Prescribing guidance: read by indication and jurisdiction
Source-checked guidance · 21 October 2026
A guideline, marketing authorisation and NHS funding decision answer different questions. This chapter compares selected current sources; it is not a merged prescribing algorithm. The UK reference points are NICE NG28 for adult type 2 diabetes, the relevant technology appraisal for weight management or cardiovascular prevention, and the exact product SmPC for indication, dose and safety.
Source check: 21 October 2026. Previous unsourced recommendation numbers, quotations and evidence grades have been removed. International guidance does not establish a UK licence or NHS entitlement. NICE NG28 · Wegovy UK SmPC · Mounjaro UK SmPC
Compare the current frameworks
Source-checked guidance · 21 October 2026
| Source | Population / purpose | Practical distinction |
|---|---|---|
| NICE NG28 · February 2026 | Adults with type 2 diabetes | Comorbidity-led medicines selection; use the current initial and further-treatment pathways. Initial medicines · Further medication |
| NICE TA875 / TA1026 | Semaglutide / tirzepatide for weight management | Different eligibility, duration, stopping and implementation conditions. TA875 · TA1026 |
| NICE TA1152 · May 2026 | Semaglutide for secondary cardiovascular prevention | A separate appraisal for established CVD and overweight/obesity. TA1152 |
| ADA Standards of Care · 2026 | US diabetes practice | Organ protection and individualised glycaemic/weight goals; not UK commissioning rules. ADA 2026 |
| ADA/EASD consensus · 2026 | Type 2 diabetes management (US and Europe) | Earlier SGLT2 inhibitor and/or GLP-1-based therapy for organ protection; holistic multimorbidity focus. 2026 consensus report |
| KDIGO · published 2022 / draft 2026 | Diabetes and CKD | Distinguish published recommendations, later evidence and a public-review draft. KDIGO source status |
| WHO · December 2025 | Global adult obesity guidance | Conditional recommendations within comprehensive long-term care. WHO guidance |
NICE NG28 — type 2 diabetes, February 2026
Source-checked guidance · 21 October 2026
NICE NG28 was updated on 18 February 2026. For adults with type 2 diabetes and atherosclerotic cardiovascular disease, the initial-medicines pathway offers modified-release metformin, an SGLT-2 inhibitor and subcutaneous semaglutide (Ozempic) up to 1 mg weekly, with alternatives if metformin cannot be used. NICE initial-medicines recommendations
Other pathways distinguish early-onset diabetes, obesity, CKD, heart failure and frailty. When a person living with obesity needs further glucose lowering, consider a GLP-1 receptor agonist or tirzepatide after at least 3 months of the specified initial therapy. Review benefit and the current stopping recommendations rather than applying the historical 1% HbA1c / 3% weight rule to everyone. NICE further-medication recommendations
The NG28 GLP-1 recommendations cover liraglutide, dulaglutide and semaglutide; subcutaneous semaglutide evidence in this pathway is up to 1 mg weekly. Tirzepatide has separate benefit statements. Product authorisation at a higher dose is not the same as a NICE recommendation at that dose.
NICE TA875 and TA1026 — weight management
Source-checked guidance · 21 October 2026
| Appraisal | Selected conditions | Review |
|---|---|---|
| Semaglutide · TA875 | Specialist weight-management service; at least one weight-related comorbidity and BMI ≥35 kg/m², or BMI 30–34.9 kg/m² with the specified specialist-referral criteria. Lower ethnicity-adjusted thresholds apply. | Maximum 2 years under this appraisal; consider stopping if less than 5% of initial weight is lost after 6 months. |
| Tirzepatide · TA1026 | Initial BMI ≥35 kg/m² and at least one weight-related comorbidity; lower ethnicity-adjusted thresholds apply. NHS England implementation is phased. | If less than 5% of initial weight is lost after 6 months on the highest tolerated dose, decide whether to continue using individual benefits and risks. |
These are selected appraisal conditions, not the full eligibility check. The licensing thresholds are broader and do not automatically determine NHS availability. Check the full appraisal and local pathway.
UK specialist practice — apply the relevant national pathway
Source-checked guidance · 21 October 2026
Specialist care should align the treatment goal, nutritional status, comorbidities, patient preference and follow-up plan. No single Society for Endocrinology obesity guideline with the previously displayed title, year and graded recommendations has been substantiated for this page; those attributed rules have been removed.
Use NICE overweight and obesity management (NG246) and the relevant technology appraisal. A local service protocol must be identified by its issuing organisation and version; it should not be presented as a national recommendation.
