Type 2 diabetes in adults: management

Take the Driver and Vehicle Licensing Agency (DVLA)'s Assessing fitness to drive: a guide for medical professionals into account when offering self‑monitoring of capillary blood glucose levels for adults with type 2 diabetes. [2015, amended 2022]

Do not routinely offer self-monitoring of capillary blood glucose levels for adults with type 2 diabetes unless:

• the person is on insulin or

• there is evidence of hypoglycaemic episodes or

• the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery or

• the person is pregnant or is planning to become pregnant (see the NICE guideline on diabetes in pregnancy). [2015, amended 2022]

Consider short-term self-monitoring of capillary blood glucose levels in adults with type 2 diabetes, reviewing treatment as necessary:

• when starting treatment with oral or intravenous corticosteroids or

• to confirm suspected hypoglycaemia. [2015, amended 2022]

Be aware that adults with type 2 diabetes who have acute intercurrent illness are at risk of worsening hyperglycaemia. Review treatment as necessary. [2015]

If adults with type 2 diabetes are self-monitoring their capillary blood glucose levels, carry out a structured assessment at least annually. The assessment should include:

• the person's self-monitoring skills

• the quality and frequency of testing

• checking that the person knows how to interpret the blood glucose results and what action to take

• the impact on the person's quality of life

• the continued benefit to the person

• the equipment used. [2015, amended 2022]

Offer intermittently scanned continuous glucose monitoring (isCGM, commonly referred to as 'flash') to adults with type 2 diabetes on multiple daily insulin injections if any of the following apply:

• they have recurrent hypoglycaemia or severe hypoglycaemia

• they have impaired hypoglycaemia awareness

• they have a condition or disability (including a learning disability or cognitive impairment) that means they cannot self-monitor their blood glucose by capillary blood glucose monitoring but could use an isCGM device (or have it scanned for them)

• they would otherwise be advised to self-measure at least 8 times a day.
  
  For guidance on continuous glucose monitoring (CGM) for pregnant women, see the NICE guideline on diabetes in pregnancy. [2022]

Offer isCGM to adults with insulin-treated type 2 diabetes who would otherwise need help from a care worker or healthcare professional to monitor their blood glucose. [2022]

Consider real-time continuous glucose monitoring (rtCGM) as an alternative to isCGM for adults with insulin-treated type 2 diabetes if it is available for the same or lower cost. [2022]

CGM should be provided by a team with expertise in its use, as part of supporting people to self-manage their diabetes. [2022]

Advise adults with type 2 diabetes who are using CGM that they will still need to take capillary blood glucose measurements (although they can do this less often). Explain that is because:

• they will need to use capillary blood glucose measurements to check the accuracy of their CGM device

• they will need capillary blood glucose monitoring as a back-up (for example when their blood glucose levels are changing quickly or if the device stops working).
  
  Provide them with enough test strips to take capillary blood glucose measurements as needed. [2022]

If a person is offered rtCGM or isCGM but cannot or does not want to use any of these devices, offer capillary blood glucose monitoring. [2022]

Ensure CGM is part of the education provided to adults with type 2 diabetes who are using it (see the section on education). [2022]

Monitor and review the person's use of CGM as part of reviewing their diabetes care plan (see the section on individualised care). [2022]

If there are concerns about the way a person is using the CGM device:

• ask if they are having problems using their device

• look at ways to address any problems and concerns to improve their use of the device, including further education and emotional and psychological support. [2022]

Commissioners, providers and healthcare professionals should address inequalities in CGM access and uptake by:

• monitoring who is using CGM

• identifying groups who are eligible but who have a lower uptake

• making plans to engage with these groups to encourage them to consider CGM. [2022]

Discuss with adults with type 2 diabetes the benefits and risks of drug treatment and the options available. Base the choice of drug treatments on:

• the person's individual clinical circumstances, for example comorbidities, contraindications, weight, and risks from polypharmacy

• the person's individual preferences and needs

• the effectiveness of the drug treatments in terms of metabolic response and cardiovascular and renal protection

• safety and tolerability of the drug treatment

• monitoring requirements

• the licensed indications or combinations available

• cost (if 2 drugs in the same class are appropriate, choose the option with the lowest acquisition cost). [2015, amended 2022]
  
  See the NICE guideline on shared decision making and the section on safety of medicines for diabetes before and during pregnancy in the NICE guideline on diabetes in pregnancy.

