FRCA Notes

NICE Guidance on Type 2 Diabetes Medicines

Resources

  • NICE NG28 sets out how to choose, start and change medicines for adults with type 2 diabetes
  • Its 2026 update places greater emphasis on drugs with cardiovascular and renal benefit, chosen according to comorbidity
  • Insulin and its regimens are covered on the insulin page

  • Reinforce diet and healthy living advice at every stage
  • Make shared decisions, considering each drug's effect on HbA1c and weight, its cardiorenal benefits, contraindications and cost
  • Where more than one comorbidity exists, agree which to prioritise when choosing medicines
  • Give clear sick day rules in each individualised treatment plan

Starting and titrating

  • Start medicines sequentially, not simultaneously
  • Only move to the next step having reached and confirmed the maximum tolerated dose of the current medicine
  • If symptomatic hyperglycaemia occurs at any stage, consider insulin-based treatment or a sulphonylurea, and review once glucose is within target

  • Assess cardiovascular status and risk, renal status and frailty
  • For most people: modified-release metformin and an SGLT2 inhibitor
    • If metformin is contraindicated or not tolerated, offer an SGLT2 inhibitor alone

Comorbidity Initial treatment Further treatment if needed
None Metformin + SGLT2 inhibitor Add a DPP-4 inhibitor; then a sulphonylurea, pioglitazone or insulin
Atherosclerotic cardiovascular disease Metformin + SGLT2 inhibitor + subcutaneous semaglutide (up to 1mg weekly) Add a sulphonylurea, pioglitazone or insulin
Heart failure Metformin + SGLT2 inhibitor Add a DPP-4 inhibitor; then a sulphonylurea or insulin (pioglitazone contraindicated)
Obesity Metformin + SGLT2 inhibitor Consider a GLP-1 RA or tirzepatide after ≥3 months; DPP-4 inhibitor if these are unsuitable
Early onset (before age 40) Metformin + SGLT2 inhibitor; consider adding a GLP-1 RA or tirzepatide Add a sulphonylurea, pioglitazone or insulin
CKD, eGFR ≥30 Metformin + SGLT2 inhibitor Consider a DPP-4 inhibitor; then pioglitazone, a sulphonylurea or insulin
CKD, eGFR 20-30 DPP-4 inhibitor + dapagliflozin or empagliflozin Consider pioglitazone or insulin
CKD, eGFR <20 Consider a DPP-4 inhibitor Consider pioglitazone or insulin
Frailty Metformin; add an SGLT2 inhibitor only if not at risk of adverse effects (e.g. hypotension) Consider a DPP-4 inhibitor; take into account hypoglycaemia and falls with sulphonylureas and insulin

  • If atherosclerotic cardiovascular disease develops after starting treatment, add subcutaneous semaglutide
  • At the time of publication, 'GLP-1 receptor agonist' refers to liraglutide, dulaglutide and semaglutide

  • Optimise the current regimen before changing treatment, considering adverse effects, doses, formulations, adherence and lifestyle
  • If the response suggests type 2 diabetes may not be the correct diagnosis, revisit it
  • Continue medicines that have helped the person reach their glycaemic and weight targets
  • Consider continuing SGLT2 inhibitors for their cardiovascular or renal benefits even if they do not help reach glycaemic targets
  • Switch from standard- to modified-release metformin if not tolerated, or by preference

Stopping

  • Stop GLP-1 RAs or tirzepatide if:
    • The person becomes underweight (BMI <18.5kg/m2), or
    • They do not help reach glycaemic targets and are not being taken for cardiovascular benefit
  • Do not offer a GLP-1 RA or tirzepatide together with a DPP-4 inhibitor
  • In frailty, review the plan to use the smallest effective number of medicines at the lowest effective dose