NICE backs changes to NHS' diabetes care pathway

NHS patients with type 2 diabetes (T2D) in England will get earlier access to SGLT-2 inhibitors, now that generics of one of the main drugs in the class – AstraZeneca's Forxiga – are available.

Final guidance from reimbursement authority NICE suggests that savings from switching to generic dapagliflozin, the active ingredient in AZ's drug, could total £560 million by the end of the 2026/27 financial year – money that could be diverted into "other areas of diabetes care, such as education programmes and community support services or other parts of the NHS."

Moreover, earlier use of SGLT2 inhibitors on top of the current go-to option for T2D – metformin – in the treatment pathway could prevent around 17,000 deaths over a three-year period across the UK by reducing the risk of heart attacks, strokes, and kidney problems.

Metformin has been the recommended first-line option for T2D patients for decades in the NHS, but does not have the heart- and kidney-protecting qualities of the SGLT2 drugs.

The new NICE guidance recommends that most people should now be offered metformin along with an SGLT-2 inhibitor from the start, while also advising that they get a slow-release formulation of metformin, which can cause fewer gastrointestinal side effects like stomach upset than the regular, standard-release form.

Douglas Twenefour, head of clinical at the Diabetes UK charity, said the guidance will "transform treatment for people living with type 2 diabetes across the UK [and reduce] the harm caused by this relentless condition."

In 2013, the health technology assessment (HTA) agency turned down this earlier use of the Forxiga, but said it could be used for patients whose blood glucose levels were not satisfactorily controlled on diet and exercise alone and who could not tolerate metformin.

In a statement, NICE said it had developed the new guidance after a study of the anonymised records of almost 590,000 people, which found that – despite being recommended for NHS use as second-line options – SGLT2 inhibitors were under-prescribed, particularly for women, older people, and Black or Black British individuals.

Access to GLP-1 drugs also expanded

There are also new recommendations for GLP-1 agonists used by the NHS to treat T2D, which include Novo Nordisk's Ozempic (semaglutide) and Victoza (liraglutide), and Eli Lilly's Trulicity (dulaglutide).

Specifically, Ozempic will now be recommended for people with T2D who also have cardiovascular disease caused by blocked arteries. Meanwhile, GLP-1 drugs, as well as Lilly's dual GLP-1/GIP agonist Mounjaro (tirzepatide), will now be an option for people with T2D who were diagnosed before age 40, or who are also living with obesity.

"This is a landmark moment for diabetes care," commented Eric Power, interim director of the centre for guidelines at NICE.

"This is a landmark moment for diabetes care," he added. "Our independent committee conducted a rigorous review of the evidence and concluded that, by offering certain medicines earlier, we can prevent thousands of heart attacks, strokes, and cases of kidney failure – keeping people healthier for longer while reducing pressure on NHS services."