If an adult with type 2 diabetes is symptomatically hyperglycaemic, consider insulin (see the section on insulin-based treatments) or a sulfonylurea, and review treatment when blood glucose control has been achieved. [2015]

Offer standard-release metformin as first-line drug treatment to adults with type 2 diabetes. [2015]

Assess the person's cardiovascular status and risk to determine whether they have chronic heart failure or established atherosclerotic cardiovascular disease or are at high risk of developing cardiovascular disease.

See the recommendations on using risk scores and QRISK2 to assess cardiovascular disease risk in adults with type 2 diabetes in NICE's guideline on cardiovascular disease: risk assessment and reduction, including lipid modification. [2022]

Based on the cardiovascular risk assessment for the person with type 2 diabetes:

• If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.

• If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin. [2022]

When starting an adult with type 2 diabetes on dual therapy with metformin and an SGLT2 inhibitor as first-line therapy, introduce the drugs sequentially, starting with metformin and checking tolerability. Start the SGLT2 inhibitor as soon as metformin tolerability is confirmed. [2022]

Gradually increase the dose of standard-release metformin over several weeks to minimise the risk of gastrointestinal side effects in adults with type 2 diabetes. [2015]

If an adult with type 2 diabetes experiences gastrointestinal side effects with standard‑release metformin, consider a trial of modified‑release metformin. [2015]

For first-line drug treatment in adults with type 2 diabetes, if metformin is contraindicated or not tolerated:

• If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit.

• If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit. [2022]

For first-line drug treatment in adults with type 2 diabetes, if metformin is contraindicated or not tolerated and if they are not in either of the groups in recommendation 1.7.9, consider:

• a DPP‑4 inhibitor or

• pioglitazone or

• a sulfonylurea or

• an SGLT2 inhibitor for people who meet the criteria in NICE's technology appraisal guidance on canagliflozin, dapagliflozin and empagliflozin as monotherapies or ertugliflozin as monotherapy or with metformin for treating type 2 diabetes. [2015, amended 2022]

Before starting an SGLT2 inhibitor, check whether the person may be at increased risk of diabetic ketoacidosis (DKA), for example if:

• they have had a previous episode of DKA

• they are unwell with intercurrent illness

• they are following a very low carbohydrate or ketogenic diet. [2022]

Address modifiable risks for DKA before starting an SGLT2 inhibitor. For example, for people who are following a very low carbohydrate or ketogenic diet, they may need to delay treatment until they have changed their diet. [2022]

Advise adults with type 2 diabetes who are taking an SGLT2 inhibitor about the need to minimise their risk of DKA by not starting a very low carbohydrate or ketogenic diet without discussing it with their healthcare professional, because they may need to suspend SGLT2 inhibitor treatment. [2022]

When reviewing or considering changing treatments for adults with type 2 diabetes, think about and discuss the following with the person:

• how to optimise their current treatment regimen before thinking about changing treatments, taking into account factors such as:

  • adverse effects

  • adherence to existing medicines

  • the need to revisit advice about diet and lifestyle

  • prescribed doses and formulations

• stopping medicines that have had no impact on glycaemic control or weight, unless there is an additional clinical benefit, such as cardiovascular or renal protection, from continued treatment (see the note below on off-label use)

• whether switching rather than adding drugs could be effective

• the considerations about treatment choice in recommendation 1.7.1. [2022]
  
  In February 2022, using ertugliflozin to reduce cardiovascular risk when blood glucose is well controlled was off-label. See NICE's information on prescribing medicines.
  
  Also see the recommendations on medication review in the NICE guideline on medicines optimisation and on reviewing medicines and supporting adherence in the NICE guideline on medicines adherence.

