How to introduce 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.

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.

1.20 Introducing medicines in a stepwise manner

1.20.1

Introduce medicines in a stepwise manner, checking for tolerability and effectiveness of each medicine. [2015]

1.20.2

When an adult with type 2 diabetes starts initial therapy with metformin and one or more other medicines:

introduce the medicines one at a time, starting with metformin and checking tolerability
if using an SGLT-2 inhibitor, start this as soon as metformin is at the maximum tolerated dose
if using a GLP-1 receptor agonist or tirzepatide, start this as soon as the SGLT-2 inhibitor is at the maximum tolerated dose.

For guidance on how to prevent any negative impact on the person's eyes from starting blood glucose lowering treatment, see the section on effects of a rapid reduction in HbA1c in NICE's guideline on diabetic retinopathy. [2022, amended 2026]

1.21 Preventing diabetic ketoacidosis when taking SGLT-2 inhibitors

1.21.1

Before starting an SGLT-2 inhibitor, check whether the person may be at increased risk of diabetic ketoacidosis (DKA), for example if they:

have had a previous episode of DKA
are unwell with intercurrent illness
are at risk of dehydration or volume depletion
are following a very low carbohydrate or ketogenic diet. [2022, updated 2026]

1.21.2

Address modifiable risks of DKA before starting an SGLT-2 inhibitor. For example, people who are following a very low carbohydrate or ketogenic diet may need to delay treatment until they have changed their diet. [2022]

1.21.3

Advise adults with type 2 diabetes who are taking an SGLT-2 inhibitor that a very low carbohydrate or ketogenic diet would increase their risk of DKA and so:

they should speak with their healthcare professional before starting such a diet, and
their SGLT-2 inhibitor treatment may need to be suspended for the duration of the diet. [2022]

For a short explanation of why the committee made the 2022 recommendations and how they might affect practice, see the rationale and impact section on how to introduce medicines.

Full details of the evidence and the committee's discussion are in evidence review B: pharmacological therapies with cardiovascular and other benefits in people with type 2 diabetes.