Early Access to Weight Loss Jabs in NICE Diabetes Plan

People with type 2 diabetes (T2D) in England could be offered earlier access to newer treatments, including weight loss jabs, under draft guidance from the National Institute for Health and Care Excellence (NICE).

The guidance, described as the “biggest shake-up in care for a decade”, would see a shift from a one-size-fits-all approach to a focus on personalised treatment to prevent heart failure, heart attacks, and other serious complications.

Expanded Use of SGLT-2 Inhibitors

The draft guidance recommends expanding access to sodium-glucose co-transporter-2 (SGLT-2) inhibitors, including canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin.

Currently prescribed as a second-line option, SGLT-2 inhibitors would be available as a joint first-line treatment alongside metformin. They may also be used as monotherapy in patients intolerant to metformin.

SGLT-2 inhibitors are once-daily tablets that selectively block the SGLT-2 cotransporter in the proximal renal tubule, responsible for reabsorbing about 90% of filtered glucose. This lowers the renal glucose threshold, increasing urinary glucose excretion and inducing mild osmotic diuresis. 

However, a 2024 NICE analysis of nearly 590,000 people with T2D in England found under-prescribing of these drugs, particularly among women, older adults, and Black patients. Only 20% of patients with atherosclerotic cardiovascular disease received SGLT-2 inhibitors, with prescribing rates declining in older age groups. 

NICE estimates that wider use of SGLT-2 inhibitors could save nearly 22,000 lives once uptake reaches 90%.

Earlier Access to GLP-1 Agonists

The draft guidance also recommends earlier use of glucagon-like peptide-1 (GLP-1) receptor agonists such as liraglutide or semaglutide. These drugs, previously reserved for later stages of disease, would be considered earlier in treatment for selected groups.

NICE further supports wider adoption of digital health tools, including continuous glucose monitoring and community-based digital care.

Personalised Treatment Approaches

The guidance proposes tailored treatment strategies based on patient characteristics and comorbidities: 

• Adults with cardiovascular disease should receive triple therapy (metformin, an SGLT-2 inhibitor, and a GLP-1 receptor agonist)
• Those with early-onset T2D (diagnosed before age 40) should receive dual therapy before considering a GLP-1 receptor agonist
• Patients with obesity or chronic kidney disease should have specific combinations based on their condition and kidney function, respectively.
• Adults with clinical frailty should start with metformin monotherapy.

Professor Jonathan Benger, deputy chief executive and chief medical officer at NICE, said the draft guidance marks a “significant evolution” in diabetes care.

“The evidence shows that certain medicines can provide important cardiovascular benefits, and by recommending them as part of initial treatment, we could help prevent heart attacks, strokes, and other serious complications before they occur,” he said.

Burden of Diabetes in the UK

Approximately 4.6 million people in the UK have diabetes, with 90% diagnosed with T2D. Diabetes UK estimates that a further 1.3 million may be undiagnosed.

The condition costs the NHS £1 million per hour, with 60% of spending linked to complications. Each week, diabetes contributes to more than 930 strokes, 660 heart attacks, and nearly 2990 cases of heart failure.

Douglas Twenefour, head of clinical at Diabetes UK, welcomed the draft guidance. “The majority of people with T2D are not currently taking the most effective medication for them, putting them at risk of devastating diabetes-related complications,” he said. “Tailoring treatment based on individual risk could protect thousands against heart attacks and kidney disease.”

Waqaar Shah, a GP partner at Chatfield Health Care in London and chair of the NICE guideline committee, said that these recommendations “could help reduce health inequalities while providing better outcomes for everyone”.

Implementation and Safety 

The draft guidance remains open for public consultation until 2 October. NICE will review feedback before publishing final recommendations. 

The guidance aims to promote equitable access to recommended therapies, supported by local training initiatives.

Healthcare professionals have also stressed the need for safe prescribing of SGLT-2 inhibitors, which carry risks including diabetic ketoacidosis (DKA).

Before starting treatment, providers should assess whether patients have previously experienced DKA, have acute illness, or follow very low-carbohydrate or ketogenic diets.