandtheirfamilymembersandcarerstodevelopattitudes,beliefs,knowledgeandskillstoself-managediabetes hasastructuredcurriculumthatistheorydriven,evidence-basedandresource-effective,hassupportingmaterialsandiswrittendown isdeliveredbytrainededucatorswho: haveanunderstandingofeducationaltheoryappropriatetotheageandneedsoftheperson aretrainedandcompetenttodelivertheprinciplesandcontentoftheprogramme isqualityassured,andreviewedbytrained,competent,independentassessorswhomeasureitagainstcriteriathatensureconsistency hasoutcomesthatareauditedregularly.[2015] 1.2.3Ensurethateducationprogrammesforadultswithtype 2diabetesprovidethenecessaryresourcestosupporttheeducators,andthateducatorsareproperlytrainedandgiventimetodevelopandmaintaintheirskills.[2009] 1.2.4Offeradultswithtype 2diabetesgroupeducationprogrammesasthepreferredoption.Provideanalternativeofequalstandardforpeoplewhoareunableorprefernottotakepartingroupeducation.[2009] 1.2.5Ensurethateducationprogrammesforadultswithtype 2diabetesmeetthecultural,linguistic,cognitiveandliteracyneedsofpeopleinthelocalarea.[2009] 1.2.6Ensurethatallmembersofthediabeteshealthcareteamarefamiliarwiththeeducationprogrammesavailablelocallyforadultswithtype 2diabetes,andthattheseprogrammesareintegratedwiththerestofthecarepathway.[2009] 1.2.7Ensurethatadultswithtype 2diabetesandtheirfamilymembersandcarers(asappropriate)havetheopportunitytocontributetothedesignandprovisionoflocaleducationprogrammesforadultswithtype 2diabetes.[2009] 1.3Dietaryadviceandbariatricsurgery 1.3.1Provideindividualisedandongoingnutritionaladvicefromahealthcareprofessionalwithspecificexpertiseandcompetenciesinnutrition.[2009] 1.3.2Providedietaryadviceinaformsensitivetotheperson'sneeds,cultureandbeliefs,beingsensitivetotheirwillingnesstochangeandtheeffectsontheirqualityoflife.[2009] 1.3.3Encourageadultswithtype 2diabetestofollowthesamehealthyeatingadviceasthegeneralpopulation,whichincludes: eatinghigh-fibre,low-glycaemic-indexsourcesofcarbohydrate,suchasfruit,vegetables,wholegrainsandpulses choosinglow-fatdairyproducts eatingoilyfish controllingtheirintakeofsaturatedandtransfattyacids.[2009] 1.3.4Integratedietaryadvicewithapersonaliseddiabetesmanagementplan,includingotheraspectsoflifestylemodificationsuchasincreasingphysicalactivityandlosingweight.[2009] 1.3.5Foradultswithtype 2diabeteswhoareoverweight,discussandagreeaninitialbodyweightlosstargetof5%to10%.Rememberthatasmallamountofweightlossmaystillbebeneficial,andalargeramountwillhaveadvantageousmetabolicimpactinthelongterm.[2009] 1.3.6Individualiserecommendationsforcarbohydrateandalcoholintake,andmealpatterns.Makereducingtheriskofhypoglycaemiaaparticularaimforpeopleusinginsulinoraninsulinsecretagogue.[2009] 1.3.7Adviseadultswithtype 2diabetesthattheycansubstitutealimitedamountofsucrose-containingfoodsforothercarbohydrateinthemealplanbutshouldtakecaretoavoidexcessenergyintake.[2009] 1.3.8Discourageadultswithtype 2diabetesfromusingfoodsmarketedspecificallyforpeoplewithdiabetes.[2009] 1.3.9Whenadultswithtype 2diabetesareadmittedasinpatientstohospitaloranyothercaresetting,implementamealplanningsystemthatprovidesconsistencyinthecarbohydratecontentofmealsandsnacks.[2009] 1.3.10Forrecommendationsonlifestyleadvice,seetheNICEguidelinesonpreventingexcessweightgain,weightmanagement,obesity,physicalactivityandtobacco.[2015] 1.3.11Forrecommendationsonbariatricsurgeryforpeoplewithrecent-onsettype 2diabetes,seethesectiononbariatricsurgeryforpeoplewithrecent-onsettype2diabetesintheNICEguidelineonobesity.[2015] 1.4Diagnosingandmanaginghypertension Therecommendationsondiagnosingandmanaginghypertensionhavebeenremoved.Forrecommendationsonhypertensioninpeoplewithtype 2diabetes,seetheNICEguidelineonhypertensioninadults.Diagnosis,treatmentandmonitoringofhypertensionisbroadlythesameforpeoplewithtype 2diabetesasforotherpeople.Whenadifferentapproachisneededforpeoplewithtype 2diabetes,thisisspecifiedinthehypertensionguideline. 1.5Antiplatelettherapy 1.5.1Donotofferantiplatelettherapy(aspirinorclopidogrel)toadultswithtype 2diabeteswithoutcardiovasculardisease.[2015] 1.5.2Forguidanceontheprimaryandsecondarypreventionofcardiovasculardiseaseinadultswithtype 2diabetes,seetheNICEguidelinesoncardiovasculardiseaseandacutecoronarysyndromes.[2015] 1.6Bloodglucosemanagement HbA1cmeasurementandtargets Measurement 1.6.1MeasureHbA1clevelsinadultswithtype 2diabetesevery: 3 to6 months(tailoredtoindividualneeds)untilHbA1cisstableonunchangingtherapy 6 monthsoncetheHbA1clevelandbloodglucoseloweringtherapyarestable.