NHS access — commissioning follows the specific appraisal
Source-checked guidance · 21 October 2026
For weight management, semaglutide and tirzepatide have separate access pathways. Tirzepatide implementation under TA1026 is phased, so meeting its broad eligibility criteria does not mean everyone can start immediately. Confirm the current NHS England implementation plan and local ICB pathway. TA1026 implementation resources
For cardiovascular prevention, NICE published TA1152 on 7 May 2026. It covers semaglutide up to 2.4 mg weekly in eligible adults with established CVD and BMI ≥27 kg/m², alongside diet and physical activity. This is distinct from TA875 weight-management commissioning. TA1152 recommendations
ADA — 2026 Standards of Care
Source-checked guidance · 21 October 2026
The 2026 Standards of Care supersede the 2025 edition as the current annual ADA reference. For type 2 diabetes with established or high-risk ASCVD, heart failure or CKD, select therapies with demonstrated benefit in the relevant population, including GLP-1-based therapies and/or SGLT2 inhibitors as appropriate, independently of HbA1c. ADA 2026 pharmacological treatment
The 2026 framework also addresses symptomatic HFpEF with obesity, CKD and MASLD/MASH. These are US professional recommendations; check current UK product information and NICE guidance before applying them in UK practice.
AACE — 2026 diabetes algorithm
Source-checked guidance · 22 October 2026
AACE published its consensus statement Algorithm for Management of Adults With Type 2 Diabetes – 2026 Update in Endocrine Practice on 17 March 2026, the first update since 2023. It adds a diabetes classification pathway, recognises MASLD as a comorbidity and expands comorbidity-driven pharmacotherapy guidance. These are US recommendations. Endocrine Practice (DOI 10.1016/j.eprac.2026.01.006) · AACE 2026 algorithm
US cardiology — ACC weight-management guidance
Source-checked guidance · 21 October 2026
The relevant identified document is the 2025 ACC concise clinical guidance on medical weight management for cardiovascular health; it should not be called a 2023 AHA/ACC obesity guideline based on SELECT. Its US context differs from NHS access decisions. ACC 2025 guidance announcement
For UK semaglutide cardiovascular prevention, use NICE TA1152 and the UK SmPC. Cardiovascular outcome evidence is agent- and population-specific; weight-loss superiority alone does not establish superiority for cardiovascular events.
ADA/EASD — 2026 consensus report
Source-checked guidance · 22 October 2026
The ADA and EASD published Management of type 2 diabetes, 2026 on 2 October 2026, simultaneously in Diabetologia and Diabetes Care, and presented it at EASD 2026 in Milan. It replaces the 2022 consensus report, which is now superseded. Diabetologia (DOI 10.1007/s00125-026-06855-7) · Diabetes Care (DOI 10.2337/dci26-0141)
The update broadens the focus from hyperglycaemia to holistic management of type 2 diabetes and its associated long-term conditions. It advocates earlier use, potentially from diagnosis, of SGLT2 inhibitors and/or GLP-1-based therapies for organ protection, and earlier combination of the two in people with cardiovascular disease, chronic kidney disease or heart failure. Healthy lifestyle behaviours, psychological support and weight management remain fundamental.
This is a US and European consensus report, not UK commissioning guidance. For UK treatment selection use NICE NG28 and the product SmPC; for annual US recommendations use the ADA 2026 Standards of Care. Historical reference: ADA/EASD 2022 consensus.
ESC — heart-failure guidance updated in 2026
Source-checked guidance · 22 October 2026
The 2026 ESC heart-failure guidelines (published 28 August 2026, European Heart Journal) give a Class IIa recommendation that semaglutide or tirzepatide should be considered in symptomatic heart failure with LVEF ≥45% and BMI ≥30 kg/m², regardless of diabetes status, to reduce weight and improve exercise capacity and quality of life. Do not extend this to other heart-failure phenotypes. 2026 ESC heart-failure guidelines · ESC summary
Patients still require assessment and treatment of the underlying heart failure. An obesity recommendation does not replace heart-failure disease-modifying therapy or the applicable UK prescribing pathway.
EASO — 2026 pharmacotherapy framework
Source-checked guidance · 22 October 2026
EASO published the 2026 update of its framework for the pharmacological treatment of obesity and its complications (“Algorithm 2.0”) in Nature Medicine on 13 May 2026, after its launch at ECO2026. It matches therapy to obesity-related complications and treatment goals. The 2026 update adds MASH resolution, for which semaglutide or tirzepatide is recommended, and liver fibrosis improvement, for which semaglutide is recommended. Nature Medicine (DOI 10.1038/s41591-026-04397-4)
This is a professional framework; treatment still requires the correct jurisdiction-specific licence, safety assessment and funding pathway. Comparative effects from separate placebo-controlled trials should not be treated as direct head-to-head comparisons.
WHO — obesity guidance and essential medicines, 2025
Source-checked guidance · 21 October 2026
WHO issued its first GLP-1 obesity guideline on 1 December 2025, with conditional recommendations on long-term treatment in adults as part of comprehensive care. It addresses liraglutide, semaglutide and tirzepatide. WHO also reported that GLP-1 therapies had been added to the 2025 Essential Medicines List for selected high-risk type 2 diabetes groups. WHO December 2025 announcement and guideline
Essential Medicines List inclusion does not itself guarantee availability, a particular price reduction or UK reimbursement. Unsubstantiated forecasts of generic entry and price reductions have been removed.
