NICE guidance - adults with type 2 diabetes and heart failure (with any ejection fraction, unless specified)

Confirm diagnosis of type 2 diabetes

• refer to practice nurse for baseline assessments for diabetes - feet, urine, BMI; refer for retinal screening
• refer for DESMOND or equivalent
• modified release metformin and a sodium–glucose cotransporter-2 (SGLT-2) is generally the first line treatment option in type 2 diabetes (1)

NICE suggest targets for management of type 2 diabetes as (1)

Targets

• for adults whose type 2 diabetes is managed either by healthy living and diet, or healthy living and diet combined with an initial medication regimen that is not
  associated with hypoglycaemia, support them to aim for an HbA1c level of 48 mmol/mol (6.5%)
• for adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53mmol/mol (7.0%)
• in adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
  • reinforce advice about diet, lifestyle and adherence to drug treatment and
  • support the person to aim for an HbA1c level of 53mmol/mol (7.0%)
  • and intensify drug treatment
• consider relaxing the target HbA1c level on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes:
  • who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
  • for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job
  • for whom intensive management would not be appropriate, for example, people with significant comorbidities

HbA1c lower than target:

• If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it
  • be aware that there are other possible reasons for a low HbA1c level, for example, deteriorating renal function or sudden weight loss

Adults with heart failure (with any ejection fraction, unless specified)

Offer:

• modified-release metformin, and
• an SGLT-2 inhibitor

If metformin is contraindicated or not tolerated, offer monotherapy with an SGLT-2 inhibitor

Introducing medicines in a stepwise manner

Medicines should be introduced in a stepwise manner, checking for tolerability and effectiveness of each medicine.

When an adult with type 2 diabetes starts initial therapy with metformin and one or more other medicines:

• introduce the medicines one at a time, starting with metformin and checking tolerability
• if using an SGLT-2 inhibitor, start this as soon as metformin is at the maximum tolerated dose

For adults with type 2 diabetes and heart failure who need further medicines to reach their individualised glycaemic targets:

• offer to add a DPP-4 inhibitor to their current treatment
• if this is contraindicated, not tolerated or not effective, offer to add:
  • a sulfonylurea or
  • an insulin-based treatment

Reviewing metformin

For adults with type 2 diabetes who are already taking standard-release metformin:

• continue with this treatment or
• switch to modified-release metformin if standard-release metformin is not tolerated or if this is the person's preference

Reviewing other medicines

• consider continuing SGLT-2 inhibitors for their cardiovascular or renal benefits, even if they do not help the person reach their individualised glycaemic targets.

Do not routinely offer self-monitoring of blood glucose levels for adults with type 2 diabetes unless:

• the person is on insulin or
• there is evidence of hypoglycaemic episodes or
• the person is on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery
• or the person is pregnant, or
• is planning to become pregnant. For more information, see the NICE guideline on diabetes in pregnancy

Consider short-term self-monitoring of capillary blood glucose levels in adults with type 2 diabetes, reviewing treatment as necessary:

• when starting treatment with oral or intravenous corticosteroids or
• to confirm suspected hypoglycaemia

For detailed guidance then consult the full guideline.

Notes:

• LADA
  • patients with LADA are relatively 'insulin deficient' rather than 'insulin resistant'. These patients do not have the classic type 2 diabetic phenotype. These patients are likely to require insulin earlier in their management compared to 'insulin resistant' diabetics. Caution is required in management of these patients because insulin therapy may be indicated from diagnosis of diabetes in these patients if presenting with persistently high blood glucose values

Reference:

• NICE (February 2026). Type 2 diabetes in adults: management