[2015] 1.6.2MeasureHbA1cusingmethodscalibratedaccordingtoInternationalFederationofClinicalChemistry(IFCC)standardisation.[2015] 1.6.3IfHbA1cmonitoringisinvalidbecauseofdisturbederythrocyteturnoverorabnormalhaemoglobintype,estimatetrendsinbloodglucosecontrolusingoneofthefollowing: quality-controlledplasmaglucoseprofiles totalglycatedhaemoglobinestimation(ifabnormalhaemoglobins) fructosamineestimation.[2015] 1.6.4InvestigateunexplaineddiscrepanciesbetweenHbA1candotherglucosemeasurements.Seekadvicefromateamwithspecialistexpertiseindiabetesorclinicalbiochemistry.[2015] Targets NICEhasproducedapatientdecisionaidonagreeingHbA1ctargets,whichalsocoversfactorstoweighupwhendiscussingHbA1ctargetswithpatients. 1.6.5 DiscussandagreeanindividualHbA1ctargetwithadultswithtype 2diabetes(seerecommendations1.6.6to1.6.10).Encouragethemtoreachtheirtargetandmaintainit,unlessanyresultingadverseeffects(includinghypoglycaemia),ortheireffortstoachievetheirtargetimpairtheirqualityoflife.ThinkaboutusingtheNICEpatientdecisionaidonweighingupHbA1ctargetstosupportthesediscussions.[2015,amended2022] 1.6.6 Offerlifestyleadviceanddrugtreatmenttosupportadultswithtype 2diabetestoreachandmaintaintheirHbA1ctarget(seethesectionsondietaryadviceandbariatricsurgeryandchoosingdrugtreatments).Formoreinformationaboutsupportingadherence,seetheNICEguidelineonmedicinesadherence.[2015] 1.6.7 Foradultswhosetype 2diabetesismanagedeitherbylifestyleanddiet,orlifestyleanddietcombinedwithasingledrugnotassociatedwithhypoglycaemia,supportthemtoaimforanHbA1clevelof48 mmol/mol(6.5%).Foradultsonadrugassociatedwithhypoglycaemia,supportthemtoaimforanHbA1clevelof53 mmol/mol(7.0%).[2015] 1.6.8 Inadultswithtype 2diabetes,ifHbA1clevelsarenotadequatelycontrolledbyasingledrugandriseto58 mmol/mol(7.5%)orhigher: reinforceadviceaboutdiet,lifestyleandadherencetodrugtreatmentand supportthepersontoaimforanHbA1clevelof53 mmol/mol(7.0%)and intensifydrugtreatment.[2015] 1.6.9ConsiderrelaxingthetargetHbA1clevel(seerecommendations1.6.7and1.6.8andNICE'spatientdecisionaid)onacase-by-casebasisandindiscussionwithadultswithtype 2diabetes,withparticularconsiderationforpeoplewhoareolderorfrailer,if: theyareunlikelytoachievelonger-termrisk-reductionbenefits,forexample,peoplewithareducedlifeexpectancy tightbloodglucosecontrolwouldputthemathighriskiftheydevelopedhypoglycaemia,forexample,iftheyareatriskoffalling,theyhaveimpairedawarenessofhypoglycaemia,ortheydriveoroperatemachineryaspartoftheirjob intensivemanagementwouldnotbeappropriate,forexampleiftheyhavesignificantcomorbidities.[2015,amended2022] 1.6.10 Ifadultswithtype 2diabetesreachanHbA1clevelthatislowerthantheirtargetandtheyarenotexperiencinghypoglycaemia,encouragethemtomaintainit.BeawarethatthereareotherpossiblereasonsforalowHbA1clevel,forexampledeterioratingrenalfunctionorsuddenweightloss.[2015] 1.6.11ForguidanceonHbA1ctargetsforwomenwithtype 2diabeteswhoarepregnantorplanningtobecomepregnant,seetheNICEguidelineondiabetesinpregnancy.[2015] Self-monitoringofcapillarybloodglucose Theserecommendationsrelatetoself-monitoringbycapillarybloodglucosemonitoring. 1.6.12TaketheDriverandVehicleLicensingAgency(DVLA)'sAssessingfitnesstodrive:aguideformedicalprofessionalsintoaccountwhenofferingself‑monitoringofcapillarybloodglucoselevelsforadultswithtype 2diabetes.[2015,amended2022] 1.6.13Donotroutinelyofferself-monitoringofcapillarybloodglucoselevelsforadultswithtype 2diabetesunless: thepersonisoninsulinor thereisevidenceofhypoglycaemicepisodesor thepersonisonoralmedicationthatmayincreasetheirriskofhypoglycaemiawhiledrivingoroperatingmachineryor thepersonispregnantorisplanningtobecomepregnant(seetheNICEguidelineondiabetesinpregnancy).[2015,amended2022] 1.6.14Considershort-termself-monitoringofcapillarybloodglucoselevelsinadultswithtype 2diabetes,reviewingtreatmentasnecessary: whenstartingtreatmentwithoralorintravenouscorticosteroidsor toconfirmsuspectedhypoglycaemia.[2015,amended2022] 1.6.15Beawarethatadultswithtype 2diabeteswhohaveacuteintercurrentillnessareatriskofworseninghyperglycaemia.Reviewtreatmentasnecessary.[2015] 1.6.16Ifadultswithtype 2diabetesareself-monitoringtheircapillarybloodglucoselevels,carryoutastructuredassessmentatleastannually.Theassessmentshouldinclude: theperson'sself-monitoringskills thequalityandfrequencyoftesting checkingthatthepersonknowshowtointerpretthebloodglucoseresultsandwhatactiontotake theimpactontheperson'squalityoflife thecontinuedbenefittotheperson theequipmentused.