NICE guideline [NG28] Type 2 diabetes in adults: management. Last updated: Feb 2026.
NICE CKS Diabetes – type 2. Last revised: Jul 2025.
Article Last Updated:05/06/2026
The 2026 NICE guideline moves away from a unified treatment ladder toward individualised, comorbidity-guided therapeutic pathways.
Key changes in the 2026 NICE guideline
1) 1st line dual therapy is now standard for most patients
Metformin PLUS an SGLT-2 inhibitor is recommended in step 1 to provide cardiovascular and renal protection
Exceptions mainly include significant renal impairment or frailty, where individualisation and safety considerations take priority
In the previous 2022 guideline, SGLT-2 inhibitors were mainly indicated in patients with QRISK ≥10% / heart failure / atherosclerotic cardiovascular disease
2) GLP-1 agonists and tirzepatide are introduced earlier in treatment pathways
Used sooner in people with obesity, early-onset T2DM, and those needing additional glucose-lowering
Tirzepatide is a dual GLP-1/GIP agonist newly incorporated into the updated NICE guideline
3) Pivotal role of semaglutide (a GLP-1 agonist) in atherosclerotic cardiovascular disease
If a patient develops atherosclerotic cardiovascular disease → semaglutide should be added immediately (regardless of HbA1c)
Given the scale of these updates, the previous 2022 NICE guideline is retained in this article for clear reference and comparison
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Previous NICE Guidance: Type 2 Diabetes Pharmacological Management (2022)
An important rule to bear in mind is: at any stage, if the patient meets the criteria for SGLT-2 inhibitor (i.e. develops chronic heart failure / atherosclerotic CVD / QRISK >10%) → consider adding or replacing an existing drug with an SGLT-2 inhibitor.
For instance, if a T2DM patient who has developed heart failure has an HbA1c of 46 mmol/mol (target <48 mmol/mol), and is stable on metformin monotherapy. In strict glycaemic terms, there is no indication to add another drug, as the HbA1c is at target. However, under the “SGLT‑2 rule”, an SGLT‑2 inhibitor should still be considered as an add‑on to metformin because of the new heart failure indication.
Step 1
There are 2 possibilities, depending on the patient category:
Offer dual therapy – add ANY of the following to the existing monotherapy:
DPP-4 inhibitor (e.g. sitagliptin, linagliptin)
Sulfonylurea (e.g. gliclazide)
Pioglitazone
SGLT-2 inhibitor (e.g. dapagliflozin) (only if there is chronic heart failure / atherosclerotic CVD / QRISK >10%)
The only clear-cut indication to add a 2nd drug is if HbA1c ≥58 mmol/mol.
If the patient has an HbA1c that is above the agreed target (usually 48 mmol/mol) but is below 58 mmol/L → NICE guideline does NOT give a clean-cut recommendation
NICE says that intensification is guided by the individually agreed threshold and shared decision‑making
In practice, most local pathways treat this as a “grey zone” and recommend 1) optimise lifestyle, 2) up-titrate metformin to maximum dose (2g per day), 3) check adherence etc.
Note that if the patient is already established on dual therapy (metformin and SGLT-2 inhibitor) in step 1 (i.e. since they have chronic heart failure / atherosclerotic CVD / QRISK >10%), these patients would skip this step 2 stage if their HbA1c is above target.
Since they are already on dual therapy, they would move straight to step 3, if their HbA1c is above target.
Step 3
If dual therapy is not controlling HbA1c under the agreed target → consider either of the following:
Triple therapy (of oral medications)
Add ANY of the following to existing dual therapy (→ triple therapy):
DPP-4 inhibitor (e.g. sitagliptin, linagliptin)
Sulfonylurea (e.g. gliclazide)
Pioglitazone
SGLT-2 inhibitor (e.g. dapagliflozin) (only if there is chronic heart failure / atherosclerotic CVD / QRISK >10%)
Further step up (if triple therapy is still not meeting the target): consider switching 1 drug for a GLP-1 agonist (e.g. liraglutide, semaglutide) if:
BMI ≥35 kg/m2 + obesity associated medical or psychological problems, or
Insulin is not appropriate, or
Weight loss would benefit other significant obesity-related comorbidities
Insulin-based therapy
Choice of insulin:
1st line: human isophane insulin (NPH insulin) (once or twice daily basal insulin)
2nd line (1st line option not achieving control): basal bolus insulin regimenor use biphasic insulin twice daily
If patient needs assistance to inject insulin: use long-acting insulin (detemir / glargine)
Changes to existing oral diabetic medications
Metformin should be continued (unless contraindicated)
Review the need to continue other oral medications
SGLT-2 inhibitors are generally continued (due to cardio- and renal-protective effects)
Other oral agents are usually stopped to minimise the risk of hypoglycaemia
Type 2 Diabetes Mellitus (T2DM)
Background Information
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder caused by insulin resistance and relative insulin deficiency, leading to persistent hyperglycaemia and long-term microvascular and macrovascular complications.
