CLIFFORD J BAILEY
Aston University, Birmingham, UK
Address for correspondence: Professor Clifford J Bailey, Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
E-mail: c.j.bailey@aston.ac.uk
Br J Diabetes 2026;ONLINE AHEAD OF PUBLICATION
https://doi.org/10.15277/bjd.2026.508
Key words: type 2 diabetes, NICE guidance, NG28, individualised care
The National Institute for Health and Care Excellence (NICE) recently (February 2026) published another update to the NG28 guidance for 'Type 2 diabetes in adults: management'.1 The underlying theme remains much the same as earlier versions dating from December 2015, namely individualised care tailored to patient needs and wishes. The latest version follows international consensus statements that are moving the treatment algorithm from a 'glucocentric' to a more 'complications-driven' approach designed to focus strongly on cardiorenal risk reduction.2 Accordingly, the initial assessment has been updated to take full account of pre-existing, current or high risk for atherosclerotic cardiovascular disease (ASCVD), heart failure and chronic kidney disease (CKD), as well as obesity, frailty and early adult onset (<40 years old) of type 2 diabetes (T2DM). Recommendations for glucose-lowering therapies are then based on this assessment, aiming to control blood glucose with minimal risk of overt hypoglycaemia and to manage body weight without undue loss of muscle. The main changes from the previous (2022) version of NG28 are summarised in table 1.
Diagnosis and initial consultation
Diagnostic criteria for T2DM remain unchanged: they are not included in NG28 but are listed in the Clinical Knowledge Summary (CKS; table 2).3 CKS provides useful reminders about clinical signs and interpretations of hyperglycaemia, but does not address prediabetes (intermediate hyperglycaemia) when preventative intervention can usefully be initiated (table 3).4
Initial recommendations after diagnosis continue to emphasise a personalised approach with lifestyle advice (diet, exercise and healthy living) preferably supported by a structured education programme. This should be open to family members or carers and include guidance on self-monitoring of capillary blood glucose, precautions for driving, hypoglycaemia awareness and avoidance, and sick-day adjustments relevant to the anticipated therapies and care pathway. Lifestyle should be reinforced whenever possible, and NG28 provides a link to information about the low-calorie diet programme (800-900 kcal/day for 12 weeks) which aims for remission of newly diagnosed T2DM.5
Although the latest NG28 guidance adopts a more complications-driven approach, it is accepted that the management of hyperglycaemia remains fundamental. HbA1c, checked at least twice yearly, continues as the customary measure of overall glycaemic control. Targets are unchanged: aim for <48 mmol/mol (6.5%), or less stringent (<53 mmol/mol; 7.0%) if using a medicine associated with hypoglycaemia (e.g. insulin or sulfonylurea). Intensify glucose-lowering therapy if HbA1c >58 mmol/mol (7.5%), although those who warn against clinical inertia will dutifully recommend against waiting for HbA1c to rise to this level.
While self-monitoring of capillary blood glucose or continuous glucose monitoring are established for the introduction and dose titration of glucose-lowering and other glycaemia-altering medicines, such monitoring is otherwise generally reserved for those at increased risk of hypoglycaemia (e.g. insulin users, drivers using a sulfonylurea) and in pregnancy.
The shift towards a more complications-driven approach emphasises assessment of cardiorenal status/risk as well as body weight management, frailty and risk of hypoglycaemia when selecting initial glucose-lowering medication. The importance of patient involvement in the selection process continues to be stressed, to optimise compatibility with patient lifestyle preferences and constraints, and hopefully to support adherence (all part of usual individualised care).
The main new medication features of the 2026 iteration of NG28 focus on preferred use of the modified-release formulation of metformin, early addition of a sodium-glucose cotransporter-2 (SGLT2) inhibitor and consideration of early introduction of a glucagon-like peptide-1 (GLP-1) receptor agonist. Accordingly, increased attention to co-morbidities and risk reduction has necessitated a bolder approach to early combination therapy, introducing medicines sequentially: availability of fixed-dose combinations to reduce pill burden is not discussed. The structure of the treatment algorithm now categorises individuals into those with (as yet) no relevant co-morbidities, early-onset disease (<40 years old) and/or living with obesity, heart failure, ASCVD, CKD or frailty. These treatment categories are summarised in a detailed illustration in NG28, so I have taken the liberty of attempting a less ambitious version herein (Figure 1).
Modified-release metformin (rather than the standard-release formulation) is recommended as initial glucose-lowering medication for all categories, even in CKD provided the estimated glomerular filtration rate (eGFR) is >30 ml/min/1.73m2 (dose reductions appreciated if eGFR <45 ml/min/1.73m2). Early addition of an SGLT2 inhibitor is also encouraged for all categories if further glucose lowering is required, noting caution with frail individuals. Recommendations for third-line glucose-lowering medications are divided between a GLP-1 receptor agonist (for obese, early-onset, atherosclerotic or frail individuals) or a dipeptidyl peptidase-4 inhibitor (DPP-4i; for those with heart failure, CKD or no relevant co-morbidity). If the algorithm is interrupted by a contraindication or intolerance then pioglitazone (except in heart failure) or a sulfonylurea (except if eGFR <30ml/min/1.73m2) may be considered. Insulin-based therapies remain as last resort and especially for individuals with an HbA1c >75 mmol/mol (9.0%).
The complications-driven approach of the 2026 version of NG28 is logically guided by its recognition of vulnerable groups. Obesity guidance overlaps with NICE guideline NG246 (management of overweight and obesity) but rather underplays the opportunities for use of GLP-1 receptor agonists as third-line treatment.6 Early onset of T2DM is notoriously susceptible to accelerated complications and deservedly warrants intensive intervention from diagnosis, and frailty is suitably flagged to receive delicately nuanced pharmacotherapy.7,8 For people with heart failure, the value of an SGLT2 inhibitor alongside metformin is appropriately acknowledged, and the additional benefit of a GLP-1 receptor agonist beyond glycaemic control is noted for people with ASCVD, although NG28 only extends this option to semaglutide (1 mg subcutaneously, once weekly). In severe CKD (eGFR <30 ml/min/1.73m2) where a DPP-4 inhibitor is suggested alongside an SGLT2 inhibitor (either dapagliflozin or empagliflozin is specified), pioglitazone is suggested as third line before considering insulin. Dose adjustment of renally eliminated DPP-4 inhibitors and especial caution with insulin initiation are noteworthy.
While NG28 might be viewed as an economy guideline in some respects (eg GLP-1 therapies third line, biosimilar insulins where available, limited glucose monitoring), the guidance could also be regarded as cost-efficiently judicious. But perhaps the real value is the unwritten message that we have the expertise, care pathways and resources to significantly improve the health prospects for people with T2DM, and the earlier and more rigorously we deploy them …….the better.
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