[2015,amended2022] Continuousglucosemonitoring 1.6.17Offerintermittentlyscannedcontinuousglucosemonitoring(isCGM,commonlyreferredtoas'flash')toadultswithtype 2diabetesonmultipledailyinsulininjectionsifanyofthefollowingapply: theyhaverecurrenthypoglycaemiaorseverehypoglycaemia theyhaveimpairedhypoglycaemiaawareness theyhaveaconditionordisability(includingalearningdisabilityorcognitiveimpairment)thatmeanstheycannotself-monitortheirbloodglucosebycapillarybloodglucosemonitoringbutcoulduseanisCGMdevice(orhaveitscannedforthem) theywouldotherwisebeadvisedtoself-measureatleast8timesaday.Forguidanceoncontinuousglucosemonitoring(CGM)forpregnantwomen,seetheNICEguidelineondiabetesinpregnancy.[2022] 1.6.18OfferisCGMtoadultswithinsulin-treatedtype 2diabeteswhowouldotherwiseneedhelpfromacareworkerorhealthcareprofessionaltomonitortheirbloodglucose.[2022] 1.6.19Considerreal-timecontinuousglucosemonitoring(rtCGM)asanalternativetoisCGMforadultswithinsulin-treatedtype 2diabetesifitisavailableforthesameorlowercost.[2022] 1.6.20CGMshouldbeprovidedbyateamwithexpertiseinitsuse,aspartofsupportingpeopletoself-managetheirdiabetes.[2022] 1.6.21Adviseadultswithtype 2diabeteswhoareusingCGMthattheywillstillneedtotakecapillarybloodglucosemeasurements(althoughtheycandothislessoften).Explainthatisbecause: theywillneedtousecapillarybloodglucosemeasurementstochecktheaccuracyoftheirCGMdevice theywillneedcapillarybloodglucosemonitoringasaback-up(forexamplewhentheirbloodglucoselevelsarechangingquicklyorifthedevicestopsworking).Providethemwithenoughteststripstotakecapillarybloodglucosemeasurementsasneeded.[2022] 1.6.22IfapersonisofferedrtCGMorisCGMbutcannotordoesnotwanttouseanyofthesedevices,offercapillarybloodglucosemonitoring.[2022] 1.6.23EnsureCGMispartoftheeducationprovidedtoadultswithtype 2diabeteswhoareusingit(seethesectiononeducation).[2022] 1.6.24 Monitorandreviewtheperson'suseofCGMaspartofreviewingtheirdiabetescareplan(seethesectiononindividualisedcare).[2022] 1.6.25IfthereareconcernsaboutthewayapersonisusingtheCGMdevice: askiftheyarehavingproblemsusingtheirdevice lookatwaystoaddressanyproblemsandconcernstoimprovetheiruseofthedevice,includingfurthereducationandemotionalandpsychologicalsupport.[2022] 1.6.26Commissioners,providersandhealthcareprofessionalsshouldaddressinequalitiesinCGMaccessanduptakeby: monitoringwhoisusingCGM identifyinggroupswhoareeligiblebutwhohavealoweruptake makingplanstoengagewiththesegroupstoencouragethemtoconsiderCGM.[2022] Forashortexplanationofwhythecommitteemadetheserecommendationsseetherationaleandimpactsectiononcontinuousglucosemonitoring. Fulldetailsoftheevidenceandthecommittee'sdiscussionareinevidencereview C:continuousglucosemonitoringinadultswithtype 2diabetes. 1.7Drugtreatment Recommendationsinthissectionthatcoverdipeptidylpeptidase‑4(DPP‑4)inhibitors,glucagon‑likepeptide‑1(GLP‑1)mimetics,sulfonylureasandsodium–glucosecotransporter‑2(SGLT2)inhibitorsrefertoeachofthesegroupsofdrugsatclasslevelunlessotherwisestated. NICEtechnologyappraisalsforSGLT2inhibitorsrecommendtheuseofthesemedicinesonlyinspecificpopulationsandincertaincircumstances.The2022updateofthisguidelinelookedattheclinical-andcost-effectivenessevidenceforSGLT2inhibitorsinpeoplewithcardiovasculardiseaseorathighriskofdevelopingcardiovasculardisease.TheguidelinerecommendsSGLT2inhibitorsinawiderpopulationthanthetechnologyappraisalsthatwerepublishedbeforeFebruary 2022. Choosingdrugtreatments Wehaveproducedavisualsummarytoprovideanoverviewoftherecommendationsandadditionalinformationtosupportmedicineschoice. 1.7.1 Discusswithadultswithtype 2diabetesthebenefitsandrisksofdrugtreatmentandtheoptionsavailable.Basethechoiceofdrugtreatmentson: theperson'sindividualclinicalcircumstances,forexamplecomorbidities,contraindications,weight,andrisksfrompolypharmacy theperson'sindividualpreferencesandneeds theeffectivenessofthedrugtreatmentsintermsofmetabolicresponseandcardiovascularandrenalprotection safetyandtolerabilityofthedrugtreatment monitoringrequirements thelicensedindicationsorcombinationsavailable cost(if2 drugsinthesameclassareappropriate,choosetheoptionwiththelowestacquisitioncost).[2015,amended2022]SeetheNICEguidelineonshareddecisionmakingandthesectiononsafetyofmedicinesfordiabetesbeforeandduringpregnancyintheNICEguidelineondiabetesinpregnancy. Rescuetherapyatanyphaseoftreatment 1.7.2Ifanadultwithtype 2diabetesissymptomaticallyhyperglycaemic,considerinsulin(seethesectiononinsulin-basedtreatments)orasulfonylurea,andreviewtreatmentwhenbloodglucosecontrolhasbeenachieved.