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.
NICE has produced a visual summary that provides an overview of the recommendations and additional information to support medicine choice up to the point at which a person starts insulin-based treatment.
Discuss dietary advice and other aspects of healthy living, such as increasing physical activity, alongside medicines to support adults with type 2 diabetes with their personalised diabetes management plan. For more information on how to achieve this see the:
Discuss the benefits and risks of each medicine treatment option with adults with type 2 diabetes and support them to make an informed decision about their treatment. Take into account the:
effect of each medicine on HbA1c and weight
effectiveness of each medicine at preventing and managing cardiovascular and renal conditions
factors that might prevent the person from following a specific treatment option (for example, pioglitazone is contraindicated for people with heart failure)
cost: when more than 1 medicine from the same drug class are equally suitable for the person, use the least expensive. [2015, amended 2026]
See also NICE's guideline on shared decision making and the section on safety of medicines for diabetes before and during pregnancy in NICE's guideline on diabetes in pregnancy.
If a person has more than one comorbidity (for example, atherosclerotic cardiovascular disease and obesity), make a shared decision with them about which comorbidity to prioritise when choosing medicines. Take into account:
medicines required for cardiovascular and renal protection (for example, subcutaneous semaglutide for people with atherosclerotic cardiovascular disease)
medicines that are contraindicated (for example, metformin for people with chronic kidney disease and an eGFR of less than 30 mL/min/1.73 m2)
any other medicines they are taking and at what dose, particularly if the person has frailty (see recommendations for people with frailty in the initial medicines section).
See also the recommendations on individualised care and NICE's guideline on multimorbidity. [2026]
When discussing GLP-1 receptor agonists and tirzepatide with women, trans men and non-binary people of childbearing potential, tell them:
what Medicines and Healthcare products Regulatory Agency (MHRA) guidance on GLP-1 medicines for weight loss and diabetes says about the use of GLP-1 receptor agonists and tirzepatide in pregnancy and breastfeeding
weight loss may improve fertility
effective contraception must be used while taking the medicine
that if they want to become pregnant, they should continue to use contraception for a period after stopping the medication (see MHRA guidance on GLP-1 medicines for weight loss and diabetes for specific length of time). [2026]
Use non-judgemental language in all medication discussions to support people with starting and adhering to treatment. For guidance on this, see NHS England's guide to language and diabetes [2026]
Continuing care is critical to ensuring good outcomes for people with type 2 diabetes. Therefore, the committee made a recommendation about advice on healthy living, including physical activity, losing weight, quitting smoking and drinking less alcohol. It also includes a link to the NHS Path to Remission programme, which is of great importance. While the committee did not find any evidence of using medicines to support remission, considering how to use medicines alongside the programme to support remission is key to preventing long-term adverse events.
The committee agreed that discussing the effects of each medicine ahead of time was important. They agreed the discussion should include the effectiveness of the medicine on glycaemic and cardiometabolic response, whether it has cardiovascular and renal protection benefits and any adverse effects or other problems that someone could experience and that could be a barrier to adherence. The committee agreed that working together in this way would help to promote concordance and improve long-term adherence, leading to better outcomes.
Guidance was agreed for when people have more than one comorbidity. For most people, initial therapy should consist of an SGLT‑2 inhibitor combined with modified‑release metformin, although metformin alone may be used when frailty makes SGLT‑2 inhibitors unsuitable. People with chronic kidney disease require kidney‑specific prescribing adjustments, which may involve dose changes, choosing SGLT‑2 inhibitors licensed for renal impairment or substituting metformin with a DPP‑4 inhibitor if appropriate. Early treatment with GLP‑1 receptor agonists may be appropriate for those at high cardiovascular or renal risk, with subcutaneous semaglutide (Ozempic), up to 1 mg once a week, recommended for people with atherosclerotic cardiovascular disease. Any GLP-1 receptor agonist or tirzepatide can be considered for early onset type 2 diabetes, with tirzepatide being considered for the glycaemic benefits.
The committee noted that there is a particular risk for women, trans men and non-binary people of childbearing potential in this group who take GLP-1 receptor agonists or tirzepatide. The committee agreed that the effects of such a medicine can lead to improved fertility. MHRA guidance on GLP-1 medicines recommends that GLP-1 receptor agonists and tirzepatide should not be taken during pregnancy and breastfeeding because there is not enough safety data to know whether doing this can cause harm. It also recommended that all people of childbearing potential should take steps to ensure they do not become pregnant while taking a GLP-1 receptor agonist or tirzepatide and for a duration after taking it (this duration depends on the specific medicine the person takes). The committee noted this was particularly important for people with early onset type 2 diabetes because of their age and this guideline's recommendations to consider GLP-1 receptor agonists or tirzepatide for this group.
