The video version of this podcast can be found here: ·      https://youtu.be/xB8BStN4OwgThis episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through the draft NICE guideline on type 2 diabetes, which is open for public consultation until October 2025, and the final guidance being due in February 2026. Today’s episode is based on the NICE visual summary and the link to it is below.The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will review the general guidance and we will cover the various groups in future episodes.I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   Disclaimer:The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through  There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The NICE announcement on Type 2 diabetes management can be found here: ·      https://www.nice.org.uk/news/articles/biggest-shake-up-in-type-2-diabetes-care-in-a-decade-announced The NICE draft guideline on Type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/gid-ng10336/documents/450 The visual summary of the NICE draft guideline on type 2 diabetes can be found here: ·      https://www.nice.org.uk/guidance/GID-NG10336/documents/draft-guideline-2 TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we are going to review the draft NICE guideline on type 2 diabetes, focusing on the visual summary created by NICE. I will cover the information over several episodes, so stay tuned.Right, let’s jump into it.As you may know, the draft NICE guideline on type 2 diabetes is open for public consultation until October, and the final guidance is due in February 2026. It has attracted a lot of attention, but we need to remember that, for now, it is only a draft, which means it could still change. So, we should not be making clinical decisions based on it yet.Today’s episode is based on the NICE visual summary and the link to it is in the episode description.The visual summary includes general guidance for all patient, and specific guidance for 7 different group of patients. In today’s episode we will review the general guidance and we will cover the various groups in future episodes.The first page of the draft visual summary sets out the general approach for all.NICE begins by emphasising that diet and lifestyle are the foundation of management, and these need to be reinforced at every stage of the treatment pathway, pointing out that medicines should come on top of, and not instead of, these lifestyle measures.When choosing drug therapy, the draft recommends discussing the benefits and risks of every option. That includes looking at each drug’s effectiveness for glycaemic control but also, and this is new compared with the previous guideline, weighing its impact on cardiovascular and renal outcomes.The guideline also stresses that if a person has more than one comorbidity, for example obesity, cardiovascular disease or chronic kidney disease, we should make a shared decision with the patient about which comorbidity to prioritise in choosing treatment. This means that we move away from a purely HbA1c-driven model towards a model focused on complications and their prevention.On reviewing medicines, the draft says that before changing therapy, we should first optimise the current regimen, bearing in mind that it may be appropriate to continue some treatment options, like SGLT-2 inhibitors or GLP-1 receptor agonists even if the effect on glycaemic control is not perfect. In fact, the draft advises continuing SGLT-2 inhibitors for their heart and kidney benefits even if they are not achieving glucose or weight targets.For GLP-1 receptor agonists, the draft changes the stop rules: we will stop if they do not help the person achieve glycaemic or weight goals but only, and this is important, if the person does not have cardiovascular disease or early-onset type 2 diabetes, understood as type 2 diabetes diagnosed under the age of 40. This a huge change.  Previously, stopping criteria were more tightly linked to weight and HbA1c thresholds, for example, if the person had not lost at least 3% of body weight and dropped their HbA1c by 1% within six months. Now, because of the cardiovascular benefit of GLP-1 receptor agonists, it basically means that for people with atherosclerotic cardiovascular disease, it is continued long term, regardless of weight loss or HbA1c change. And a similar, more relaxed attitude also applies to people with early onset type 2 diabetes.But, why this recommendation?Well, this comes from trial evidence over the past decade. SGLT-2 inhibitors have consistently reduced hospitalisation for heart failure and slowed CKD progression, even when HbA1c effects were modest. Similarly, GLP-1 receptor agonists have reduced rates of major adverse cardiovascular events. Why these benefits? The pathophysiology is important here: SGLT-2 inhibitors reduce intraglomerular pressure, improve renal haemodynamics, induce diuresis, and reduce preload and afterload on the heart. On the other hand, GLP-1 receptor agonists improve weight, and have an effect on blood pressure and lipids. All these effects are the reason for the beneficial outcomes over and above glucose controlWhat this means in practice is that:The decision to start or continue medicines is now less about HbA1c in isolation, and more about long-term organ protection.SGLT-2 inhibitors should be maintained even if glycaemic targets aren’t achieved.GLP-1 receptor agonists should be stopped if they don’t achieve targets unless the person has early-onset diabetes or established cardiovascular disease in which case, their longer-term benefits justify continuation.Finally, NICE advises against combining GLP-1 receptor agonists with DPP-4 inhibitors, as this combination offers no additional benefit.Why is this? Let’s remember that DPP-4 inhibitors prevent breakdown of endogenous GLP-1, whereas GLP-1 receptor agonists directly activate GLP-1 receptors. Because the GLP-1 agonists already saturate the receptor and they are not affected by DPP-4 degradation, adding a DPP-4 inhibitor offers no additional glycemic or weight benefit. That’s why guidelines recommend using one or the other, but never both.And before we end, let’s also quickly list the main current recommendations in the draft guideline, making reference to the recommendations that have been either deleted or changed in a major way.1.   