[2015] First-linedrugtreatment Alsoseethevisualsummaryonfirst-linedrugtreatmentforanoverviewoftherecommendationsandadditionalinformationtosupportmedicineschoice. Foradultswithtype 2diabetesandchronickidneydisease,followrecommendationsonSGLT2inhibitorsinthesectiononchronickidneydiseaseinthisguideline. 1.7.3 Offerstandard-releasemetforminasfirst-linedrugtreatmenttoadultswithtype 2diabetes.[2015] 1.7.4 Assesstheperson'scardiovascularstatusandrisktodeterminewhethertheyhavechronicheartfailureorestablishedatheroscleroticcardiovasculardiseaseorareathighriskofdevelopingcardiovasculardisease.SeetherecommendationsonusingriskscoresandQRISK2toassesscardiovasculardiseaseriskinadultswithtype 2diabetesinNICE'sguidelineoncardiovasculardisease:riskassessmentandreduction,includinglipidmodification.[2022] 1.7.5 Basedonthecardiovascularriskassessmentforthepersonwithtype 2diabetes: Iftheyhavechronicheartfailureorestablishedatheroscleroticcardiovasculardisease,offeranSGLT2inhibitorwithprovencardiovascularbenefitinadditiontometformin. Iftheyareathighriskofdevelopingcardiovasculardisease,consideranSGLT2inhibitorwithprovencardiovascularbenefitinadditiontometformin.[2022] Seetherationaleandimpactsectiononfirst-linedrugtreatmentforanexplanationof'provencardiovascularbenefit' 1.7.6Whenstartinganadultwithtype 2diabetesondualtherapywithmetforminandanSGLT2inhibitorasfirst-linetherapy,introducethedrugssequentially,startingwithmetforminandcheckingtolerability.StarttheSGLT2inhibitorassoonasmetformintolerabilityisconfirmed.[2022] 1.7.7Graduallyincreasethedoseofstandard-releasemetforminoverseveralweekstominimisetheriskofgastrointestinalsideeffectsinadultswithtype 2diabetes.[2015] 1.7.8 Ifanadultwithtype 2diabetesexperiencesgastrointestinalsideeffectswithstandard‑releasemetformin,consideratrialofmodified‑releasemetformin.[2015] 1.7.9 Forfirst-linedrugtreatmentinadultswithtype 2diabetes,ifmetforminiscontraindicatedornottolerated: Iftheyhavechronicheartfailureorestablishedatheroscleroticcardiovasculardisease,offeranSGLT2inhibitorwithprovencardiovascularbenefit. Iftheyareathighriskofdevelopingcardiovasculardisease,consideranSGLT2inhibitorwithprovencardiovascularbenefit.[2022] 1.7.10 Forfirst-linedrugtreatmentinadultswithtype 2diabetes,ifmetforminiscontraindicatedornottoleratedandiftheyarenotineitherofthegroupsinrecommendation1.7.9,consider: aDPP‑4inhibitoror pioglitazoneor asulfonylureaor anSGLT2inhibitorforpeoplewhomeetthecriteriainNICE'stechnologyappraisalguidanceoncanagliflozin,dapagliflozinandempagliflozinasmonotherapiesorertugliflozinasmonotherapyorwithmetforminfortreatingtype 2diabetes.[2015,amended2022] 1.7.11 BeforestartinganSGLT2inhibitor,checkwhetherthepersonmaybeatincreasedriskofdiabeticketoacidosis(DKA),forexampleif: theyhavehadapreviousepisodeofDKA theyareunwellwithintercurrentillness theyarefollowingaverylowcarbohydrateorketogenicdiet.[2022] 1.7.12AddressmodifiablerisksforDKAbeforestartinganSGLT2inhibitor.Forexample,forpeoplewhoarefollowingaverylowcarbohydrateorketogenicdiet,theymayneedtodelaytreatmentuntiltheyhavechangedtheirdiet.[2022] 1.7.13 Adviseadultswithtype 2diabeteswhoaretakinganSGLT2inhibitorabouttheneedtominimisetheirriskofDKAbynotstartingaverylowcarbohydrateorketogenicdietwithoutdiscussingitwiththeirhealthcareprofessional,becausetheymayneedtosuspendSGLT2inhibitortreatment.[2022] Forashortexplanationofwhythecommitteemadetheserecommendationsandhowtheymightaffectpractice,seetherationaleandimpactsectiononfirst-linedrugtreatment. Fulldetailsoftheevidenceandthecommittee'sdecisionareinevidencereviewB:pharmacologicaltherapieswithcardiovascularandotherbenefitsinpeoplewithtype 2diabetes. Reviewingdrugtreatments 1.7.14 Whenreviewingorconsideringchangingtreatmentsforadultswithtype 2diabetes,thinkaboutanddiscussthefollowingwiththeperson: howtooptimisetheircurrenttreatmentregimenbeforethinkingaboutchangingtreatments,takingintoaccountfactorssuchas: adverseeffects adherencetoexistingmedicines theneedtorevisitadviceaboutdietandlifestyle prescribeddosesandformulations stoppingmedicinesthathavehadnoimpactonglycaemiccontrolorweight,unlessthereisanadditionalclinicalbenefit,suchascardiovascularorrenalprotection,fromcontinuedtreatment(seethenotebelowonoff-labeluse) whetherswitchingratherthanaddingdrugscouldbeeffective theconsiderationsabouttreatmentchoiceinrecommendation1.7.1.