The National Institute for Health and Care Excellence (NICE) has released a major update to NG28, the guideline for the management of type 2 diabetes in adults. This is the most significant shift in prescribing strategy since the original guideline was introduced.
The update reflects a growing evidence base demonstrating that diabetes treatments must do more than lower HbA1c. Cardiovascular protection, renal preservation, and early risk reduction are now central to treatment decisions.
This article summarises the key changes and what they mean for clinical practice.
1. SGLT2 inhibitors are now part of first-line therapy
The most important change is that SGLT2 inhibitors have moved from second-line to first-line treatment in most patients.
NICE now recommends offering:
Modified-release metformin together with an SGLT2 inhibitor
This applies to adults with type 2 diabetes regardless of whether they have established cardiovascular disease, obesity, or chronic kidney disease.
This reflects strong evidence that SGLT2 inhibitors reduce:
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Heart failure hospitalisation
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Progression of chronic kidney disease
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Cardiovascular mortality
This marks a clear shift from a glucose-centric model to a cardio-renal protection model.
2. Triple therapy is now recommended first-line in cardiovascular disease
For patients with established atherosclerotic cardiovascular disease, NICE now recommends starting:
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Modified-release metformin
-
An SGLT2 inhibitor
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Semaglutide
This represents a major change. Previously, GLP-1 receptor agonists were introduced later in the treatment pathway.
The rationale is clear: early cardiovascular risk reduction improves long-term outcomes.
3. Early-onset type 2 diabetes now has its own treatment pathway
For the first time, NICE has introduced specific recommendations for adults diagnosed before the age of 40.
These patients should be offered:
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Modified-release metformin
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An SGLT2 inhibitor
And clinicians should consider early addition of:
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A GLP-1 receptor agonist
or -
Tirzepatide
This reflects the more aggressive disease progression and higher lifetime cardiovascular risk in this group.
4. Tirzepatide is now included in NICE guidance
Tirzepatide has been formally incorporated into the treatment pathway.
It can now be considered:
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In early-onset type 2 diabetes
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In obesity
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When further glycaemic control is required
This reflects its significant effects on glycaemic control and weight reduction.
5. Expanded treatment options in chronic kidney disease
NICE has broadened treatment options for patients with reduced renal function.
For patients with an eGFR between 20 and 30:
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Dapagliflozin or empagliflozin can now be used
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Alongside a DPP-4 inhibitor
This is a major change, as these therapies were previously restricted at lower kidney function levels.
This provides clinicians with more options to protect renal function.
6. Frailty-specific prescribing guidance introduced
A new frailty pathway has been introduced.
In patients with frailty:
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Modified-release metformin is recommended first-line
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SGLT2 inhibitors should be used cautiously
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DPP-4 inhibitors may be preferred where safety is a concern
This reflects the importance of balancing benefit and risk in vulnerable populations.
7. Cardiovascular and renal protection now central to prescribing
The guideline explicitly states that SGLT2 inhibitors and GLP-1 receptor agonists should be used not only for glycaemic control, but also for cardiovascular and renal protection.
Importantly, NICE now recommends continuing SGLT2 inhibitors even when glycaemic targets are achieved, if cardiovascular or renal benefit is present.
8. New safety and prescribing recommendations
Several new safety recommendations have been introduced:
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Do not prescribe a GLP-1 receptor agonist together with a DPP-4 inhibitor
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Stop GLP-1 receptor agonists or tirzepatide if ineffective
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Provide clear sick-day guidance, particularly for metformin and SGLT2 inhibitors
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Assess cardiovascular risk, renal function, and frailty before starting treatment
These changes aim to improve safety and individualise care.
What this means for clinical practice
The NICE 2026 update represents a fundamental shift in the management of type 2 diabetes.
Treatment is no longer focused solely on reducing HbA1c.
Instead, clinicians must consider:
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Cardiovascular risk
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Kidney protection
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Weight
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Frailty
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Long-term outcomes
In practical terms, most newly diagnosed patients should now be started on:
Modified-release metformin and an SGLT2 inhibitor
This represents a major evolution in diabetes care.
Conclusion
The 2026 NICE update reflects modern evidence and represents a move towards earlier, more effective intervention.
These changes will improve patient outcomes by reducing cardiovascular events, slowing kidney disease progression, and supporting safer prescribing.
For prescribers, it is essential to understand and apply these updates to ensure best practice.
For Further Information visit: https://www.nice.org.uk/guidance/ng28
