Initial medicines

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Healthcare professionals should follow our general guidelines for people delivering care:

Read this guideline alongside the NHS Type 2 diabetes Path to Remission Programme.

See the visual summary for an overview of the recommendations and additional information to support medicine choice up to the point at which a person starts insulin-based treatment.

Recommendations in this section that cover dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagonlike peptide-1 (GLP-1) receptor agonists, sulfonylureas and sodium–glucose cotransporter-2 (SGLT-2) inhibitors refer to each of these groups of medicines at class level.

For GLP-1 receptor agonists, at the time of publication (February 2026) this only includes liraglutide, dulaglutide, and semaglutide. For subcutaneous semaglutide (Ozempic), this only includes doses up to 1 mg once a week.

SGLT-2 inhibitors and GLP-1 receptor agonists are recommended as much for their cardiovascular and renal benefits as for their glycaemic benefits (unless otherwise specified).

Healthcare professionals should also refer to the summary of product characteristics for individual medicines for contraindications and precautions to take in pregnancy and breastfeeding and for women, trans men and non-binary people of childbearing potential.

1.13 People with type 2 diabetes and no relevant comorbidities

1.13.1

For adults with type 2 diabetes and no relevant comorbidity, offer:

modified-release metformin, and
an SGLT-2 inhibitor. [2026]

1.13.2

If metformin is contraindicated or not tolerated, offer monotherapy with an SGLT-2 inhibitor. [2026]

For a short explanation of why the committee made the 2026 recommendations and how they might affect practice, see the rationale and impact section on initial medicines for people with type 2 diabetes and no relevant comorbidity.

Full details of the evidence and the committee's discussion are in:

1.14 People with heart failure (with any ejection fraction, unless specified)

1.14.1

For adults with type 2 diabetes and heart failure offer:

modified-release metformin, and
an SGLT-2 inhibitor. [2026]

1.14.2

If metformin is contraindicated or not tolerated, offer monotherapy with an SGLT-2 inhibitor. [2026]

Full details of the evidence and the committee's discussion are in:

1.15 People with atherosclerotic cardiovascular disease

1.15.1

For adults with type 2 diabetes and atherosclerotic cardiovascular disease, offer:

modified-release metformin, and
an SGLT-2 inhibitor, and
subcutaneous semaglutide (Ozempic), up to 1 mg once a week, for its cardiovascular, renal and glycaemic benefits. [2026]

1.15.2

If metformin is contraindicated or not tolerated, offer:

an SGLT-2 inhibitor, and
subcutaneous semaglutide (Ozempic), up to 1 mg once a week, for its cardiovascular, renal and glycaemic benefits. [2026]

Full details of the evidence and the committee's discussion are in:

1.16 People with early onset type 2 diabetes

1.16.1

For adults with early onset type 2 diabetes, offer modified-release metformin and an SGLT-2 inhibitor, and consider adding either:

a GLP-1 receptor agonist for its cardiovascular, renal and glycaemic benefits or
tirzepatide for its glycaemic benefits. [2026]

1.16.2

If metformin is contraindicated or not tolerated, offer an SGLT-2 inhibitor and consider adding either:

a GLP-1 receptor agonist for its cardiovascular, renal and glycaemic benefits or
tirzepatide for its glycaemic benefits. [2026]

Full details of the evidence and the committee's discussion are in:

1.17 People living with obesity

1.17.1

For adults with type 2 diabetes who are living with obesity, offer:

modified-release metformin and
an SGLT-2 inhibitor.

For a definition of obesity, see the section on classifying overweight and obesity in adults in NICE's guideline on overweight and obesity management. [2026]

1.17.2

If metformin is contraindicated or not tolerated, offer monotherapy with an SGLT-2 inhibitor. [2026]

Full details of the evidence and the committee's discussion are in:

1.18 People with chronic kidney disease

Medicines vary in their contraindications and precautions for use in people with renal impairment. See NICE's information on prescribing medicines and refer to the summary of product characteristics for individual products.

1.18.1

For adults with type 2 diabetes and an estimated glomerular filtration rate (eGFR) above 30 ml/min/1.73 m²:

Offer modified-release metformin and an SGLT-2 inhibitor.
If metformin is contraindicated or not tolerated, offer monotherapy with an SGLT-2 inhibitor. [2026]

1.18.2

For adults with type 2 diabetes and an eGFR of 20 ml/min/1.73 m² and up to 30 ml/min/1.73 m², offer:

either dapagliflozin or empagliflozin and
a DPP-4 inhibitor. [2026]

1.18.3

For adults with type 2 diabetes and an eGFR below 20 ml/min/1.73 m², consider a DPP-4 inhibitor. [2026]

1.18.4

If a DPP-4 inhibitor is contraindicated, not tolerated or not effective, consider:

pioglitazone or
an insulin-based treatment. [2026]

1.18.5

For guidance on managing other aspects of kidney disease in adults with type 2 diabetes, see NICE's guideline on chronic kidney disease. [2015]

Full details of the evidence and the committee's discussion are in:

1.19 People with frailty

1.19.1

For adults with type 2 diabetes and frailty:

Offer modified-release metformin.
Only offer an SGLT2 inhibitor 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). [2026]

1.19.2

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. [2026]

1.19.3

Consider reviewing the person's overall diabetes treatment plan to ensure that they are taking the smallest effective number of medications, at the lowest effective dosage.

For further guidance on making a treatment plan for people with frailty (including when associated with multimorbidity), see NICE's guidelines on clinically assessing and managing multimorbidity, medicines optimisation and shared decision making. [2026]

Full details of the evidence and the committee's discussion are in: