NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2026. This update reflected the advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors.

HbA1c targets

Approach

• individual targets should be agreed with patients to encourage motivation
• HbA1c should be checked every 3-6 months until stable, then 6 monthly
• NICE encourage us to consider relaxing targets on 'a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes'

Targets

• aim for 48 mmol/mol (6.5%) if managed by healthy living alone, or with an initial drug regimen not associated with hypoglycaemia
• aim for 53 mmol/mol (7.0%) if taking a medicine associated with hypoglycaemia
• if HbA1c rises to 58 mmol/mol (7.5%) or higher on the initial medication regimen, NICE says to:
  • reinforce advice about diet, healthy living and adherence
  • support the person to aim for 53 mmol/mol (7.0%)
  • intensify medicines

Initial medication

Previously standard-release metformin was the cornerstone of T2DM management. Now, adults should be started on the two following core drugs:

• modified-release metformin
  • should be started first
• an SGLT-2 inhibitor
  • start this as soon as metformin is at the maximum tolerated dose

If metformin contraindicated or not tolerated then add an SGLT-2 inhibitor alone.

Specific scenarios:

• a history of cardiovascular disease
  • subcutaneous semaglutide (ozempic) 1mg/week should be added to two core drugs
• patients develop early-onset T2DM (< 40 years)
  • consider adding a GLP-1 receptor agonist or tirzepatide to two core drugs
• chronic kidney disease (eGFR 20-30 ml/min/1.73 m²)
  • metformin is contraindicated, therefore:
  • dapagliflozin or empagliflozin and
  • a DPP-4 inhibitor
• chronic kidney disease (eGFR < 20 ml/min/1.73 m²)
  • both core drugs are contraindicated, therefore:
  • a DPP-4 inhibitor