NICE NG28 Update, February 2026: Metformin Plus an SGLT2 Inhibitor Is the New Starting Point

NICE updated NG28 on 18 February 2026. It is the biggest change to UK type 2 diabetes prescribing in years — though not the one a quick reading suggests. Metformin has not been replaced. What changed is that, for most adults, an SGLT2 inhibitor is now started alongside metformin from diagnosis, rather than added later once cardiovascular or renal risk has been assessed.

This post is a plain-English summary for busy clinicians. The authoritative source is the NICE guideline itself. We summarise; we do not replace NICE, and nothing here substitutes for clinical judgement on individual patients.

The headline change

For more than a decade, NG28 started most adults on metformin alone, with an SGLT2 inhibitor added second-line — or earlier where cardiovascular or renal risk was established. The February 2026 update brings that second drug forward to the point of diagnosis.

Under the updated NG28, the default for an adult with no relevant comorbidities is modified-release metformin and an SGLT2 inhibitor, together, from the start. Metformin remains the foundation of treatment; the SGLT2 inhibitor is no longer something to add once risk is assessed, but part of the initial offer for most people. An SGLT2 inhibitor on its own is reserved for the narrower group in whom metformin is contraindicated or not tolerated.

Two smaller changes travel with it. Metformin is now specified as the modified-release formulation for most people (standard-release remains an option, for example where swallowing is difficult). And the GLP-1 receptor agonists and tirzepatide move earlier in the pathway, with fewer restrictions.

NICE's rationale is the accumulated trial evidence: SGLT2 inhibitors have become cardio- and reno-protective agents with a glucose-lowering effect, and the committee also noted their under-use — particularly in women, older people, some ethnic groups, and more deprived populations.

What the pathway now says

The 2026 update sets out initial treatment by comorbidity.

• No relevant comorbidities — offer modified-release metformin and an SGLT2 inhibitor.
• Chronic heart failure — offer modified-release metformin and an SGLT2 inhibitor.
• Established atherosclerotic cardiovascular disease — offer modified-release metformin and an SGLT2 inhibitor, and add subcutaneous semaglutide (up to 1 mg once weekly).
• Metformin contraindicated or not tolerated — offer an SGLT2 inhibitor as monotherapy.

Beyond initial treatment, GLP-1 receptor agonists and tirzepatide are positioned earlier:

• Early-onset type 2 diabetes — consider adding a GLP-1 receptor agonist or tirzepatide.
• Type 2 diabetes with obesity — consider adding a GLP-1 receptor agonist or tirzepatide after at least three months of initial therapy, in line with NICE's obesity guidance (NG246).
• DPP-4 inhibitors remain an option for people without obesity, cardiovascular disease, or early-onset diabetes; sulfonylureas and pioglitazone sit as alternatives where the newer agents are unsuitable.

Intensification is still driven by individualised HbA1c targets rather than a single threshold.

What hasn't changed

Lifestyle modification remains the foundation — structured education, weight management, physical activity, and dietary advice carry the same weight as before. Individualised HbA1c targets are retained: 48 mmol/mol (6.5%) for adults on monotherapy or where hypoglycaemia risk is low, and 53 mmol/mol (7.0%) on combination therapy or where hypoglycaemia risk is significant, with lower ambition accepted for older adults and those with significant comorbidity.

And metformin, far from being deprecated, remains the first drug for most people. Existing patients stable on metformin monotherapy with a normal risk profile and HbA1c at target do not need their regimen changed simply because the guideline has moved: the new default applies to new prescribing decisions, with existing therapy reviewed as usual.

What this means for UK primary care

The practical shift is at two points. For new diagnoses, the default is now two drugs, not one — modified-release metformin and an SGLT2 inhibitor, with semaglutide added where there is established cardiovascular disease. For the existing register, the update is a prompt to find adults on metformin monotherapy, particularly those with cardiovascular or renal disease, who would now be candidates for an SGLT2 inhibitor.

Every SGLT2 initiation still needs its safety framework: a documented foot check, written sick-day rules covering dehydration and euglycaemic DKA, and ketone advice for those at higher risk. Local formularies already list a preferred SGLT2 inhibitor (commonly dapagliflozin or empagliflozin); check local guidance and the BNF for agent choice and dosing before prescribing.

The practical companion

For the operational detail — agent choice, eligibility, cautions, and the initiation workflow at the appointment level — see our longer companion post: SGLT2 inhibitors in UK primary care 2026: what NICE NG28 means in practice.

Related reading

• SGLT2 inhibitors in UK primary care 2026: the practical prescribing guide — the operational companion to this summary: agents, eligibility, cautions, and the initiation workflow.
• Tirzepatide in the GP QOF 2026/27 — the year's other major primary-care prescribing change.
• Semaglutide for cardiovascular risk (NICE TA1152) — semaglutide for atherosclerotic cardiovascular disease, the same drug NG28 now adds for that group.
• SGLT2 inhibitors for CKD in UK primary care 2026 — the same drug class for kidney protection, including CKD without diabetes.
• Statins and CVD prevention in UK primary care 2026 — lipid management in the same high-cardiovascular-risk population.

A note on what this post is — and is not

This is a guideline summary for awareness. It is not a substitute for the NICE guideline itself, the BNF, or local prescribing policy. Where there is doubt, NICE's published visual summary at nice.org.uk/guidance/ng28 and the BNF entry for each agent should be consulted. Clinical decisions remain the responsibility of the prescribing clinician.

The Monday Clinical Brief publishes weekly summaries of the most important new papers and guideline updates across 31 UK medical specialties. We do not replace the source documents. We surface them, summarise them, and link to them — so the practice-changing material does not get missed in a busy clinical week.

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