For adults with type 2 diabetes who start taking an SGLT2 inhibitor before they are 40 because they have an elevated lifetime risk of cardiovascular disease, do not stop the SGLT2 inhibitor when they turn 40 even if their QRISK2 score is below 10%. Only stop the SGLT2 inhibitor if the person's circumstances have changed and the SGLT2 inhibitor is no longer appropriate. [2022]

Introduce drugs used in combination therapy in a stepwise manner, checking for tolerability and effectiveness of each drug. [2015]

For adults with type 2 diabetes, if monotherapy has not continued to control HbA1c to below the person's individually agreed threshold for further intervention, consider adding:

• a DPP‑4 inhibitor or

• pioglitazone or

• a sulfonylurea or

• an SGLT2 inhibitor for people who meet the criteria in NICE's technology appraisal guidance on canagliflozin in combination therapy, ertugliflozin as monotherapy or with metformin, or dapagliflozin or empagliflozin in combination therapy. [2015, amended 2022]

For adults with type 2 diabetes, if dual therapy with metformin and another oral drug has not continued to control HbA1c to below the person's individually agreed threshold for further intervention consider either:

• triple therapy by adding a DPP‑4 inhibitor, pioglitazone or a sulfonylurea or an SGLT2 inhibitor for people who meet the criteria in NICE's technology appraisal guidance on canagliflozin in combination therapy, dapagliflozin in triple therapy, empagliflozin in combination therapy, or ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor or

• starting insulin-based treatment (see the section on insulin-based treatments). [2015, amended 2022]

In adults with type 2 diabetes, if metformin is contraindicated or not tolerated and dual therapy with 2 oral drugs has not continued to control HbA1c to below the person's individually agreed threshold for intervention, consider insulin-based treatment (see the section on insulin-based treatments). [2015, amended 2022]

If triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated, consider triple therapy by switching one drug for a GLP‑1 mimetic for adults with type 2 diabetes who:

• have a body mass index (BMI) of 35 kg/m² or higher (adjust accordingly for people from Black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity or

• have a BMI lower than 35 kg/m² and:

  • for whom insulin therapy would have significant occupational implications or

  • weight loss would benefit other significant obesity-related comorbidities. [2015, amended 2022]

Only continue GLP‑1 mimetic therapy if the adult with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and weight loss of at least 3% of initial body weight in 6 months). [2015]

For adults with type 2 diabetes, only offer combination therapy with a GLP‑1 mimetic and insulin along with specialist care advice and ongoing support from a consultant-led multidisciplinary team. [2015]

For adults with type 2 diabetes starting insulin therapy, provide a structured programme using active insulin dose titration that encompasses:

• injection technique, including rotating injection sites and avoiding repeated injections at the same point within sites

• continuing telephone support

• self-monitoring

• dose titration to target levels

• dietary advice

• the DVLA's Assessing fitness to drive: a guide for medical professionals

• managing hypoglycaemia

• managing acute changes in plasma glucose control

• support from an appropriately trained and experienced healthcare professional. [2015]

For adults with type 2 diabetes starting insulin therapy, continue to offer metformin for people without contraindications or intolerance. Review the continued need for other blood glucose lowering therapies. [2015]

Start insulin therapy for adults with type 2 diabetes from a choice of the following insulin types and regimens:

• Offer neutral protamine Hagedorn (NPH) insulin injected once or twice daily according to need.

• Consider starting both NPH and short‑acting insulin (particularly if the person's HbA1c is 75 mmol/mol [9.0%] or higher), administered either:

  • separately or

  • as a pre-mixed (biphasic) human insulin preparation.

• Consider, as an alternative to NPH insulin, using insulin detemir or insulin glargine if:

  • the person needs help from a carer or healthcare professional to inject insulin, and use of insulin detemir or insulin glargine would reduce the frequency of injections from twice to once daily or

  • the person's lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes or

  • the person would otherwise need twice‑daily NPH insulin injections in combination with oral glucose‑lowering drugs.

