Working Diagnosis.

❍ Field Note

Thoughts on the NZ diabetes guidelines (2026)

What's actually changed since 2021, and what to keep close at hand in clinic.

The NZSSD type 2 diabetes management guidance is now the de facto standard for primary care in NZ [1]. It replaced an aging 2012 document and arrived in February 2021, the same week PHARMAC began funding empagliflozin (an SGLT2 inhibitor); dulaglutide (a GLP-1 RA) followed that September [2]. That timing wasn't an accident — the guidance and the funded toolkit were designed to land together. Five years on, a few things are clearly settled, and a few things still aren't.

The targets are gentler than people remember

HbA1c < 53 mmol/mol is the default for most adults with T2DM [1]. Older patients, those with limited life expectancy, advanced complications, or recurrent hypoglycaemia get individualised — usually higher — targets. The temptation when someone walks in at 64 mmol/mol with no symptoms is to escalate. The guidance keeps reminding us to look at the whole patient first, including the actual likelihood of microvascular benefit from another drug versus the certainty of lifestyle and cardiovascular risk reduction.

Lifestyle isn't the lip service it used to be

The framing is worth quoting:

  • 5% sustained body-weight loss → improvement in metabolic parameters [1]
  • 10–15% sustained body-weight loss → typically needed for remission [1]

The DiRECT trial in UK primary care put real numbers behind that ceiling: at one year, 46% of participants in the structured weight-management arm were in diabetes remission, rising further with greater weight loss [3]. The lesson isn't that everyone can or should do this. It's that for the right person at the right point in their disease, this is a real option — and prescribing another tablet first can foreclose it.

The 2021 shift, plainly

Pre-2021, the funded path after metformin in NZ was vildagliptin, then a sulfonylurea or pioglitazone, then insulin. SGLT2 inhibitors and GLP-1 receptor agonists existed; you paid for them.

Post-2021, for eligible patients, an SGLT2i or GLP-1 RA can be added at step 2 — often before vildagliptin, and certainly before sulfonylureas. The reason isn't just glycaemic. It's the cardiorenal data: EMPA-REG OUTCOME showed a 38% relative reduction in cardiovascular death with empagliflozin in patients with T2DM and established CVD [4]; CREDENCE showed reduced renal endpoints with canagliflozin in T2DM with CKD [5]; REWIND showed a reduction in major adverse cardiovascular events with dulaglutide [6].

In practice, this means metformin + empagliflozin is often the sensible early combination for someone with T2DM and any of: CKD, established CVD, heart failure, or high cardiovascular risk. Vildagliptin, a perfectly capable glucose-lowering drug, has quietly lost its place at the front of the queue [7].

The ethnicity criterion

This is the part the rest of the world finds startling, and the part I think is right.

Funded access to empagliflozin or dulaglutide in NZ requires HbA1c > 53 mmol/mol after at least three months of regular glucose-lowering therapy, plus one of [1]:

  • Māori and/or Pacific ethnicity, or
  • known diabetic renal disease, or
  • known CVD, or
  • 5-year CVD risk > 15%, or
  • onset of diabetes in childhood or as a young adult.

The ethnicity criterion is grounded in a well-documented reality: Māori and Pacific peoples in NZ develop type 2 diabetes earlier, accumulate complications faster, and experience higher diabetes-related mortality than non-Māori-non-Pacific populations [1]. A criterion that accelerates access for those at highest baseline risk isn't a thumb on the scale; it's an attempt to correct one. Whether it does so adequately is a separate question — funding still requires you to choose between SGLT2i and GLP-1 RA rather than combine them, and many patients would benefit from both.

Things I keep close at hand

Three operational details that come up almost every week:

  1. Sick day rules with SGLT2 inhibitors. Withhold during acute illness with reduced oral intake, and pre-operatively. Euglycaemic diabetic ketoacidosis is rare but real — Medsafe reissued the warning in December 2024 [8]. Patients should leave the consult with a written plan, not a verbal one.
  2. The dulaglutide supply situation. The global GLP-1 RA shortage from 2023 onwards reshaped prescribing in NZ. NZSSD's standing advice: don't switch between dulaglutide and liraglutide; use empagliflozin if no contraindication; reserve GLP-1 RAs for glycaemic indications, not weight loss alone [9]. Always check supply with the patient's pharmacy before issuing a new script.
  3. HbA1c > 90 mmol/mol at diagnosis. Don't fiddle. The guidance is to initiate insulin alongside metformin, with a view to weaning it once glucotoxicity resolves [1,7].

What's still unsettled

A few things I'd watch over the next couple of years:

  • Whether NZ moves toward funded SGLT2i + GLP-1 RA combination therapy — the additive benefits are clear and this is now standard internationally [10].
  • Whether tirzepatide (a dual GIP/GLP-1 agonist) gets funded; SURPASS-2 showed greater HbA1c and weight reductions than semaglutide [11], with cardiovascular and mortality data continuing to mature.
  • Whether the ethnicity criterion holds up under future scrutiny. I hope it does. The equity argument is strong, and the alternative — an apparently neutral rule that systematically delays access for the population at highest risk — isn't neutral at all.

The NZSSD guidance is genuinely well-built — short, navigable, and updated as evidence shifts [1]. If you treat diabetes in NZ, it's the document to know.

References

  1. New Zealand Society for the Study of Diabetes. Type 2 diabetes management guidance [Internet]. Auckland: NZSSD; 2021 [cited 2026 May 2]. Available from: https://t2dm.nzssd.org.nz/
  2. Snell H. Updated primary care guidance on the management of type 2 diabetes brings New Zealand in line with international best practice. NZ Doctor [Internet]. 2021 Mar 31 [cited 2026 May 2]. Available from: https://www.nzdoctor.co.nz/article/undoctored/updated-primary-care-guidance-management-type-2-diabetes-brings-new-zealand-line
  3. Lean MEJ, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018;391(10120):541–51. doi:10.1016/S0140-6736(17)33102-1
  4. Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med. 2015;373(22):2117–28. doi:10.1056/NEJMoa1504720
  5. Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med. 2019;380(24):2295–306. doi:10.1056/NEJMoa1811744
  6. Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial. Lancet. 2019;394(10193):121–30. doi:10.1016/S0140-6736(19)31149-3
  7. Best Practice Advocacy Centre New Zealand. Type 2 diabetes management toolbox: from lifestyle to insulin [Internet]. Dunedin: BPACnz; 2021 [updated 2025 Jul; cited 2026 May 2]. Available from: https://bpac.org.nz/2021/diabetes-management.aspx
  8. Medsafe. Reminder: risk factors for ketoacidosis with SGLT-2 inhibitors. Prescriber Update [Internet]. Wellington: Medsafe; 2024 Dec [cited 2026 May 2]. Available from: https://medsafe.govt.nz/profs/PUArticles/December2024/Reminder-risk-factors-for-ketoacidosis-with-SGLT-2-inhibitors.html
  9. New Zealand Society for the Study of Diabetes. GLP-1 receptor agonist supply and special authority updates [Internet]. NZSSD; 2024 [cited 2026 May 2]. Available from: https://t2dm.nzssd.org.nz/Special-Authority.html
  10. American Diabetes Association Professional Practice Committee. 9. Pharmacologic approaches to glycemic treatment: Standards of Care in Diabetes—2025. Diabetes Care. 2025;48(Suppl 1):S181–206. doi:10.2337/dc25-S009
  11. Frías JP, Davies MJ, Rosenstock J, et al. Tirzepatide versus semaglutide once weekly in patients with type 2 diabetes. N Engl J Med. 2021;385(6):503–15. doi:10.1056/NEJMoa2107519

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