Updated UKMLA guide to type 2 diabetes mellitus based on the latest NICE 2026 guideline: clinical features, complications, diagnosis, and the new comorbidity-guided management pathways.
Definition
T2DM is defined as a chronic metabolic disorder characterised by hyperglycemia resulting from a combination of peripheralinsulin resistance and relative insulin deficiency.
Cutaneous signs of peripheral insulin resistance: [Ref]
Acanthosis nigricans
Acrochordons (skin tags)
Central obesity
Be aware that the classic symptoms stated above are NOT specific to any type of diabetes. They are simply consequences of hyperglycaemia affecting various body systems.
Features / factors that suggest T2DM:
Associated with weight gain and obesity (unlike weight loss in T1DM)
If hyperglycaemia is confirmed by abnormal biochemical tests (below) +/- classic symptoms, and T2DM is suspected clinically, no further tests are needed to diagnose T2DM.
Be aware of features that are suggestive of T1DM (see this article for details on T1DM):
Ketosis
Rapid weight loss
Onset <50 y/o
BMI <25 kg/m2
Personal and/or family history of autoimmune disease
Diabetes mellitus diagnostic rules:
Typical symptoms + 1 abnormal test, or
Asymptomatic + 2 abnormal tests (same test on different day or 2 different tests on the same day)
The biochemical cut-offs for diagnosing diabetes mellitus are the same regardless of type:
Test
Diabetes Cut-off
Fasting plasma glucose
≥7.0 mmol/L
Random plasma glucose
≥11.1 mmol/L
2-hour post-oral glucose tolerance test
HbA1c
≥48 mmol/mol (6.5%)
A ‘finger prick’ capillary blood glucose level CANNOT be used to diagnose diabetes mellitus.
HbA1c Interpretation
HbA1c should not be used to diagnose diabetes mellitus in the following patient populations: [Ref]
All children and young people.
Pregnancy – current or recent (< 2 months).
Suspected type 1 diabetes, regardless of age
Short duration of diabetes symptoms (< 2 months)
Patients at high risk of diabetes who are acutely ill
Patients recently taking (for < 2 months) medication that may cause rapid glucose rise (e.g., corticosteroids, antipsychotic drugs)
Acute pancreatic damage or pancreatic surgery
Renal failure
Human immunodeficiency virus (HIV) infection
Causes of false HbA1c levels:
Falsely low HbA1c
Falsely high HbA1c
(↓ RBC lifespan → less time for glycation)
(↑ RBC lifespan → more time for glycation)
Acute blood loss
Haemolytic anaemia
Haemoglobinopathies
Pregnancy
Haemodialysis
Hypersplenism/Splenomegaly
Iron deficiency
Vitamin B12 / folate deficiency
Splenectomy
Alternative recommended tests if HbA1c monitoring is invalid (due to disturbed erythrocyte turnover, haemoglobinopathies or abnormal haemoglobin type):
Quality-controlled plasma glucose profiles
Total glycated haemoglobin estimation (especially useful if abnormal haemoglobin/haemoglobinopathies)
Blood fructosamine
Management (New 2026 Guideline)
A separate article is dedicated to the pharmacology and prescribing information for diabetes medications. See Diabetes Medications
Discourage the use of foods marketed specifically for people with diabetes
Advice on other aspects of healthy living:
Regular physical activity
Lose weight if overweight / obese
Whenever possible, offer individualised care and advice, taking the person’s needs, culture and beliefs. Be sensitive to their willingness to change and the effects on their quality of life.