• Consider pre-mixed (biphasic) preparations that include short‑acting insulin analogues, rather than pre‑mixed (biphasic) preparations that include short‑acting human insulin preparations, if:

  • the person prefers injecting insulin immediately before a meal or

  • hypoglycaemia is a problem or

  • blood glucose levels rise markedly after meals. [2015]

Consider switching to insulin detemir or insulin glargine from NPH insulin in adults with type 2 diabetes:

• who do not reach their target HbA1c because of significant hypoglycaemia or

• who experience significant hypoglycaemia on NPH insulin irrespective of the level of HbA1c reached or

• who cannot use the device needed to inject NPH insulin but could administer their own insulin safely and accurately if a switch to one of the long‑acting insulin analogues was made or

• who need help from a carer or healthcare professional to administer insulin injections and for whom switching to one of the long‑acting insulin analogues would reduce the number of daily injections. [2015]

Monitor adults with type 2 diabetes who are on a basal insulin regimen (NPH insulin, insulin detemir or insulin glargine) for the need for short‑acting insulin before meals (or a pre‑mixed [biphasic] insulin preparation). [2015]

Monitor adults with type 2 diabetes who are on pre‑mixed (biphasic) insulin for the need for a further injection of short‑acting insulin before meals or for a change to a basal-bolus regimen with NPH insulin or insulin detemir or insulin glargine, if blood glucose control remains inadequate. [2015]

When starting an insulin for which a biosimilar is available, use the product with the lowest acquisition cost. [2021]

Ensure the risk of medication errors with insulins is minimised by following the Medicines and Healthcare products Regulatory Agency (MHRA) guidance on minimising the risk of medication error with high strength, fixed combination and biosimilar insulin products, which includes advice for healthcare professionals when starting treatment with a biosimilar. [2021]

When people are already using an insulin for which a lower cost biosimilar is available, discuss the possibility of switching to the biosimilar. Make a shared decision with the person after discussing their preferences. [2021]

For guidance on insulin delivery for adults with type 2 diabetes, see the section on insulin delivery in the NICE guideline on type 1 diabetes. [2015]

Advise adults with type 2 diabetes at their annual review that:

• they are at higher risk of periodontitis

• if they get periodontitis, managing it can improve their blood glucose control and can reduce their risk of hyperglycaemia. [2022]

Advise adults with type 2 diabetes to have regular oral health reviews (their oral healthcare or dental team will tell them how often, in line with the NICE guideline on dental checks: intervals between oral health reviews). [2022]

For guidance for oral healthcare and dental teams on how to provide oral health advice, see the NICE guideline on oral health promotion. [2022]

For adults with type 2 diabetes who have been diagnosed with periodontitis by an oral healthcare or dental team, offer dental appointments to manage and treat their periodontitis (at a frequency based on their oral health needs). [2022]

Think about a diagnosis of gastroparesis in adults with type 2 diabetes who have erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses. [2009, amended 2015]

For adults with type 2 diabetes who have vomiting caused by gastroparesis, explain that:

• there is no strong evidence that any available antiemetic therapy is effective

• some people have had benefit with domperidone, erythromycin or metoclopramide

• the strongest evidence for effectiveness is for domperidone, but prescribers must take into account its safety profile, in particular its cardiac risk and potential interactions with other medicines. [2015]
  
  In December 2015, the use of erythromycin was off-label. See NICE's information on prescribing medicines.

To treat vomiting caused by gastroparesis in adults with type 2 diabetes:

• consider alternating the use of erythromycin and metoclopramide

• consider domperidone only in exceptional circumstances (if domperidone is the only effective treatment) and in accordance with MHRA guidance on domperidone. [2015]
  
  In December 2015, the use of erythromycin was off-label. See NICE's information on prescribing medicines.