The language healthcare professionals use can have an impact. People with type 2 diabetes can experience a lot of stigma in discussions about medications, even when healthcare professionals are not doing this intentionally. People can also struggle with stereotypes about diabetes and weight. This can lead to them feeling blame, shame and guilt, which can have a significant impact on their wellbeing. Stigma and stereotypes can also make it difficult for people to start or continue taking medication. The committee's experience was that this is quite common. So, it's important that particular efforts are being made to get the words right in conversations about medication. More guidance on communication for healthcare professionals can be found in NHS England's guide to language and diabetes.
Full details of the evidence and the committee's discussion are in
Improvements in long-term adherence lead to better outcomes. They are more likely if medicine options are discussed with the person using non-judgemental language. The person should feel involved in decisions made regarding their cardiometabolic targets and comorbidities.
Give clear sick day rules in each person's individualised treatment plan. Depending on the person's needs and the medicines they are taking, these rules may need to specify:
whether medicine should change (and how) if the person is unwell or is having surgery
whether any medicines should be stopped if there is a risk of dehydration, vomiting and diarrhoea (relevant for metformin, SGLT-2 inhibitors)
how to adjust insulin doses
how to restart medication after recovery. [2026]
Follow the MHRA's safety advice on monitoring ketones during SGLT-2 inhibitor treatment interruption.
Sick day rules are common in diabetes care, but in the committee's experience there are inconsistencies in practice. In particular, the committee have seen issues with people having medications stopped but not started again. The recommendation will improve consistency and quality of care in this area.
Full details of the evidence and the committee's discussion are in:
Including sick day rules in people's treatment plans may help avoid delays in providing the right medication and treating any underlying illness. This may reduce the chance of adverse events or shorten hospital stays (or avoid the need for a stay altogether), which would reduce costs.
Assess the person's current cardiovascular and renal status, and risk of developing cardiovascular disease in the future. [2022, amended 2026]
If frailty is a concern, assess for it before starting medicines.
See the recommendations on how to assess frailty in NICE's guideline on clinically assessing and managing multimorbidity. [2026]
The committee agreed it was important to assess people's cardiovascular status and risk to help determine which treatments are suitable for them. The definition they used for the established cardiovascular disease groups (adults with type 2 diabetes and chronic heart failure or established atherosclerotic cardiovascular disease) reflects the people included in all the clinical trials and modelled as a subgroup in the economic model.
Adverse treatment effects and polypharmacy are a particular concern for people with frailty. The committee did not review the evidence on specific criteria that should trigger a frailty assessment, so healthcare professionals will need to use clinical judgement for this.
Full details of the evidence and the committee's discussion are in:
Assessing for cardiovascular risk and frailty before initiating medicines may reduce the need for additional appointments further down the treatment pathway for:
cardiovascular and renal comorbidities or
concerns regarding frailty and adverse events.
This is because it will ensure that a person takes medicines most suited to their personal situation from the start.
Commissioners, providers and healthcare professionals should address inequalities in SGLT-2 inhibitor access and uptake by:
monitoring who is using SGLT-2 inhibitors
identifying groups who are eligible but who have a lower uptake
making plans to engage with these groups to encourage them to use SGLT-2 inhibitors. [2026]
Analysis showed that, for people with type 2 diabetes who are eligible to receive SGLT-2 inhibitors, the uptake was low considering it was recommended by NICE since 2022. This was associated with age, gender, ethnicity and areas of deprivation. To address this issue, the committee made a recommendation outlining actions for commissioners, providers and healthcare professionals to identify those who are eligible to receive SGLT-2 inhibitors but who are currently not taking them, and to encourage them to do so. Achieving higher and more equal uptake of SGLT-2 inhibitors will mean that people living in the most deprived areas will experience greater net benefits.
This, combined with the recommendation for research to assess how prescribing and access to SGLT-2 inhibitors can be improved for people with type 2 diabetes from the most deprived groups, may help to address health inequalities.
Full details of the evidence and the committee's discussion are in:
The recommendation will encourage the assessment of SGLT-2 inhibitor uptake in different groups of people to ensure universal access to treatment. This would increase the number of people taking SGLT-2 inhibitors and help to address health inequalities. This may require additional resources to make interventions to support people in more deprived areas. However, this is more likely to reduce poor outcomes in the long term by supporting people who are more likely to experience adverse health outcomes.