Latest NICE Guidelines on Diabetes Management
Screening and Diagnosis
Screen all adults aged ≥35 years for type 2 diabetes using fasting plasma glucose, HbA1c, or oral glucose tolerance test in a healthcare setting. 1
Who Should Be Screened Earlier
- Adults younger than 35 years with BMI ≥25 kg/m² (≥23 kg/m² for Asian Americans) plus any additional diabetes risk factor (family history, hypertension, dyslipidemia, prior gestational diabetes, high-risk ethnicity, physical inactivity). 2, 1
- Adults with hypertension or hyperlipidemia regardless of other risk factors, because early detection dramatically improves cardiovascular risk stratification. 1
- Children/adolescents after puberty onset or age 10 years (whichever is earlier) if overweight/obese plus at least one additional risk factor (maternal diabetes during gestation, family history, high-risk ethnicity, signs of insulin resistance). 2, 1
Screening Frequency
- Repeat testing every 3 years when initial results are normal. 1
- Annual screening for individuals with prediabetes (fasting glucose 100–125 mg/dL or HbA1c 5.7–6.4%). 1
- More frequent screening if weight gain occurs or new hyperglycemic symptoms develop. 1
Diagnostic Criteria (Requires Confirmation on Separate Day)
- Fasting plasma glucose ≥126 mg/dL after ≥8-hour fast. 1, 3
- HbA1c ≥6.5% measured with NGSP-certified laboratory method (not point-of-care). 1, 3
- 2-hour oral glucose tolerance test ≥200 mg/dL after 75-g glucose load. 1, 3
- Random plasma glucose ≥200 mg/dL with classic symptoms (polyuria, polydipsia, unexplained weight loss)—this is the only scenario not requiring repeat confirmation. 1, 3
Critical Diagnostic Pitfalls to Avoid
- Never use point-of-care HbA1c for diagnosis—only NGSP-certified laboratory methods are acceptable. 1, 3
- Never use capillary blood glucose for diagnosis—it is poorly standardized despite reasonable sensitivity. 1, 3
- Do not use HbA1c in patients with hemoglobinopathies, hemolytic anemia, pregnancy (2nd/3rd trimester), recent blood loss/transfusion, hemodialysis, or erythropoietin therapy—use only plasma glucose criteria in these populations. 3
- Always confirm abnormal results with repeat testing on a separate day (except symptomatic random glucose ≥200 mg/dL). 3
Glycemic Targets (NICE Recommendations)
Involve patients in decisions about their individual HbA1c target and encourage them to achieve it unless adverse effects or efforts to reach the target impair quality of life. 2
Specific HbA1c Targets by Treatment Intensity
- 48 mmol/mol (6.5%) for patients managed by lifestyle/diet alone or lifestyle/diet plus a single drug not associated with hypoglycemia (e.g., metformin). 2
- 53 mmol/mol (7.0%) for patients on any drug associated with hypoglycemia (e.g., sulfonylureas, insulin). 2
- 53 mmol/mol (7.0%) when intensifying to dual therapy if HbA1c rises to 58 mmol/mol (7.5%) or higher on monotherapy—reinforce diet/lifestyle adherence and add a second agent. 2
When to Relax Targets (Individualized Approach)
Consider relaxing the HbA1c target on a case-by-case basis for: 2
- Older or frail adults unlikely to achieve longer-term risk-reduction benefits (e.g., reduced life expectancy).
- Patients at high risk of hypoglycemia consequences (those at risk of falling, impaired hypoglycemia awareness, drivers, machinery operators).
- Patients with significant comorbidities for whom intensive management is inappropriate.