[2022]InFebruary 2022,usingertugliflozintoreducecardiovascularriskwhenbloodglucoseiswellcontrolledwasoff-label.SeeNICE'sinformationonprescribingmedicines.AlsoseetherecommendationsonmedicationreviewintheNICEguidelineonmedicinesoptimisationandonreviewingmedicinesandsupportingadherenceintheNICEguidelineonmedicinesadherence. AddinganSGLT2inhibitoratanystageafterfirst-linetreatmenthasbeenstarted 1.7.15 Foradultswithtype 2diabetesatanystageaftertheyhavestartedfirst-linetreatment: Iftheyhaveordevelopchronicheartfailureorestablishedatheroscleroticcardiovasculardisease,offeranSGLT2inhibitorwithprovencardiovascularbenefitinadditiontocurrenttreatmentorreplaceanexistingdrugwiththeSGLT2inhibitor. Iftheyareorbecomeathighriskofdevelopingcardiovasculardisease,consideraddinganSGLT2inhibitorwithprovencardiovascularbenefittocurrenttreatmentorreplacinganexistingdrugwiththeSGLT2inhibitor.Takeintoaccounttheperson'scurrenttreatmentregimenandpreferencesandmakeashareddecisionaboutswitchingtreatmentsoraddinganSGLT2inhibitor,asappropriate(alsoseerecommendations1.7.12and1.7.13onstartinganSGLT2inhibitor).[2022]InFebruary 2022,usingertugliflozintoreducecardiovascularriskwhenbloodglucoseiswellcontrolledwasoff-label.SeeNICE'sinformationonprescribingmedicines. Forashortexplanationofwhythecommitteemadetheserecommendationsandhowtheymightaffectpractice,seetherationaleandimpactsectiononreviewingdrugtreatments. Fulldetailsoftheevidenceandthecommittee'sdiscussionareinevidencereviewB:pharmacologicaltherapieswithcardiovascularandotherbenefitsinpeoplewithtype 2diabetes. Treatmentoptionsiffurtherinterventionsareneeded Alsoseeourvisualsummaryontreatmentoptionsiffurtherinterventionsareneededforanoverviewoftherecommendationsandadditionalinformationtosupportmedicineschoice. 1.7.16 Introducedrugsusedincombinationtherapyinastepwisemanner,checkingfortolerabilityandeffectivenessofeachdrug.[2015] 1.7.17 Foradultswithtype 2diabetes,ifmonotherapyhasnotcontinuedtocontrolHbA1ctobelowtheperson'sindividuallyagreedthresholdforfurtherintervention,consideradding: aDPP‑4inhibitoror pioglitazoneor asulfonylureaor anSGLT2inhibitorforpeoplewhomeetthecriteriainNICE'stechnologyappraisalguidanceoncanagliflozinincombinationtherapy,ertugliflozinasmonotherapyorwithmetformin,ordapagliflozinorempagliflozinincombinationtherapy.[2015,amended2022] 1.7.18 Foradultswithtype 2diabetes,ifdualtherapywithmetforminandanotheroraldrughasnotcontinuedtocontrolHbA1ctobelowtheperson'sindividuallyagreedthresholdforfurtherinterventionconsidereither: tripletherapybyaddingaDPP‑4inhibitor,pioglitazoneorasulfonylureaoranSGLT2inhibitorforpeoplewhomeetthecriteriainNICE'stechnologyappraisalguidanceoncanagliflozinincombinationtherapy,dapagliflozinintripletherapy,empagliflozinincombinationtherapy,orertugliflozinwithmetforminandadipeptidylpeptidase-4inhibitor or startinginsulin-basedtreatment(seethesectiononinsulin-basedtreatments)[2015,amended2022] 1.7.19 Inadultswithtype 2diabetes,ifmetforminiscontraindicatedornottoleratedanddualtherapywith2 oraldrugshasnotcontinuedtocontrolHbA1ctobelowtheperson'sindividuallyagreedthresholdforintervention,considerinsulin-basedtreatment(seethesectiononinsulin-basedtreatments).[2015,amended2022] 1.7.20 Iftripletherapywithmetforminand2 otheroraldrugsisnoteffective,nottoleratedorcontraindicated,considertripletherapybyswitchingonedrugforaGLP‑1mimeticforadultswithtype 2diabeteswho: haveabodymassindex(BMI)of35 kg/m2orhigher(adjustaccordinglyforpeoplefromBlack,Asianandotherminorityethnicgroups)andspecificpsychologicalorothermedicalproblemsassociatedwithobesityor haveaBMIlowerthan35 kg/m2 and: forwhominsulintherapywouldhavesignificantoccupationalimplicationsor weightlosswouldbenefitothersignificantobesity-relatedcomorbidities.[2015,amended2022] 1.7.21OnlycontinueGLP‑1mimetictherapyiftheadultwithtype 2diabeteshashadabeneficialmetabolicresponse(areductionofatleast11 mmol/mol[1.0%]inHbA1candweightlossofatleast3%ofinitialbodyweightin6 months).[2015] 1.7.22Foradultswithtype 2diabetes,onlyoffercombinationtherapywithaGLP‑1mimeticandinsulinalongwithspecialistcareadviceandongoingsupportfromaconsultant-ledmultidisciplinaryteam.