Type 2 diabetes in adults: choosing medicines for first line and further treatment

Oct 13, 2026

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Guidance for adults with type 2 diabetes on selecting, reviewing, and changing medicines within individualized treatment plans. It emphasizes shared decision-making by discussing benefits, risks, effects on HbA1c and weight, cardiovascular and renal protection, contraindications, and medication cost. During review, current regimens are optimized before switching, with consideration of adverse effects, dose/formulation, adherence, diet advice, and diagnostic reassessment when response is atypical. It also specifies when to continue or stop certain drug classes, and provides decision logic for people already on standard-release metformin and for key comorbidities such as obesity.

LanguageEnglish

CategoryGeneral

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Selecting medicines

Shared decision-making

Reviewing and changing treatments

Medication pathways and key rules

Standard-release metformin

SGLT-2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors

Stopping and avoiding combinations

Special considerations for comorbidities (e.g., obesity)

Type 2 diabetes in adults: choosing, reviewing and changing medicines | Diet and healthy living advice | | --- | | At each point, reinforce advice about diet and other aspects of healthy living (also see the NICE guideline on overweight and obesity and the NHS better health website ) . | | Involving people in medicine discussions | | --- | | 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.
If a person has more than one comorbidity (for example, atherosclerotic cardiovascular disease and obesity; see recommendation 1.9.3 ), 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 (Ozempic) 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 m 2), and 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 ) .
Give clear sick day rules in each person’s individualised treatment plan (also see the guideline section on sick day rules ) . | | Reviewing medicines | | --- | | When reviewing treatments, make a shared decision about changes with the person with type 2 diabetes. See the recommendations on involving people in medicine discussions. Optimise their current treatment regimen before changing treatments, taking into account factors such as:
• adverse effects
• prescribed doses and formulations
• adherence to, and management of, existing medicines
• the need to revisit advice about diet and healthy living.
If response to medicines suggests that type 2 diabetes might not be the correct diagnosis, see the recommendations on initial diagnosis and revisiting initial diagnosis in NICE's guideline on managing type 1 diabetes.
If the person has reached their individualised glycaemic and weight targets (as defined in NICE's guideline on overweight and obesity ), consider continuing any medicines that have contributed to this.
Consider continuing SGLT-2 inhibitors for their cardiovascular or renal benefits, even if they do not help the person reach their individualised glycaemic targets.
Stop GLP-1 receptor agonists or tirzepatide if:
• the person becomes underweight (BMI under 18.5 kg/m2), or
• they do not help the person reach their individualised glycaemic targets and they are not being taken for their cardiovascular benefits.
Do not offer a GLP-1 receptor agonist or tirzepatide and a DPP-4 inhibitor together to treat type 2 diabetes. | | People already on standard-release metformin | | --- | | Continue standard-release metformin if it is effective. Switch to modified-release metformin if standard-release metformin is not tolerated, or this is the person's preference. | This diagram covers only part of the guideline content. For full details, see NG28 Type 2 diabetes in adults: management.© NICE 2026. All rights reserved. Subject to Notice of rights. Last updated September 2026. ISBN 978-1-4731-9709-1. Type 2 diabetes in adults: choosing medicines for first line and further treatment ! For all medications: • Start medications sequentially, not simultaneously • Only move on to the next step having re

FAQs

How does the guidance support shared decision-making when choosing medicines?

It asks clinicians to discuss benefits and risks of each option and involve adults in informed decisions. Factors include effects on HbA1c and weight, cardiovascular and renal effectiveness, contraindications affecting eligibility, and cost when alternatives are equally suitable.

What principles should be followed when reviewing treatments before changing medicines?

The guidance recommends making shared decisions about changes and optimizing the current regimen first. It highlights adverse effects, prescribed doses and formulations, adherence and management, and revisiting diet and healthy living advice.

When should GLP-1 receptor agonists or tirzepatide be stopped?

They should be stopped if the person becomes underweight (BMI under 18.5 kg/m2), or if they do not help achieve individualized glycaemic targets and are not being taken for cardiovascular benefits.

Oct 13, 2026

Upload by SANS