If gastroparesis is suspected, consider referring adults with type 2 diabetes to specialist services if:

• the differential diagnosis is in doubt or

• the person has persistent or severe vomiting. [2009]

For guidance on managing painful diabetic peripheral neuropathy in adults with type 2 diabetes, see the NICE guideline on neuropathic pain in adults. [2015]

Think about the possibility of contributory sympathetic nervous system damage in adults with type 2 diabetes who lose the warning signs of hypoglycaemia. [2009, amended 2015]

Think about the possibility of autonomic neuropathy affecting the gut in adults with type 2 diabetes who have unexplained diarrhoea that happens particularly at night. [2009, amended 2015]

For adults with type 2 diabetes and autonomic neuropathy who are taking tricyclic drugs and antihypertensive drug treatments, be aware of the increased likelihood of side effects such as orthostatic hypotension. For guidance on safe prescribing of antidepressants (such as tricyclic drugs) and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms. [2009]

For adults with type 2 diabetes who have unexplained bladder‑emptying problems, investigate the possibility of autonomic neuropathy affecting the bladder. [2009]

In managing autonomic neuropathy symptoms, include specific interventions indicated by the manifestations (for example, for abnormal sweating or nocturnal diarrhoea). [2009]

For guidance on preventing and managing foot problems in adults with type 2 diabetes, see the NICE guideline on diabetic foot problems. [2015]

For adults with chronic kidney disease (CKD) and type 2 diabetes, offer an angiotensin receptor blocker (ARB) or an angiotensin‑converting enzyme (ACE) inhibitor (titrated to the highest licensed dose that the person can tolerate) if albumin-to-creatinine ratio (ACR) is 3 mg/mmol or more, as recommended in the section on pharmacotherapy for CKD in adults, children, and young people with related persistent proteinuria in the NICE guideline on chronic kidney disease. [2021]

For adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate), offer an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if:

• ACR is over 30 mg/mmol and

• they meet the criteria in the marketing authorisation (including relevant estimated glomerular filtration rate [eGFR] thresholds).
  
  In November 2021, not all SGLT2 inhibitors were licensed for this indication. See NICE's information on prescribing medicines. [2021]

For adults with type 2 diabetes and CKD who are taking an ARB or an ACE inhibitor (titrated to the highest licensed dose that they can tolerate), consider an SGLT2 inhibitor (in addition to the ARB or ACE inhibitor) if:

• ACR is between 3 and 30 mg/mmol and

• they meet the criteria in the marketing authorisation (including relevant eGFR thresholds).
  
  In November 2021, not all SGLT2 inhibitors were licensed for this indication. See NICE's information on prescribing medicines. [2021]

For guidance on dapagliflozin for adults with CKD, see NICE's technology appraisal guidance on dapagliflozin for treating chronic kidney disease. [2022]

For further guidance on managing kidney disease in adults with type 2 diabetes, see the NICE guideline on chronic kidney disease. [2015]

Offer men with type 2 diabetes the opportunity to discuss erectile dysfunction as part of their annual review. [2015]

Assess, educate and support men with type 2 diabetes who have problematic erectile dysfunction, addressing contributory factors such as cardiovascular disease as well as possible treatment options. [2015]

Consider a phosphodiesterase‑5 inhibitor to treat problematic erectile dysfunction in men with type 2 diabetes. Initially choose the drug with the lowest acquisition cost and take into account any contraindications. [2015]

After discussion, refer men with type 2 diabetes to a service offering other medical, surgical or psychological management of erectile dysfunction if treatment (including a phosphodiesterase‑5 inhibitor, as appropriate) has been unsuccessful. [2015]

When adults are diagnosed with type 2 diabetes, refer them immediately to the local eye screening service. [2009, amended 2020]

Encourage adults to attend eye screening, and explain that it will help them to keep their eyes healthy and help to prevent problems with their vision. Explain that the screening service is effective at identifying problems so that they can be treated early. [2009]

Arrange emergency review by an ophthalmologist for:

• sudden loss of vision

• rubeosis iridis

• pre-retinal or vitreous haemorrhage

• retinal detachment. [2009]

Refer to an ophthalmologist in accordance with the UK National Screening Committee criteria and timelines for any large sudden unexplained drop in visual acuity. [2009, amended 2020]