For adults with overweight or obesity and type 2 diabetes, low-energy or very-low-energy diets may be appropriate. However, these should be delivered under medical supervision as part of a structured programme, and are not recommended universally for all patients.
Sick Day Rules
Sick day rules are specific instructions given to patients with diabetes (BOTH type I and II) during periods of acute illness (e.g. vomiting, gastroenteritis, upper or lower respiratory tract infections).
The purpose of these sick-day rules are to avoid acute complications like DKA. [Ref]
ALL diabetic patients
Increase frequency of monitoring blood glucose and ketones (blood – preferred / urine) to every 2-4 hours
Maintain hydration (at least 3L a day to prevent dehydration)
If normal / high blood glucose → drink water / carbohydrate-free fluids
If low blood glucose → carbohydrate-containing drinks + fast-acting carbohydrate
Maintain the person’s normal meal pattern, if possible
Replace normal meals with carbohydrate-containing drinks (e.g. milk, fruit juice, sugary drinks) if necessary (e.g. due to reduced appetite)
Patients who take insulin
NEVER stop insulin
Even if the patient is not eating or vomiting
Insulin dose would be maintained or require adjustment based on blood glucose and ketones
Patients who take oral medications
Most oral drugs are typically temporarily stopped during acute illness and restarted once the person is feeling better + eating and drinking for 24-28 hours
Metformin (due to risk of lactic acidosis)
SGLT-2 inhibitor and GLP-1 agonist (due to risk of euglycaemic DKA)
Sulfonylureas (due to risk of hypoglycaemia)
Not directly relevant, but other medications like ACE inhibitors, ARBs, diuretics, NSAIDs should also be stopped to reduce the risk of AKI (if there is a risk of dehydration)
Patient should be advised to seek medical advice for potential hospital admission if:
Hypoglycaemia (unable to maintain blood glucose >3.9 mmol/L)
Monitoring and Targets
Monitoring T2DM
T2DM should be monitored by measuring HbA1c levels:
Initially, every 3-6 months until HbA1c is stable on current therapy
Then, every 6 months once stable
If HbA1c monitoring is invalid due to disturbed erythrocyte turnover or abnormal haemoglobin type (see the diagnosis section – HbA1c interpretation for more detail), use one of the following:
Quality-controlled plasma glucose profiles
Total glycated haemoglobin estimation (if there are abnormal haemoglobins)
Fructosamine estimation
Do NOT routinely offer self-monitoring of capillary blood glucose levels, unless:
The patient is on insulin, or
There is evidence of hypoglycaemic episodes, or
The patient is on oral medication that may increase risk of hypoglycaemia while driving / operating machinery, or
The patient is pregnant or planning to become pregnant (see the Diabetes in Pregnancy article)
Blood Glucose Targets
Scenario
Target (HbA1c level)
Lifestyle measures (healthy living and diet alone) only
48 mmol/mol (6.5%)
Low hypoglycaemic risk therapy only (e.g. metformin)
Any therapy associated with hypoglycaemia risk (e.g. sulfonylureas, insulin)
53 mmol/mol (7.0%)
If HbA1c rises to ≥58 mmol/mol (7.5%) despite current therapy*
*In addition to increasing the target to 53 mmol/mol, these patients should also have their drug treatment intensified, as outlined in the anti-diabetic medication section below.
Blood glucose target should be individualised whenever possible.
For instance, some patients might benefit from relaxing the HbA1c target if:
Patients are unlikely to achieve long-term risk reduction benefits (e.g. patients with reduced life expectancy)
Tight blood glucose control would put them at high risk of developing hypoglycaemia (e.g. high risk of falls, impaired awareness of hypoglycaemia, patient drive / operate machinery as part of their job)
Pharmacological Management (Drug Choices and Algorithm)
Key Prescribing Principles
For patients who are already taking standard-release metformin:
If not tolerated or the patient prefers → switch to modified-release
Otherwise, it can be continued
Management of Symptomatic Hyperglycaemia
If a person has symptoms of hyperglycaemia (e.g. polyuria, polydipsia, weight loss):
Consider insulin or a sulfonylurea for rapid glucose lowering
Review and rationalise therapy once blood glucose is within the target range
This is typically a short-term strategy (temporary intensification) and does not replace comorbidity-guided pathway selection.