First, the recommendation to start metformin alone as first-line for most people without complications has gone. Now we will start dual Therapy with Metformin + SGLT-2 Inhibitor as Initial Therapy, the reason being the need to maximise the cardiorenal benefits of SGLT2 inhibitors.2.   Second, the restrictive conditions to start GLP1 receptor agonists have also gone. Now there is Earlier and More Explicit Use of GLP-1 Receptor Agonists, Specifically Semaglutide, in order to maximise the weight and cardiovascular benefits of GLP1 receptor agonists. In particular, semaglutide is the preferred option because it has the most consistent and strong evidence as well as being the most cost-effective.3.   Third, there is more weight on Stratification by Kidney Function and Frailty. As a result, the draft puts more weight on eGFR thresholds when deciding which medicines to use and it also identifies frailty as a modifier given that frailty increases treatment risks such as dehydration, side effects, hypoglycaemia, etc. 4.   Continuation Criteria and Stop Rules for GLP-1 receptor agonists are now different, meaning that if a person has cardiovascular disease or early onset diabetes, the recommendation is to continue GLP-1 even if glycaemic or weight targets are not fully met. 5.   The advice on how to introduce multiple medicines when initial therapy is combination therapy is also clearer. The draft specifies that medicines should be introduced one at a time. For example, first confirm tolerability of metformin, then of the SGLT-2 inhibitor, then if adding a GLP-1 RA, confirm tolerability of that in turn.6.   Another change is that the draft is more explicit about reviewing medicines: checking effectiveness, and discontinuing medicines that are not effective unless there is an additional benefit like cardiovascular or renal protection.7.   Then, insulin guidance has also had a major refresh. The new draft simplifies the advice into a more practical, class-based approach, giving more flexibility as to whether human or analogues insulins are recommended. This is pragmatic response to insulin product withdrawals and shortages. By focusing on broader insulin classes instead of individual types, the guidance is more flexible and easier to apply, even when supply issues arise. 8.   Another significant change is that GLP-1 receptor agonists can now be combined with insulin without the need for specialist approval, making access easier and quicker in primary care.9.   The ordering and priority of Subsequent Therapy Options has also changed. The draft places DPP-4 inhibitors as the recommended option after Initial treatment. Sulfonylureas, pioglitazone, and insulin remain options but are considered after DPP4 inhibitors. 10. The recommendation against combining a GLP-1 receptor agonist with a DPP-4 inhibitor is repeated and is more strongly worded in the draft. The combinations does not add benefit so it should be avoided and removed if present.11. The priority of additional therapies is also more dependent on the clinical group that the patient belongs to. This means that the draft makes the escalation pathway group-specific, and more prescriptive, with risks explicitly considered for each clinical category. And to summarise and close, let’s review again how we think about treatment escalation from a general perspective. The general pathway looks like this:We will start most people on metformin plus an SGLT-2 inhibitor right from the beginning.For people with atherosclerotic cardiovascular disease, obesity and early onset type 2 diabetes we will consider semaglutide, early in the pathway, not as a late rescue option.If HbA1c isn’t controlled with first line treatment and more glucose lowering is needed, the first recommended add-on is a DPP-4 inhibitor, because these are well tolerated, weight neutral, and easy to use, but this only applies as long as the patient is not on a GLP1 receptor agonist.If a DPP4 inhibitor not suitable or not effective, then other options like sulfonylureas, pioglitazone, or insulin, can be introduced depending on the person’s needs.And finally, frailty will modify how we manage treatment escalation, prioritising safety and symptoms over artificial targetsThe main message to remember is that the rationale of the draft guideline is to avoid the old problem of incremental, reactive prescribing, that is, waiting for one drug to fail before adding another, often leaving patients years without treatment that could protect their heart and kidneys. So that is it, an initial review of the new draft NICE guideline on type 2 diabetes focusing on the visual summary. In the next episode we will cover the recommendations for specific clinical groups.We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.Thank you for listening and goodbye. 

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