Synopsis
Select diabetes medicines using current UK recommendations, prescribe common regimens accurately, and prevent hypoglycaemia, ketoacidosis and avoidable treatment burden.
- NICE NG28 changed in February 2026: initial treatment for many adults is modified-release metformin plus an SGLT2 inhibitor, with separate cardiovascular, renal and frailty branches.
- Introduce medicines stepwise: start metformin and establish its highest tolerated dose, then add the SGLT2 inhibitor without unnecessary delay. Choosing an initial combination does not require starting every drug on the same day.
- A selected metformin prolonged-release regimen starts at 500 mg orally once daily with the evening meal, increasing by 500 mg every 10–15 days to 2 g daily if appropriate; renal function limits the permitted dose.
Investigation priorities
Assess longer-term response and patterns that inform adjustment.
Management branches
An adult has confirmed type 2 diabetes without an acute metabolic emergency.
- Identify the relevant comorbidity and frailty pathway, agree an individual glycaemic goal and discuss the purpose of each proposed medicine. Check renal function, current symptoms, pregnancy plans and factors that increase ketoacidosis or dehydration risk.
- For an appropriate adult, begin modified-release metformin at a low dose with food and increase gradually within the selected product’s renal limits. Review gastrointestinal tolerability rather than assuming that the first episode of mild nausea requires permanent abandonment.
Key medicines
Metformin hydrochloride prolonged-release tabletsSelected UK SmPC: 500 mg orally once daily with the evening meal; increase by 500 mg every 10–15 days if tolerated, usually to 2 g daily maximum. At GFR 30–44 mL/min, maximum 1 g daily; below 30, contraindicated.At GFR 45–59, assess lactic-acidosis risks and start no higher than half the 2 g maximum; at 30–44 start no higher than half the 1 g maximum. Hold for relevant acute dehydration or hypoxia; assess B12 and pregnancy-specific guidance.
Dapagliflozin10 mg orally once daily for suitable adults; continue according to indication and regular benefit–risk review. The current Forxiga SmPC does not recommend starting below eGFR 15 mL/min/1.73 m².Glucose efficacy is reduced below eGFR 45. Severe hepatic impairment uses a 5 mg starting dose with potential increase to 10 mg. Avoid assuming suitability in pregnancy or insulin deficiency; manage dehydration and DKA risk explicitly.