The NICE guideline emphasizes balancing benefits with harms—particularly hypoglycemia and weight gain—and stresses that efforts to achieve HbA1c below 7% may increase risk for death, weight gain, and hypoglycemia in many patients. 2
Initial Management of Type 2 Diabetes
First-Line Pharmacotherapy
Initiate metformin at diagnosis unless contraindicated; verify adequate renal function (serum creatinine <1.5 mg/dL in men, <1.4 mg/dL in women) before starting. 1
- Measure serum creatinine at least annually and whenever metformin dose is increased. 1
- Metformin may be used in patients with stable congestive heart failure if renal function is normal but should be avoided in unstable or hospitalized CHF patients. 2
Treatment Escalation Algorithm
- Re-check HbA1c after 3 months of metformin monotherapy. 4
- If HbA1c remains 7.5–8.9%, add a second glucose-lowering medication. 4
- If HbA1c ≥9.0%, add basal insulin for robust glucose lowering. 4
- If HbA1c stays above goal despite two agents, introduce a third oral agent or insulin within 3 months. 4
- Consider a GLP-1 receptor agonist for additional weight loss and cardiovascular protection. 1
Medications to Avoid in Specific Populations
- Avoid sulfonylureas in older adults because of prolonged half-life and heightened hypoglycemia risk. 1
- Avoid thiazolidinediones (TZDs) in patients with symptomatic heart failure. 2
Lifestyle Modifications (Essential Adjunct to Pharmacotherapy)
Dietary Recommendations
- Mediterranean or DASH dietary pattern emphasizing whole grains, legumes, nuts, fruits, vegetables, and minimal processed foods. 1
- Eliminate sugar-sweetened beverages entirely. 1
- Limit sodium intake to <2,300 mg/day. 1
- Reduce saturated fat, trans fat, and cholesterol; increase omega-3 fatty acids, viscous fiber, and plant sterols/stanols. 1
- Calorie-restricted diet—whether low-carbohydrate, low-fat, or Mediterranean—effectively supports weight loss and glucose control. 4
- Losing 5–10% of body weight can lower HbA1c by roughly 0.6–1.0% and may lessen the need for additional medications. 4
Physical Activity Recommendations
- ≥150 minutes per week of moderate-to-vigorous aerobic activity, spread over at least three days with no more than two consecutive days without activity. 1
- Add resistance training at least twice per week as part of the lifestyle program. 1
- Break up prolonged sedentary periods to lower post-prandial glucose excursions. 1
Collaboration with Dietitian
- Referral to a registered dietitian experienced in diabetes nutrition therapy improves outcomes and can reduce overall healthcare costs. 4
Prediabetes Management
Lifestyle intervention is first-line for all individuals with prediabetes. 1
- Prescribe ≥150 minutes per week of moderate-intensity aerobic activity (≈700 kcal/week energy expenditure). 1
- Add resistance training at least twice per week. 1
- Recommend Mediterranean or DASH dietary pattern. 1
- Break up prolonged sedentary periods. 1
Pharmacologic Prevention
- Consider metformin for high-risk individuals (BMI ≥35 kg/m² or age <60 years with prediabetes)—metformin has the strongest evidence base and long-term safety for diabetes prevention. 1
Monitoring
- Conduct annual diabetes screening (fasting glucose or HbA1c) because roughly 10% of people with prediabetes progress to diabetes each year. 1
Cardiovascular Risk Management
Blood Pressure Targets and Treatment
- Measure blood pressure at every routine diabetes visit. 1
- Target systolic <130 mmHg and diastolic <80 mmHg. 1
- For BP 130–139/80–89 mmHg: initiate lifestyle therapy (weight loss, DASH-style diet, sodium reduction, potassium increase, alcohol moderation, physical activity) for up to 3 months; add pharmacologic agents if targets remain unmet. 1
- For BP ≥140/90 mmHg: start pharmacologic therapy immediately in addition to lifestyle measures. 1
- In patients with known CVD, consider ACE inhibitor therapy to reduce cardiovascular events. 2
- In patients with prior myocardial infarction, β-blockers should be continued for at least 2 years after the event; longer-term use is reasonable if well tolerated but data are lacking. 2
Lipid Management
- Obtain a fasting lipid profile at least annually (or every 2 years if low-risk: LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150 mg/dL). 1