[2015] Forashortexplanationofwhythecommitteedidnotmakeanynew2022recommendations,seetherationaleandimpactsectionontreatmentoptionsiffurtherinterventionsareneeded. Fulldetailsoftheevidenceandthecommittee'sdiscussionareinevidencereviewB:pharmacologicaltherapieswithcardiovascularandotherbenefitsinpeoplewithtype 2diabetes. Insulin-basedtreatments 1.7.23 Foradultswithtype 2diabetesstartinginsulintherapy,provideastructuredprogrammeusingactiveinsulindosetitrationthatencompasses: injectiontechnique,includingrotatinginjectionsitesandavoidingrepeatedinjectionsatthesamepointwithinsites continuingtelephonesupport self-monitoring dosetitrationtotargetlevels dietaryadvice theDVLA'sAssessingfitnesstodrive:aguideformedicalprofessionals managinghypoglycaemia managingacutechangesinplasmaglucosecontrol supportfromanappropriatelytrainedandexperiencedhealthcareprofessional.[2015] 1.7.24Foradultswithtype 2diabetesstartinginsulintherapy,continuetooffermetforminforpeoplewithoutcontraindicationsorintolerance.Reviewthecontinuedneedforotherbloodglucoseloweringtherapies.[2015] 1.7.25 Startinsulintherapyforadultswithtype 2diabetesfromachoiceofthefollowinginsulintypesandregimens: OfferneutralprotamineHagedorn(NPH)insulininjectedonceortwicedailyaccordingtoneed. ConsiderstartingbothNPHandshort‑actinginsulin(particularlyiftheperson'sHbA1cis75 mmol/mol[9.0%]orhigher),administeredeither: separatelyor asapre-mixed(biphasic)humaninsulinpreparation. Consider,asanalternativetoNPHinsulin,usinginsulindetemirorinsulinglargineif: thepersonneedshelpfromacarerorhealthcareprofessionaltoinjectinsulin,anduseofinsulindetemirorinsulinglarginewouldreducethefrequencyofinjectionsfromtwicetooncedailyor theperson'slifestyleisrestrictedbyrecurrentsymptomatichypoglycaemicepisodesor thepersonwouldotherwiseneedtwice‑dailyNPHinsulininjectionsincombinationwithoralglucose‑loweringdrugs. Considerpre-mixed(biphasic)preparationsthatincludeshort‑actinginsulinanalogues,ratherthanpre‑mixed(biphasic)preparationsthatincludeshort‑actinghumaninsulinpreparations,if: thepersonprefersinjectinginsulinimmediatelybeforeamealor hypoglycaemiaisaproblemor bloodglucoselevelsrisemarkedlyaftermeals.[2015] 1.7.26ConsiderswitchingtoinsulindetemirorinsulinglarginefromNPHinsulininadultswithtype 2diabetes: whodonotreachtheirtargetHbA1cbecauseofsignificanthypoglycaemiaor whoexperiencesignificanthypoglycaemiaonNPHinsulinirrespectiveofthelevelofHbA1creachedor whocannotusethedeviceneededtoinjectNPHinsulinbutcouldadministertheirowninsulinsafelyandaccuratelyifaswitchtooneofthelong‑actinginsulinanalogueswasmadeor whoneedhelpfromacarerorhealthcareprofessionaltoadministerinsulininjectionsandforwhomswitchingtooneofthelong‑actinginsulinanalogueswouldreducethenumberofdailyinjections.[2015] 1.7.27Monitoradultswithtype 2diabeteswhoareonabasalinsulinregimen(NPHinsulin,insulindetemirorinsulinglargine)fortheneedforshort‑actinginsulinbeforemeals(orapre‑mixed[biphasic]insulinpreparation).[2015] 1.7.28Monitoradultswithtype 2diabeteswhoareonpre‑mixed(biphasic)insulinfortheneedforafurtherinjectionofshort‑actinginsulinbeforemealsorforachangetoabasal-bolusregimenwithNPHinsulinorinsulindetemirorinsulinglargine,ifbloodglucosecontrolremainsinadequate.[2015] 1.7.29Whenstartinganinsulinforwhichabiosimilarisavailable,usetheproductwiththelowestacquisitioncost.[2021] 1.7.30EnsuretheriskofmedicationerrorswithinsulinsisminimisedbyfollowingtheMedicinesandHealthcareproductsRegulatoryAgency(MHRA)guidanceonminimisingtheriskofmedicationerrorwithhighstrength,fixedcombinationandbiosimilarinsulinproducts,whichincludesadviceforhealthcareprofessionalswhenstartingtreatmentwithabiosimilar.[2021] 1.7.31Whenpeoplearealreadyusinganinsulinforwhichalowercostbiosimilarisavailable,discussthepossibilityofswitchingtothebiosimilar.Makeashareddecisionwiththepersonafterdiscussingtheirpreferences.[2021] Forashortexplanationofwhythecommitteemadethe2021recommendationsonbiosimilarsandhowtheymightaffectpractice,seetherationaleandimpactsectiononlong-actinginsulin. ForguidanceonusinginsulinincombinationwithSGLT2inhibitors,see: thesectionondrugtreatment NICE'stechnologyappraisalguidanceoncanagliflozin,dapagliflozin,andempagliflozinincombinationtherapy. Insulindelivery 1.7.32Forguidanceoninsulindeliveryforadultswithtype 2diabetes,seethesectiononinsulindeliveryintheNICEguidelineontype 1diabetes.[2015] 1.8Managingcomplications Periodontitis 1.8.1 Adviseadultswithtype 2diabetesattheirannualreviewthat: theyareathigherriskofperiodontitis iftheygetperiodontitis,managingitcanimprovetheirbloodglucosecontrolandcanreducetheirriskofhyperglycaemia.