NICE guidance - type 2 diabetes in adults with frailty

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

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 frailty

For adults with type 2 diabetes and frailty:

• modified-release metformin should be offered
• an SGLT2 inhibitor should only be offered if the person's level of frailty does not place them at risk of adverse events from such a medicine (for example, volume depletion or hypotension)

If metformin is contraindicated or not tolerated, assess whether their level of frailty places the person at risk of adverse events from SGLT-2 inhibitors:

• if it does not, consider monotherapy with a SGLT-2 inhibitor
• if it does, consider monotherapy with a DPP-4 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 frailty who need further medicines to manage their hyperglycaemia symptoms and reach their individualised glycaemic targets:

• consider adding a DPP-4 inhibitor to their current treatment or
• if they are already taking a DPP-4 inhibitor or if a DPP-4 inhibitor is contraindicated, not tolerated or is not effective, consider adding 1 of the following to their current treatment:
  • pioglitazone or
  • a sulfonylurea or
  • an insulin-based treatment

When choosing a treatment with the person, take into account that sulfonylureas and insulin-based treatments can increase the risk of hypoglycaemia and falls.

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
• metformin is contraindicated if a patient has eGFR of less than 30 mL/min/1.73 m2

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.

Reference:

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