Type 2 Diabetes Mellitus: NICE NG 28

This implementation guide is aimed for use by healthcare professionals within NHS South West London to support them with diagnosis and management of their type 2 diabetes mellitus (T2DM) patients.

Background

The updated NICE NG28: Type 2 diabetes in adults: management reflects increasing evidence that management of type 2 diabetes should focus not only on glycaemic control, but also on long-term cardiovascular, renal and heart failure outcomes.

The guideline places greater emphasis on treatment selection according to the presence of common comorbidities such as:

  • atherosclerotic cardiovascular disease (ASCVD)
  • chronic kidney disease (CKD)
  • heart failure
  • obesity
  • frailty

Treatment should remain individualised, with shared decision making central to care. This update primarily relates to pharmacological management. Other aspects of diabetes care, including lifestyle advice, blood glucose monitoring and personalised HbA1c targets, remain important and continue to underpin good diabetes management.

The updated guideline aligns diabetes management more closely with existing cardiovascular, renal, heart failure and obesity pathways, supporting a more joined-up long-term conditions approach.

South West London Prescribing Considerations

This information is intended as a local South West London implementation guide to support interpretation of NICE NG28 and highlight key prescribing considerations relevant to local formulary choices  and preferences. It should be used alongside the full NICE NG28 guideline, which remains the definitive source of detailed recommendations and supporting evidence.

Within South West London

  • Generic dapagliflozin is the first-line sodium-glucose cotransporter-2 (SGLT-2) inhibitor where an SGLT-2 inhibitor is indicated and clinically appropriate.
  • Generic sitagliptin is the first-line dipeptidyl peptidase (DPP-) inhibitor where a DPP-4 inhibitor is indicated.
  • Routine switching of patients stable on immediate-release metformin to modified-release metformin is not recommended.
  • Where people subsequently develop established ASCVD, consider addition of subcutaneous semaglutide (Ozempic®) up to 1 mg once weekly, except where frailty or individual clinical circumstances make escalation inappropriate.

Prescribing considerations for common comorbidites

The following sections summarise key prescribing considerations for common comorbidities and clinical scenarios within type 2 diabetes management.

No significant co-morbidities

  • Earlier combination therapy with modified-release metformin and an SGLT-2 inhibitor is recommended.
  • Use modified-release metformin for new initiations where appropriate due to improved gastrointestinal tolerability. People who are well controlled on, and tolerate immediate-release metformin should not be routinely switched to a  modified-release formulation.

Chronic kidney disease (CKD)

  • eGFR greater than 30 ml/min/1.73m², use modified-release metformin alongside an SGLT-2 inhibitor where tolerated.
  • eGFR 20 to 30 ml/min/1.73m², consider a DPP-4 inhibitor in combination with dapagliflozin or empagliflozin.
  • eGFR less than 20 ml/min/1.73m², consider a DPP-4 inhibitor; where not appropriate, consider pioglitazone or insulin-based treatment.
  • Sulfonylureas should generally only be considered where eGFR remains greater than 30 ml/min/1.73m².

Heart failure

  • SGLT-2 inhibitors are recommended for people with heart failure irrespective of ejection fraction.
  • Where metformin is contraindicated or not tolerated, an SGLT-2 inhibitor may be used alone.
  • Prescribing should consider renal function, volume status and risk of hypotension or dehydration.

Atherosclerotic cardiovascular disease (ASCVD)

  • Earlier use of subcutaneous semaglutide (Ozempic®) up to 1 mg once weekly alongside metformin and an SGLT-2 inhibitor is recommended in established ASCVD.
  • Treatment decisions should prioritise cardiovascular risk reduction alongside glycaemic control and individualised HbA1c targets.

Early-onset type 2 diabetes (age less than 40 years)

Earlier consideration of a glucogonlike peptide-1 (GLP-1) receptor agonist or tirzepatide is recommended due to increased lifetime cardiometabolic risk associated with younger-onset disease.

Obesity

  • Following at least 3 months of initial therapy and ongoing lifestyle interventions, consider addition of a GLP-1 receptor agonist or tirzepatide where additional glycaemic control is required.
  • Lifestyle intervention and weight management support should remain foundational alongside medicines optimisation.
  • Where GLP-1 receptor agonists or tirzepatide are not appropriate, consider a DPP-4 inhibitor before escalation to sulfonylurea, pioglitazone or insulin-based treatment.

Frailty

  • Only use SGLT-2 inhibitors where frailty does not place the person at increased risk of adverse effects such as hypotension, dehydration or falls.
  • Where metformin is contraindicated or not tolerated, consider either an SGLT-2 inhibitor or DPP-4 inhibitor depending on overall frailty and adverse event risk.
  • Regular medication review is recommended to minimise treatment burden and ensure use of the lowest effective number and dose of medicines.
  • Consider the increased risk of hypoglycaemia and falls when prescribing sulfonylureas or insulin-based treatment.

References

V1 approved by SWL Integrated Medicines Optimisation Committee (IMOC) July 2026.