[2022] 1.8.2Adviseadultswithtype 2diabetestohaveregularoralhealthreviews(theiroralhealthcareordentalteamwilltellthemhowoften,inlinewiththeNICEguidelineondentalchecks:intervalsbetweenoralhealthreviews).[2022] 1.8.3 Forguidancefororalhealthcareanddentalteamsonhowtoprovideoralhealthadvice,seetheNICEguidelineonoralhealthpromotion.[2022] 1.8.4Foradultswithtype 2diabeteswhohavebeendiagnosedwithperiodontitisbyanoralhealthcareordentalteam,offerdentalappointmentstomanageandtreattheirperiodontitis(atafrequencybasedontheiroralhealthneeds).[2022] Forashortexplanationofwhythecommitteemadetheserecommendations,seetherationaleandimpactsectiononperiodontitis. Fulldetailsoftheevidenceandthecommittee'sdiscussionareinevidencereview D:periodontitis. Gastroparesis 1.8.5Thinkaboutadiagnosisofgastroparesisinadultswithtype 2diabeteswhohaveerraticbloodglucosecontrolorunexplainedgastricbloatingorvomiting,takingintoaccountpossiblealternativediagnoses.[2009,amended2015] 1.8.6Foradultswithtype 2diabeteswhohavevomitingcausedbygastroparesis,explainthat: thereisnostrongevidencethatanyavailableantiemetictherapyiseffective somepeoplehavehadbenefitwithdomperidone,erythromycinormetoclopramide thestrongestevidenceforeffectivenessisfordomperidone,butprescribersmusttakeintoaccountitssafetyprofile,inparticularitscardiacriskandpotentialinteractionswithothermedicines.[2015]InDecember 2015,theuseoferythromycinwasoff-label.SeeNICE'sinformationonprescribingmedicines. 1.8.7Totreatvomitingcausedbygastroparesisinadultswithtype 2diabetes: consideralternatingtheuseoferythromycinandmetoclopramide considerdomperidoneonlyinexceptionalcircumstances(ifdomperidoneistheonlyeffectivetreatment)andinaccordancewithMHRAguidanceondomperidone.[2015]InDecember 2015,theuseoferythromycinwasoff-label.SeeNICE'sinformationonprescribingmedicines. 1.8.8Ifgastroparesisissuspected,considerreferringadultswithtype 2diabetestospecialistservicesif: thedifferentialdiagnosisisindoubtor thepersonhaspersistentorseverevomiting.[2009] Painfuldiabeticneuropathy 1.8.9Forguidanceonmanagingpainfuldiabeticperipheralneuropathyinadultswithtype 2diabetes,seetheNICEguidelineonneuropathicpaininadults.[2015] Autonomicneuropathy 1.8.10Thinkaboutthepossibilityofcontributorysympatheticnervoussystemdamageinadultswithtype 2diabeteswholosethewarningsignsofhypoglycaemia.[2009,amended2015] 1.8.11Thinkaboutthepossibilityofautonomicneuropathyaffectingthegutinadultswithtype 2diabeteswhohaveunexplaineddiarrhoeathathappensparticularlyatnight.[2009,amended2015] 1.8.12Foradultswithtype 2diabetesandautonomicneuropathywhoaretakingtricyclicdrugsandantihypertensivedrugtreatments,beawareoftheincreasedlikelihoodofsideeffectssuchasorthostatichypotension.Forguidanceonsafeprescribingofantidepressants(suchastricyclicdrugs)andmanagingwithdrawal,seeNICE'sguidelineonmedicinesassociatedwithdependenceorwithdrawalsymptoms.[2009] 1.8.13Foradultswithtype 2diabeteswhohaveunexplainedbladder‑emptyingproblems,investigatethepossibilityofautonomicneuropathyaffectingthebladder.[2009] 1.8.14Inmanagingautonomicneuropathysymptoms,includespecificinterventionsindicatedbythemanifestations(forexample,forabnormalsweatingornocturnaldiarrhoea).[2009] Diabeticfootproblems 1.8.15Forguidanceonpreventingandmanagingfootproblemsinadultswithtype 2diabetes,seetheNICEguidelineondiabeticfootproblems.[2015] Chronickidneydisease 1.8.16Foradultswithchronickidneydisease(CKD)andtype 2diabetes,offeranangiotensinreceptorblocker(ARB)oranangiotensin‑convertingenzyme(ACE)inhibitor(titratedtothehighestlicenseddosethatthepersoncantolerate)ifalbumin-to-creatinineratio(ACR)is3 mg/mmolormore,asrecommendedinthesectiononpharmacotherapyforCKDinadults,children,andyoungpeoplewithrelatedpersistentproteinuriaintheNICEguidelineonchronickidneydisease.[2021] 1.8.17Foradultswithtype 2diabetesandCKDwhoaretakinganARBoranACEinhibitor(titratedtothehighestlicenseddosethattheycantolerate),offeranSGLT2inhibitor(inadditiontotheARBorACEinhibitor)if: ACRisover30 mg/mmoland theymeetthecriteriainthemarketingauthorisation(includingrelevantestimatedglomerularfiltrationrate[eGFR]thresholds).InNovember 2021,notallSGLT2inhibitorswerelicensedforthisindication.SeeNICE'sinformationonprescribingmedicines.[2021] 1.8.18Foradultswithtype 2diabetesandCKDwhoaretakinganARBoranACEinhibitor(titratedtothehighestlicenseddosethattheycantolerate),consideranSGLT2inhibitor(inadditiontotheARBorACEinhibitor)if: ACRisbetween3and30 mg/mmoland theymeetthecriteriainthemarketingauthorisation(includingrelevanteGFRthresholds).InNovember 2021,notallSGLT2inhibitorswerelicensedforthisindication.SeeNICE'sinformationonprescribingmedicines.