When more than one medication is indicated, they should be introduced in a stepwise manner, checking for tolerability and effectiveness of each medication.
NICE recommends the following:
Always introduce metformin first
If an SGLT-2 inhibitor is indicated → start once metformin is at the maximum tolerated dose
If a GLP-1 agonist or tirzepatide is indicated → start once the SGLT-2 inhibitor is at the maximum tolerated dose
SGLT-2 Inhibitors and Risk of Diabetic Ketoacidosis
Before starting an SGLT-2 inhibitor, assess for risk factors for DKA, including:
Previous episode of DKA
Acute intercurrent illness
Risk of dehydration / volume depletion
Very low carbohydrate / ketogenic diet
Where possible, address modifiable risk factors before initiating an SGLT-2 inhibitor.
Key Prescribing Cautions / Contraindications
NICE NG28 explicitly highlights the following:
Prescribing in renal impairment
Metformin is contraindicated if eGFR <30 mL/min/1.73 m²
Sulfonylureas should be avoided if eGFR <30 mL/min/1.73 m²
SGLT-2 inhibitors are generally avoided if eGFR <20 mL/min/1.73 m²
Medications with a significant risk of hypoglycaemia include sulfonylureas and insulin
GLP-1 agonist and tirzepatide
Should NOT be used during pregnancy (timing of discontinuation before pregnancy depends on the specific drug)
Should be stopped if the person becomes underweight (BMI <18.5 kg/m²)
Do not combine a GLP-1 receptor agonist or tirzepatide with a DPP-4 inhibitor
These drug-specific considerations should be applied alongside the treatment pathways below when selecting and escalating therapy.
For broader prescribing cautions / contraindications, see the Diabetes Medications article.
When more than one comorbidity is present, NICE does not specify a single priority pathway. Treatment should be individualised using shared decision-making, while applying relevant safety rules and contraindications.
In practice, many pathways align, particularly for heart failure, obesity, and CKD, which all recommend starting with metformin PLUS an SGLT-2 inhibitor.
IMPORTANT: atherosclerotic cardiovascular disease (ASCVD) pathway should be prioritised, when applicable.
If the patient develops ASCVD at any point after starting treatment, they should be switched to the ASCVD treatment pathway, regardless of their initial comorbidity group.
The ‘prioritised’ ASCVD pathway would involve:
Immediately add semaglutide (Ozempic) to existing therapy (regardless of HbA1c level)
Continue current medications
Further escalation if HbA1c remains ≥58 mmol/mol (7.5%), by adding one of the following:
Sulfonylurea, or
Pioglitazone, or
Insulin-based treatment
Beyond the ASCVD pathway priority rule, anti-diabetic treatment pathways depend on the presence of comorbidities.
What if more than one condition applies?
When more than one comorbidity is present, NICE NG28 does not specify a single priority pathway. Treatment should be individualised using shared decision-making, applying relevant safety rules and contraindications
In practice, many pathways align, particularly for heart failure, obesity, and chronic kidney disease, which all recommend starting with metformin PLUS an SGLT-2 inhibitor
No Relevant Comorbidities
When to step up: If HbA1c remains ≥58 mmol/mol (7.5%) despite current therapy → step up to the next treatment stage
Step
Treatment
If contraindicated / not tolerated
1
Dual therapy:
Metformin (modified-release), PLUS
SGLT-2 inhibitor
If metformin not appropriate → SGLT-2 inhibitor monotherapy
2
Add DPP-4 inhibitor
Proceed to Step 3
3
Add one of the following:
Sulfonylurea, or
Pioglitazone, or
Insulin-based treatment
Choose an alternative within this step
Obesity
When to step up: If HbA1c remains ≥58 mmol/mol (7.5%) despite current therapy → step up to the next treatment stage
Step
Treatment
If contraindicated / not tolerated
1
Dual therapy:
Metformin (modified-release), PLUS
SGLT-2 inhibitor
If metformin not appropriate → SGLT-2 inhibitor monotherapy
2
Add:
GLP-1 agonist, OR
Tirzepatide
Only add after ≥3 months of starting initial therapy
If GLP-1 agonist or tirzepatide not appropriate → add DPP-4 inhibitor instead
3
Add one of the following:
Sulfonylurea, or
