Executive summary
- Holistic Goal: Control HbA1c, but prioritise CV/Renal risk reduction. Statins (Atorvastatin 20mg 1° prevention) and BP control are as vital as glucose.
- SGLT2 Update: Now indicated first-line (with Metformin) for high CV risk (QRISK ≥10%), Heart Failure, or ASCVD.
- HbA1c Target: Usually 48 mmol/mol (6.5%) monotherapy / 53 mmol/mol (7.0%) dual therapy. Relax to 58+ if frail.
First-Line Strategy
- Standard Release Metformin: 500mg od with food, titrating over weeks to 1g bd (or max tolerated). Use MR if GI side effects.
- High Risk (QRISK ≥10%, CVD, or HF): Start Metformin + SGLT2 inhibitor (e.g., Dapagliflozin 10mg / Empagliflozin 10mg) immediately. Do not wait for HbA1c failure.
- Contraindications: If eGFR <30 (Metformin) or eGFR <20 (SGLT2 initiation - check specific license), consider Gliptin or Pioglitazone.
Step 2: Intensification (HbA1c > 58 mmol/mol)
- If on Metformin only: Add SGLT2i, Gliptin (DPP-4), Pioglitazone, or Sulfonylurea (Gliclazide).
- Selection Guide:
- CVD/HF/Kidney risk: SGLT2i (Dapagliflozin/Empagliflozin/Canagliflozin).
- Obesity concern: SGLT2i.
- Frailty/Hypo risk: Gliptin (e.g., Sitagliptin, Alogliptin).
Step 3: Triple Therapy & GLP-1
- Triple: Metformin + SGLT2i + Gliptin/PIO/SU.
- GLP-1 Consideration (e.g., Semaglutide/Dulaglutide): Consider if BMI ≥35 (or ≥30 if ethnicity risk) AND psychological distress/comorbidity, OR if Insulin is the alternative. Requires 11mmol/mol HbA1c drop + 3% weight loss in 6 months to continue.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.