- Add statin therapy to lifestyle treatment for all diabetic patients with overt cardiovascular disease, and for those >40 years with one or more cardiovascular risk factors even without established disease. 1
- Primary LDL-cholesterol goal: <100 mg/dL in individuals without overt cardiovascular disease. 1
- Optional intensive goal: LDL <70 mg/dL using high-dose statin in patients with established cardiovascular disease. 1
- If LDL targets are not achieved on maximal tolerated statin, aim for a 30–40% reduction from baseline. 1
- Use aspirin therapy (75–162 mg/day) as secondary prevention in those with diabetes with a history of CVD. 2
- For patients with CVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. 2
Monitoring and Hypoglycemia Management
HbA1c Monitoring Frequency
- Check HbA1c every 3 months when glycemic control is not at goal or when the treatment regimen has changed. 4
- Once target HbA1c is achieved, monitor every 6 months to ensure continued control. 4
Self-Monitoring of Blood Glucose
- Perform self-monitoring at home, especially before meals and at bedtime, to identify patterns and prevent hypoglycemia. 4
- Point-of-care HbA1c testing during clinic visits enables immediate therapeutic adjustments. 4
Hypoglycemia Treatment Protocol
- Treat any blood glucose <70 mg/dL (3.9 mmol/L) promptly with 15–20 g of fast-acting carbohydrate (glucose tablets, juice, regular soda). 4
- Re-measure glucose 15 minutes after treatment; if still low, repeat the carbohydrate dose. 4
- After glucose normalizes, consume a meal or snack to prevent recurrence. 4
- Recognize higher-risk situations: fasting for tests, missed meals, alcohol intake, intense exercise, and overnight periods. 4
- If frequent hypoglycemia occurs or the patient cannot recognize falling glucose, consider raising the HbA1c target to avoid dangerous episodes. 4
Screening for Complications
Retinopathy Screening
- Adults with type 1 diabetes: initial dilated comprehensive eye examination by an ophthalmologist or optometrist within 5 years after diabetes onset. 2
- Patients with type 2 diabetes: initial dilated comprehensive eye examination shortly after diagnosis. 2
- Subsequent examinations: repeat annually; less-frequent exams (every 2–3 years) may be considered following one or more normal exams; more frequent if retinopathy is progressing. 2
- Women with preexisting diabetes who are planning pregnancy or who have become pregnant: comprehensive eye examination in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum. 2
- Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy to an ophthalmologist experienced in diabetic retinopathy management. 2
Nephropathy Screening
- Optimize glucose control to reduce the risk or slow the progression of nephropathy. 2
- Optimize blood pressure control to reduce the risk or slow the progression of nephropathy. 2
Foot Care
- Perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations—include inspection, assessment of foot pulses, and testing for loss of protective sensation (10-g monofilament plus testing any one of: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold). 2
- Provide general foot self-care education to all patients with diabetes. 2
- A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet, especially those with a history of prior ulcer or amputation. 2
Immunizations
- Provide an annual influenza vaccine to all diabetic patients aged ≥6 months. 1
- Administer pneumococcal polysaccharide vaccine to all diabetic patients aged ≥2 years; offer a one-time revaccination for those <64 years who were previously immunized before age 65 and >5 years have elapsed. 1
- Follow CDC recommendations for hepatitis B vaccination in diabetic individuals. 1
Special Populations: End-of-Life Care
Stable Patients in Palliative/Hospice Care
- Continue the existing regimen with emphasis on preventing hypoglycemia; maintain glucose below the renal threshold; routine HbA1c monitoring is of minimal value. 1
Patients with Organ Failure
- Prioritize hypoglycemia avoidance; for type 1 diabetes, reduce but do not stop insulin as oral intake declines; for type 2 diabetes, titrate agents that carry hypoglycemia risk. 1
Dying Patients
- Discontinue all diabetes medications for type 2 diabetes; for type 1 diabetes, a small basal insulin dose may be maintained to avert acute hyperglycemic complications. 1