NICE NG28 Update February 2026: SGLT2 Inhibitors Move to First-Line for Most Adults with Type 2 Diabetes

NICE updated NG28 on 18 February 2026. It is the biggest change to UK type 2 diabetes prescribing in years. The short version: SGLT2 inhibitors are now first-line for almost every adult diagnosed with type 2 diabetes, with metformin reserved for the narrow group who cannot tolerate or use them.

This post is a plain-English summary for busy clinicians. The authoritative source is the NICE guideline itself, and the NICE visual summary is the single best ten-minute read on the update. 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, NICE NG28 has framed metformin as default first-line therapy in type 2 diabetes, with SGLT2 inhibitors added second-line or earlier when cardiovascular or renal risk was established. The February 2026 update inverts that default.

Under the updated NG28, an SGLT2 inhibitor is the first-choice oral agent for almost all adults newly diagnosed with type 2 diabetes. Metformin remains a legitimate first-line option — but as an alternative for patients with a contraindication or intolerance to SGLT2 therapy, not as the routine default. For many patients, particularly those with established cardiovascular disease, heart failure, chronic kidney disease, or a high pre-treatment HbA1c, both agents can be initiated together at the point of diagnosis.

NICE's rationale is the accumulated trial evidence. SGLT2 inhibitors have, over the last ten years, shifted from glucose-lowering agents with cardiovascular signals to cardio- and reno-protective agents with a glucose-lowering side effect. The 2026 NG28 update brings the position statement into line with how most diabetologists have already been prescribing.

What's actually new in the pathway

Four practical things have changed.

First-line drug choice. An SGLT2 inhibitor is the first-line agent. Metformin moves to "alternative first-line" status with explicit reasons for use (SGLT2 contraindication, intolerance, or established preference). This matters most in primary care, where the default prescribing decision now flips.

Combination at diagnosis. NICE NG28 2026 explicitly supports starting an SGLT2 inhibitor and metformin together at the time of diagnosis for patients with HbA1c well above target, cardiovascular comorbidity, or chronic kidney disease with an eGFR within the licensed range. Sequential introduction remains acceptable; the change is that simultaneous initiation is now endorsed rather than implied.

Cardiorenal protection as a primary indication. The updated guideline treats cardiorenal benefit as a primary therapeutic goal, not a secondary consideration after glycaemic control. Patients with type 2 diabetes plus heart failure, established atherosclerotic cardiovascular disease, or CKD stages 3–4 are explicitly prioritised for SGLT2 initiation regardless of baseline HbA1c.

Foot care, ketone counselling, and sick-day rules. The safety framework around SGLT2 prescribing has been strengthened. Every initiation should include a documented foot examination, written sick-day rules (specifically around dehydration and euglycaemic DKA), and ketone-testing advice for patients at higher risk. These are not new clinical concepts — but they are now codified as part of the initiation pathway.

What hasn't changed

The HbA1c targets are unchanged. 48 mmol/mol (6.5%) remains the target for adults on monotherapy or where hypoglycaemia risk is low. 53 mmol/mol (7.0%) remains the target for those on combination therapy or with established hypoglycaemia risk. Individualised targets are still endorsed for older adults and those with significant comorbidity.

Lifestyle modification is still the foundation. Structured education, weight management, physical activity, and dietary advice are framed in the 2026 update with the same weight they had before. The pharmacological pathway has changed; the non-pharmacological pathway has not.

Metformin remains a fully licensed and effective first-line option. The update repositions it — it does not deprecate it. Patients already stable on metformin monotherapy with HbA1c at target and no cardiovascular or renal indication for SGLT2 addition do not need their regimen changed simply because the guideline has moved. The change applies to new prescribing decisions; existing therapy should be reviewed in the usual way.

What this means for UK primary care

The biggest practical implication is for the existing type 2 diabetes register. Most UK practices have many patients on metformin monotherapy who, under the 2026 NG28 framework, would now be appropriate candidates for SGLT2 addition. A targeted review of those patients — particularly those with cardiovascular comorbidity or rising HbA1c — is the highest-yield response to the update.

For new diagnoses, the pathway is simpler than the previous version. An SGLT2 inhibitor at diagnosis, with metformin co-initiated where the clinical case supports it, will fit most patients. The exceptions are individuals with a contraindication (active ketogenic state, recurrent genitourinary infection, severe foot disease), an inability to follow sick-day rules safely, or a preference for metformin after informed discussion.

Local formularies will need updating. Most ICB and Health Board formularies in the UK already list at least one SGLT2 inhibitor (commonly dapagliflozin or empagliflozin) as preferred. The NG28 update is likely to reinforce that choice rather than disturb it, but check local guidance before assuming.

The deeper dive on SGLT2 prescribing

The W1 NG28 summary is a top-of-funnel piece. For UK GPs, trainees, and pharmacists wanting the operational detail — eligibility criteria, dose selection between agents, the cautions in practice, and the workflow at the GP-appointment level — we have published a longer companion post: SGLT2 inhibitors in UK primary care 2026: what NICE NG28 means in practice.

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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