The video version of this podcast can be found here:

·      https://youtu.be/YX_YmP-yRfM

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I go through new and updated recommendations published in February 2026 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.  

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

·      Redcircle: https://redcircle.com/shows/primary-care-guidelines

·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The Full NICE News bulletin for February 2026 can be found here:

·      https://www.nice.org.uk/guidance/published?from=2026-02-01&to=2026-02-28&ndt=Guidance&ndt=Quality+standard

The updated guideline on Type 2 diabetes in adults: management [NG28] can be found here:

·      https://www.nice.org.uk/guidance/ng28

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome! I’m Fernando, a GP in the UK. In today’s episode, we’ll look at the NICE updates published in February 2026, focusing on what is relevant in Primary Care only.

This month there is just one updated guideline relevant to us, but it’s a major one: type 2 diabetes.

A few months ago we reviewed the draft version of the guideline. Now that the final version has been published, over the next few weeks I’ll be creating separate episodes covering the different sections in more depth.

So today, I’ll just give you an overview, highlighting the differences between the draft recommendations and the final version.

Right, let’s jump into it.

Firstly, let’s have a look at the first line treatment in people with no relevant comorbidities.

In the draft guideline, NICE recommended starting metformin plus an SGLT2 inhibitor from the outset, with SGLT2 monotherapy if metformin was not tolerated.

The final guideline confirms this, but now specifies that patients should be started on modified release metformin rather than just metformin.

This change applies throughout the guideline. Wherever standard release metformin was previously recommended, it now says modified release metformin.

Is this the death of the standard release preparation? Possibly in the long term. Anyone starting treatment should be on the modified release version, so numbers on standard release metformin will gradually fall. However, NICE also states that patients already on standard release can continue, or switch if necessary.

Now let’s look at first line treatment in specific clinical groups, starting with heart failure.

In the draft guideline, the recommendation was metformin plus an SGLT2 inhibitor, and it suggested that semaglutide could be added for weight management in selected people with preserved ejection fraction and no frailty.

In the final guideline, it’s still modified release metformin plus an SGLT2 inhibitor, with SGLT2 monotherapy if metformin is not tolerated.

However, for people with heart failure who need further treatment, the guideline moves straight to adding a DPP4 inhibitor first, then a sulfonylurea or insulin if needed. There is no recommendation in this section to add a GLP1 receptor agonist specifically for heart failure.

Next, people with atherosclerotic cardiovascular disease.

The draft guideline recommended early triple therapy with metformin plus an SGLT2 inhibitor plus semaglutide, continuing for cardiorenal benefit even if glycaemic targets were not met.

In the final guideline, this is confirmed but made more specific. Here, we should offer modified release metformin plus an SGLT2 inhibitor plus subcutaneous semaglutide up to 1 milligram once a week for cardiovascular, renal and glycaemic benefits. If metformin is not tolerated, we will use an SGLT2 inhibitor plus semaglutide. It also explicitly recommends starting semaglutide if atherosclerotic cardiovascular disease develops at any stage after initial therapy.

Next is the obesity group.

In the draft guideline, semaglutide was recommended after three months, with additional filters such as preserved ejection fraction and no frailty.

In the final guideline, NICE broadens this. It recommends either a GLP1 receptor agonist or tirzepatide after at least three months of initial therapy if further treatment is needed.

Now let’s look at chronic kidney disease.

There are three eGFR bands here: above 30, 20 to 30, and below 20.

For eGFR above 30, we will use modified release metformin. SGLT2 inhibitors are still prioritised early for kidney and cardiovascular protection, and dapagliflozin and empagliflozin are specifically named because of licensing reasons.

The 20 to 30 eGFR band is where we see a change.

In the draft guideline, if eGFR was between 20 and 30, NICE advised offering dapagliflozin or empagliflozin alone.

In the final guideline, it now says that if eGFR is 20 to 30, we should offer dapagliflozin or empagliflozin plus a DPP4 inhibitor. So, this is now explicit dual therapy rather than SGLT2 monotherapy. The rationale explains why. If the eGFR is below 30, cardiorenal protection of SGLT2 inhibitors remains, but the glucose lowering effect is reduced, so a DPP4 inhibitor is recommended for HbA1c control.

For eGFR below 20, the draft guideline advised using a DPP4 inhibitor first, then considering pioglitazone or insulin, and it stated that sulfonylureas should not be used if eGFR was below 30.

In the final guideline it remains the same, a DPP4 inhibitor first and then pioglitazone or insulin. However, there is no blanket rule about sulfonylureas in the CKD section although we need to know that hypoglycaemia risk increases as renal function falls. .

The draft also recommended not using empagliflozin or dapagliflozin if eGFR was less than 20. The final guideline does not phrase it that way. It simply directs us to DPP4 inhibitors rather than a blanket ban of SGLT2 inhibitors when eGFR is below 20.

And now, the final group is frailty.

The draft guideline recommended metformin alone, effectively deprioritising SGLT2 inhibitors as frailty increases SGLT2 risks.

In the final version, modified release metformin remains first line, but there is no automatic ban of SGLT2 inhibitors at baseline. Instead, the escalation sequence is first a DPP4 inhibitor and then consider pioglitazone, a sulfonylurea or insulin, taking into account hypoglycaemia and falls risk.

Regarding GLP1 receptor agonists and tirzepatide, the draft implied they were generally inappropriate in frailty due to weight loss and gastrointestinal effects.

However, the final guideline is more neutral. It does not specifically recommend them for frailty, but it states there is no inherent safety risk. If another indication exists, they can still be used even in frailty.

Now, let’s look at some other sections of the guideline.

Looking at GLP1 receptor agonists, the draft recommended stopping them if glycaemic or weight goals were not achieved, unless the person had atherosclerotic cardiovascular disease or early onset diabetes.

In the final guideline, NICE recommends stopping GLP1 receptor agonists or tirzepatide if BMI falls below 18.5 or if they do not help with the glycaemic targets as long as they are not being taken for cardiovascular benefit. So, the emphasis shifts from weight thresholds towards glycaemic targets and cardiovascular benefit.

Regarding combining GLP1 receptor agonists and DPP4 inhibitors, both the draft and the final guideline advise against it. The final guideline also extends this to tirzepatide.

In the insulin section, the draft stated that GLP1 receptor agonists could be combined with insulin in Primary Care without specialist approval.

The final guideline does not explicitly restate the specialist approval point. It simply states that when initiating insulin, we should continue metformin, stop other medicines used solely for glycaemic control, and discuss continuing medicines used for cardiovascular protection or weight management.

So that is it, a review of the NICE updates relevant to primary care.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.