Diabetes Mellitus: Management of Type 2

Key points

• NICE NG28 (Feb 2026) changed first-line therapy: offer modified-release metformin PLUS an SGLT2 inhibitor as first-line dual therapy for most people with type 2 diabetes needing glucose-lowering treatment, unless contraindicated — not metformin alone.
• Established atherosclerotic CVD → consider triple first-line therapy: MR metformin + SGLT2 inhibitor + subcutaneous semaglutide · early-onset T2DM (diagnosed < 40 y) → consider MR metformin + SGLT2 inhibitor + a GLP-1 receptor agonist or tirzepatide.
• Introduce medicines stepwise — start metformin to check tolerability, then add the SGLT2 inhibitor · use MR metformin in preference to standard-release · assess DKA risk factors before starting an SGLT2 inhibitor, and give sick-day rules including how to restart after recovery.
• HbA1c targets: 48 mmol/mol (6.5%) on lifestyle or a drug not associated with hypoglycaemia · 53 mmol/mol (7.0%) once on a drug that can cause hypoglycaemia (e.g. sulfonylurea) · relax the target in frailty. Individualise through shared decision-making.
• Later intensification: prioritise semaglutide, another GLP-1 RA or tirzepatide where recommended · a DPP-4 inhibitor may be added if further glucose lowering is needed (do not combine with a GLP-1 RA or tirzepatide) · then pioglitazone (not in heart failure), a sulfonylurea (if eGFR > 30) or insulin.
• Dietary advice: high-fibre low-GI carbohydrates · low-fat dairy and oily fish · limit saturated and trans fats · discourage foods marketed as "diabetic" · initial weight-loss target 5-10%.

Decision points in this pathway

• Established atherosclerotic cardiovascular disease?
• Early-onset type 2 diabetes (diagnosed under 40)?
• HbA1c above the agreed individual target despite first-line therapy?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.