Endocrinology · NICE

Type 2 diabetes in adults

NICE

Source:NICE NG28 Type 2 diabetes in adults: management (2022, with subsequent updates)ADA Standards of Care 2026

Verified Apr 2026

Ask House about this guideline

Red Flags

Hyperglycaemic emergency: DKA, HHS, severe hypoglycaemia — emergency department; IV fluids, insulin infusion, electrolyte correction^[1]
Symptoms of HHS in older T2DM (severe hyperglycaemia >600 mg/dL, hyperosmolarity, no significant ketones) — ICU; cautious fluid and insulin^[1]
T2DM with established CVD or high CV risk not on SGLT2 inhibitor or GLP-1 RA — significant evidence-care gap; initiate at next visit^[1]
Pregnancy in T2DM — switch sulfonylureas, SGLT2 inhibitors, GLP-1 RAs to insulin pre-conception or on confirmation^[1]

First-line treatment

Interventions

Structured diabetes education (DESMOND, Dose Adjustment for Normal Eating)^[1]
Group or individual structured education at diagnosis and annually; improves glycaemic control and reduces complications
Lifestyle: dietary patterns + activity^[1]
Mediterranean or low-carbohydrate diet, 5–10% weight loss target if overweight, ≥150 min/week moderate aerobic activity, smoking cessation, alcohol moderation
Annual complications surveillance^[1]
Eye, foot, kidney, cardiovascular, mental health screening annually; structured care reduces complications

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Metformin^[1]	Biguanide	500 mg PO daily, titrate to 1 g BD over 4–8 weeks; max 2 g/day; avoid if eGFR <30	10–17 years: 500 mg–2 g daily	First-line for all T2DM unless contraindicated; weight-neutral, no hypoglycaemia, mortality benefit per UKPDS
Empagliflozin or dapagliflozin^[1]	SGLT2 inhibitor	Empagliflozin 10–25 mg PO once daily; dapagliflozin 10 mg PO once daily	—	First-line addition or alternative to metformin in established CVD, heart failure, or CKD; cardio-renal protection independent of glycaemic effect
Semaglutide or dulaglutide (GLP-1 RA)^[1]	GLP-1 receptor agonist	Semaglutide 0.25 mg SC weekly titrate to 1–2 mg; dulaglutide 0.75 mg SC weekly titrate to 1.5–4.5 mg	—	Add for established ASCVD, weight reduction priority, or HbA1c not at target on metformin + SGLT2i
Sulfonylurea (gliclazide)^[1]	Insulin secretagogue	Gliclazide 30–120 mg PO daily (sustained release)	—	Cost-effective add-on when SGLT2/GLP-1 unavailable; risk of hypoglycaemia and weight gain; DPP-4 inhibitor (sitagliptin/teneligliptin) is alternative weight-neutral oral
Basal insulin (glargine, detemir, degludec)^[1]	Long-acting insulin analogue	Start 0.1–0.2 U/kg once daily; titrate by 2 units every 3 days to fasting glucose target	—	Add when oral therapies + GLP-1 fail to reach HbA1c target; basal-only often sufficient for many years before basal-bolus

Metformin^[1]

Biguanide

Adult: 500 mg PO daily, titrate to 1 g BD over 4–8 weeks; max 2 g/day; avoid if eGFR <30
Paediatric: 10–17 years: 500 mg–2 g daily

First-line for all T2DM unless contraindicated; weight-neutral, no hypoglycaemia, mortality benefit per UKPDS

Empagliflozin or dapagliflozin^[1]

SGLT2 inhibitor

Adult: Empagliflozin 10–25 mg PO once daily; dapagliflozin 10 mg PO once daily
Paediatric: —

First-line addition or alternative to metformin in established CVD, heart failure, or CKD; cardio-renal protection independent of glycaemic effect

Semaglutide or dulaglutide (GLP-1 RA)^[1]

GLP-1 receptor agonist

Adult: Semaglutide 0.25 mg SC weekly titrate to 1–2 mg; dulaglutide 0.75 mg SC weekly titrate to 1.5–4.5 mg
Paediatric: —

Add for established ASCVD, weight reduction priority, or HbA1c not at target on metformin + SGLT2i

Sulfonylurea (gliclazide)^[1]

Insulin secretagogue

Adult: Gliclazide 30–120 mg PO daily (sustained release)
Paediatric: —

Cost-effective add-on when SGLT2/GLP-1 unavailable; risk of hypoglycaemia and weight gain; DPP-4 inhibitor (sitagliptin/teneligliptin) is alternative weight-neutral oral

Basal insulin (glargine, detemir, degludec)^[1]

Long-acting insulin analogue

Adult: Start 0.1–0.2 U/kg once daily; titrate by 2 units every 3 days to fasting glucose target
Paediatric: —

Add when oral therapies + GLP-1 fail to reach HbA1c target; basal-only often sufficient for many years before basal-bolus

Safety-net

Recognise hypoglycaemia (sweating, shakiness, confusion) — carry rapid-acting carbohydrate; severe episodes need glucagon or A&E^[1]
Sick-day rules: do not stop insulin or metformin (unless dehydrated); SGLT2 inhibitor should be paused with vomiting or dehydration to avoid euglycaemic DKA^[1]
Foot inspection daily; report new ulcers same week; never walk barefoot^[1]

Referral criteria

DKA, HHS, or severe hypoglycaemiaEmergency department / ICU^[1]
T2DM in pregnancy or planning pregnancyJoint diabetes-obstetric care^[1]
Symptomatic with HbA1c >86 mmol/mol (10%) at diagnosisDiabetes specialist; consider initial insulin^[1]
Established ASCVD, HF, or CKD without SGLT2i / GLP-1 RADiabetes / cardiology / nephrology for evidence-based add-on therapy^[1]

Clinical summary

Diagnosis and stepped pharmacotherapy of T2DM per NICE NG28 — metformin first-line, SGLT2 inhibitors and GLP-1 RAs for cardio-renal protection.

References

1.NICE NG28 Type 2 diabetes in adults: management (2022, with subsequent updates); ADA Standards of Care 2026 (2022)

Drug

Class

Adult

Paediatric

Notes