Pioglitazone, or
Insulin-based treatment
Choose an alternative within this step
Chronic Kidney Disease
Chronic kidney disease is defined as abnormal kidney function / structure for ≥3 months, most commonly indicated by:
eGFR <60 mL/min/1.73 m², or
Markers of kidney damage (e.g. urinary ACR >3 mg/mmol, abnormal histology or imaging, history of kidney transplant)
When to step up: If HbA1c remains ≥58 mmol/mol (7.5%) despite current therapy → step up to the next treatment stage
Step
eGFR (mL/min/1.73m2)
Treatment
If contraindicated / not tolerated
1
≥30
Dual therapy:
Metformin (modified-release), PLUS
SGLT-2 inhibitor
If metformin not appropriate → SGLT-2 inhibitor monotherapy
20–30
Dual therapy:
DPP-4 inhibitor, PLUS
SGLT-2 inhibitor (specifically dapagliflozin or empagliflozin)
No alternative specified here
<20
Monotherapy:
DPP-4 inhibitor
If DPP-4 inhibitor not appropriate → pioglitazone OR insulin-based therapy
2
(all eGFR levels)
Add DPP-4 inhibitor (if not already used)
Proceed to Step 3
3
(all eGFR levels)
Add one of the following:
Sulfonylurea (if eGFR >30), or
Pioglitazone, or
Insulin-based treatment
Choose an alternative within this step
Heart Failure (Any Ejection Fraction)
When to step up: If HbA1c remains ≥58 mmol/mol (7.5%) despite current therapy → step up to the next treatment stage
Step
Treatment
If contraindicated / not tolerated
1
Dual therapy:
Metformin (modified-release), PLUS
SGLT-2 inhibitor
If metformin not appropriate → SGLT-2 inhibitor monotherapy
2
Add DPP-4 inhibitor
Proceed to Step 3
3
Add one of the following:
Sulfonylurea, or
Insulin-based treatment
Choose an alternative within this step
Pioglitazone is NOT mentioned in the heart failure pathway at all, reflecting its association with fluid retention and potential to worsen heart failure.
When to step up: If HbA1c remains ≥58 mmol/mol (7.5%) despite current therapy → step up to the next treatment stage
Step
Treatment
If contraindicated / not tolerated
1
Triple therapy of:
Metformin (modified-release), PLUS
SGLT-2 inhibitor, PLUS
Semaglutide (GLP-1 agonist)
If metformin not appropriate → SGLT-2 inhibitor + semaglutide
2
Add one of the following:
Sulfonylurea, or
Pioglitazone, or
Insulin-based treatment
Choose an alternative within this step
Early-Onset T2DM (<40 y/o)
Rationale of this new patient category:
Early-onset T2DM have a very high lifetime risk of cardiovascular and renal complications, largely due to longer disease duration and a higher prevalence of obesity
Therefore, early intensive treatment is recommended to reduce long-term complications
When to step up: If HbA1c remains ≥58 mmol/mol (7.5%) despite current therapy → step up to the next treatment stage
Step
Treatment
If contraindicated / not tolerated
1
Dual therapy:
Metformin (modified-release), PLUS
SGLT-2 inhibitor
Also consider early addition of GLP-1 agonist or tirzepatide
If metformin not appropriate → SGLT-2 inhibitor +/- GLP-1 agonist or tirzepatide
2
If NOT on GLP-1 agonist or tirzepatide → add GLP-1 agonist or tirzepatide
Otherwise (if already on GLP-1 agonist or tirzepatide) → move straight to Step 3
If GLP-1 agonist or tirzepatide not appropriate → add a DPP-4 inhibitor
3
Add one of the following:
Sulfonylurea (if eGFR >30), or
Pioglitazone, or
Insulin-based treatment
Choose an alternative within this step
Frailty
Frailty is a state of diminished physiological reserve and increased vulnerability to adverse health outcomes.
When to step up: If HbA1c remains ≥58 mmol/mol (7.5%) despite current therapy → step up to the next treatment stage
Step
Treatment
If contraindicated / not tolerated
1
All patients: offer metformin (modified-release)
Only offer SGLT-2 inhibitor in addition to metformin if the patient’s level of frailty does not place them at risk of adverse events (e.g. hypotension, dehydration)
If metformin not appropriate →
SGLT-2 inhibitor monotherapy, or
DPP-4 inhibitor monotherapy (if at risk of adverse events)
2
Add a DPP-4 inhibitor
Proceed to Step 3
3
Add one of the following:
Sulfonylurea, or
Pioglitazone, or
Insulin-based treatment
*Sulfonylureas and insulin carry a higher risk of hypoglycaemia and falls in frail adults and should be used with caution.