[2021] 1.8.19ForguidanceondapagliflozinforadultswithCKD,seeNICE'stechnologyappraisalguidanceondapagliflozinfortreatingchronickidneydisease.[2022] 1.8.20Forfurtherguidanceonmanagingkidneydiseaseinadultswithtype 2diabetes,seetheNICEguidelineonchronickidneydisease.[2015] Forashortexplanationofwhythecommitteemadetheserecommendationsandhowtheymightaffectpractice,seetherationaleandimpactsectiononSGLT2inhibitorsforadultswithtype 2diabetesandchronickidneydisease. Fulldetailsoftheevidenceandthecommittee'sdiscussionareinevidencereviewA:SGLT2inhibitorsforpeoplewithchronickidneydiseaseandtype 2diabetes. Erectiledysfunction 1.8.21Offermenwithtype 2diabetestheopportunitytodiscusserectiledysfunctionaspartoftheirannualreview.[2015] 1.8.22Assess,educateandsupportmenwithtype 2diabeteswhohaveproblematicerectiledysfunction,addressingcontributoryfactorssuchascardiovasculardiseaseaswellaspossibletreatmentoptions.[2015] 1.8.23Consideraphosphodiesterase‑5inhibitortotreatproblematicerectiledysfunctioninmenwithtype 2diabetes.Initiallychoosethedrugwiththelowestacquisitioncostandtakeintoaccountanycontraindications.[2015] 1.8.24Afterdiscussion,refermenwithtype 2diabetestoaserviceofferingothermedical,surgicalorpsychologicalmanagementoferectiledysfunctioniftreatment(includingaphosphodiesterase‑5inhibitor,asappropriate)hasbeenunsuccessful.[2015] Eyedisease 1.8.25Whenadultsarediagnosedwithtype 2diabetes,referthemimmediatelytothelocaleyescreeningservice.[2009,amended2020] 1.8.26Encourageadultstoattendeyescreening,andexplainthatitwillhelpthemtokeeptheireyeshealthyandhelptopreventproblemswiththeirvision.Explainthatthescreeningserviceiseffectiveatidentifyingproblemssothattheycanbetreatedearly.[2009] 1.8.27Arrangeemergencyreviewbyanophthalmologistfor: suddenlossofvision rubeosisiridis pre-retinalorvitreoushaemorrhage retinaldetachment.[2009] 1.8.28RefertoanophthalmologistinaccordancewiththeUKNationalScreeningCommitteecriteriaandtimelinesforanylargesuddenunexplaineddropinvisualacuity.[2009,amended2020] Termsusedinthisguideline Thissectiondefinestermsthathavebeenusedinaparticularwayforthisguideline.Forotherdefinitions,seetheNICEglossaryandtheThinkLocal,ActPersonalCareandSupportJargonBuster. Atheroscleroticcardiovasculardisease Thisincludescoronaryheartdisease,acutecoronarysyndrome,previousmyocardialinfarction,stableangina,previouscoronaryorotherrevascularisation,cerebrovasculardisease(ischaemicstrokeandtransientischaemicattack)andperipheralarterialdisease. Consultant-ledmultidisciplinaryteam Aconsultant-ledmultidisciplinaryteammayincludeawiderangeofstaffbasedinprimary,secondaryandcommunitycare. Continuousglucosemonitoring Thiscoversbothreal-timecontinuousglucosemonitoring(rtCGM)andintermittentlyscannedcontinuousglucosemonitoring(isCGM,commonlyreferredtoas'flash'). Acontinuousglucosemonitorisadevicethatmeasuresbloodglucoselevelsandsendsthereadingstoadisplaydeviceorsmartphone. Highriskofdevelopingcardiovasculardisease Adultswithtype 2diabeteswhohave: QRISK2morethan10%inadultsaged 40andoveror anelevatedlifetimeriskofcardiovasculardisease(definedasthepresenceof1ormorecardiovascularriskfactorsinsomeoneunder 40). Cardiovasculardiseaseriskfactors:hypertension,dyslipidaemia,smoking,obesity,andfamilyhistory(inafirst-degreerelative)ofprematurecardiovasculardisease. Insulinglargine Therecommendationsinthisguidelinealsoapplytoanycurrentorfuturebiosimilarproductofinsulinglarginethathasanappropriatemarketingauthorisationthatallowstheuseofthebiosimilarinthesameindication. Multipledailyinjections Twoormoredailyinsulininjections,whichcouldeitherbeabasal-bolusregimenormorethanonedailyinsulininjection. Periodontitis Achronicinflammatorygumdiseasethatdestroysthesupportingtissuesoftheteeth(theperiodontium). Gingivitisisamilderformofperiodontaldiseasethanperiodontitis.However,gingivitisstillcausesinflammationinthegum,andifnottreateditcanleadtoperiodontitis. Severehypoglycaemia Episodesofhypoglycaemiathatrequireassistancefromanotherpersontotreat. Recurrenthypoglycaemia Frequenteventsofhypoglycaemiathatoccureachweekormonthandhaveanimpactonqualityoflife. Verylowcarbohydrateandketogenicdiets Averylowcarbohydratediethas20 to50 gramsperdayofcarbohydrateorlessthan10%ofa2000 kcal/daydiet.Aketogenicdietisaverylowcarbohydrate,highfatdietthatisdesignedtoinduceketosis. Next