Choose an alternative within this step
This is the least objective treatment pathway for T2DM. Management in frail adults requires significant individualisation, with particular emphasis on minimising hypoglycaemia, falls, and polypharmacy.
NICE emphasis on the importance of medication review to ensure patients are taking the smallest effective number of medications, at the lowest effective dose.
Insulin-Based Treatment
For guidance on when to initiate insulin-based treatment, see the treatment pathway section above.
Choice of insulin
1st line: basal insulin regimen
If the HbA1c is ≥75 mmol/mol (9.0%) → consider a basal-bolus insulin regimen
Choosing insulin preparations
Once-daily basal insulin regimens may be particularly suitable where:
Patient prefers fewer daily injections
Concerns about nocturnal hypoglycaemia
Assistance with injections is required (e.g. a carer or healthcare professional)
Consider pre-mixed insulin if:
Patient prefers injecting insulin immediately before meals
Blood glucose rises markedly after meals
Hypoglycaemia is problematic
Changes to existing oral medications
Metformin should be continued (if the patient is taking it)
Stop any other medications that are being used solely for glycaemic control
Discuss with the person the risks and benefits of continuing medicines for other benefits (e.g. cardiovascular protection or weight management)
Monitoring
ALL patients on insulin should be offered self-monitoring using capillary blood glucose levels.
Intermittently scanned continuous glucose monitoring should be offered, if ANY of the following:
Recurrent hypoglycaemia / severe hypoglycaemia
Impaired hypoglycaemia awareness
Presence of a condition or disability (including a learning disability or cognitive impairment) that prohibits self-monitoring with capillary blood glucose monitoring
The patient would otherwise be advised to self-measure at least 8 times a day
Patients who are using continuous glucose monitoring will still need to take capillary blood glucose measurements, but less often. Click to see rationale.
Assessment and Management of Complications
Complication
Recommendations from NICE
Periodontitis
Advise patients that they are higher risk of gum disease, and that treating gum disease can improve blood glucose control
Advise regular oral health reviews
Offer dental appointments to treat periodontitis
Gastroparesis
Consider gastroparesis if there are:
Erratic blood glucose control, or
Unexplained bloating / vomiting
Management of vomiting caused by gastroparesis:
Alternating use of metoclopramide and erythromycin
Domperidone (most effective, but use with caution due to its cardiac risk)
Be aware that patients with autonomic neuropathy is at increased risk of orthostatic hypotension, particularly when using antihypertensives, volume-depleting drugs and TCA
Exact recommendation: offer if >30 mg/mmol and consider if >3 mg/mmol
DVLA and Diabetes Mellitus
The DVLA guidance on diabetes driving applies to both type 1 and 2 diabetes.
The guidance and restrictions mainly centre around insulin treatment and the occurrence of hypoglycemic episodes, therefore, it is more often applicable to those with T1DM.
When to Notify the DVLA
Inform the DVLA if:
Diabetes treated with insulin (type 1 / 2) – a must for all patients
Consider if taking medications that can cause hypoglycaemia (e.g. sulfonylurea)
When to Stop Driving
Situations to stop driving IMMEDIATELY and notify the DVLA if:
>1 episode of severe hypoglycaemia while awake in the past 12 months
Any episode of severe hypoglycaemiawhile driving
Patient developed impaired awareness of hypoglycaemia
Visual / peripheral sensation impairment that impairs driving
Starting insulin for less than 3 months may temporarily bar driving, pending medical advice and DVLA notification.
Blood Glucose Monitoring Requirement
For group 1 drivers (car or motorcycle):
Check blood glucose at least twice daily on days the person drives
Check blood glucose just before driving and at intervals no longer than two hours when driving longer journeys
For group 2 drivers (bus, lorry etc.):
Check blood glucose at least twice daily on both driving and non-driving days
Must provide 6 weeks of uninterrupted blood glucose records for annual license review