KDIGO — distinguish published guidance from drafts
Source-checked guidance · 21 October 2026
KDIGO 2022 remains the current published Diabetes in CKD guideline. A 2026 draft update has undergone public review and is being revised; it is not final guidance. The separate KDIGO 2024 CKD guideline should not be relabelled as a new diabetes guideline incorporating final FLOW results. KDIGO guideline status
The published 2022 framework recommends a long-acting GLP-1 receptor agonist for selected adults with type 2 diabetes and CKD when individualised glycaemic targets are not achieved despite metformin and SGLT2 inhibition, or these therapies cannot be used. It prioritises agents with documented cardiovascular benefit. Later FLOW evidence should be described as trial evidence, not invented KDIGO quotations or grades. Published KDIGO 2022 guideline
The kidney-outcomes benefit observed in FLOW does not by itself prove that combined GLP-1 RA/SGLT2 inhibition is superior to either treatment alone in a dedicated randomised comparison. See FLOW evidence and KDIGO CKD guidance and draft status.
Clinical reading sequence — use the original pathway
Source-checked guidance · 21 October 2026
This sequence is an educational checklist, not a validated combined guideline algorithm.
- Define the treatment goal and comorbidities: glycaemia, weight, cardiovascular disease, CKD or MASH.
- Confirm the exact brand, formulation, authorised indication and current SmPC precautions.
- Open the applicable NICE pathway or technology appraisal and check local access.
- Agree treatment goals, safety-netting and a product-specific titration and review plan.
- Review benefit, adverse effects and the indication-specific stopping conditions.
NICE NG28 · TA875 · TA1026 · TA1152 · Mounjaro SmPC · Wegovy SmPC
Why recommendations differ
Source-checked guidance · 21 October 2026
| Question | How to interpret it |
|---|---|
| Is this treatment authorised? | Use the current product-specific regulator/SmPC information; authorisations can differ by brand, formulation, indication and country. |
| Is it recommended or funded? | Use the relevant national guideline, appraisal and implementation policy; these are distinct from licensing. |
| Is an outcome proven? | Identify trial population, comparator, endpoint and analysis; do not equate non-inferiority with superiority or subgroup findings with a new indication. |
| Is the guidance final? | Check publication version. A draft, consultation response or guideline-development page is not a final recommendation. |
This comparison is editorial explanation. The linked issuing bodies remain the source of the actual recommendations. Example: KDIGO published-versus-draft status
Current oral T2DM formulation: Rybelsus 9 mg once daily is a current maintenance strength after product-specific titration through the new 1.5 mg and 4 mg strengths. The older 3/7/14 mg and newer 1.5/4/9 mg tablets must not be substituted milligram-for-milligram. See the Rybelsus formulation safety communication and current UK Rybelsus product information; historical trial doses remain labelled as such.
Visual reference for prescribing guidelines
Each illustration below is paired with a clinical summary and detailed explanation. Click any image to expand. Figures are numbered in teaching order and grouped by theme.
UK guidelines
NICE NG28 (February 2026) — T2DM management
Image description
The illustration presents UK primary reference for GLP-1 RA prescribing in type 2 diabetes.
Clinical interpretation
NG28 positions GLP-1 RAs at second/third line with specific HbA1c thresholds; February 2026 update added tirzepatide and clarified CV-risk-based prescribing independent of HbA1c when ASCVD is present.
NICE health technology assessment
Image description
The illustration presents Cost-effectiveness framework for GLP-1 agents in NHS.
Clinical interpretation
Technology appraisals define which populations receive NHS-funded therapy; obesity pathways often require specialist weight management service referral.
NICE NG203 — CKD assessment and management
Image description
The illustration presents Intersection with FLOW evidence for renal protection.
Clinical interpretation
NG203 alongside NG28 guides SGLT2i and GLP-1 RA use in diabetic kidney disease — combination therapy increasingly standard.
NICE technology appraisal context
Image description
The illustration presents Appraisal documentation for newer agents.
Clinical interpretation
TA documents define eligible populations, comparators, and managed access — essential for formulary committees.
International guidelines
ADA Standards of Care 2025/2026 — unified algorithm
Image description
The illustration presents US algorithm prioritising agents with cardiorenal benefit.
Clinical interpretation
ADA places GLP-1 RAs with proven CV benefit high in algorithm for T2DM with ASCVD/high risk, alongside SGLT2i, often independent of HbA1c or metformin use.
Therapeutic stewardship principles
Image description
The illustration presents Appropriate agent selection, titration, and deprescribing considerations.
Clinical interpretation
Stewardship emphasises matching agent to indication (glycaemia vs obesity vs CV/renal), avoiding duplication, and planning therapy around procedures (aspiration risk).
Treatment algorithms
Clinical positioning of GLP-1 RAs
Image description
The illustration presents Where GLP-1 fits among metformin, SGLT2i, insulin, and lifestyle.
Clinical interpretation
Decision tree: ASCVD → GLP-1 or SGLT2i; obesity predominant → higher-dose semaglutide/tirzepatide; renal disease → SGLT2i + GLP-1 RA with FLOW-class evidence.
Shared decision-making framework
Image description
The illustration presents Patient-centred choice among agents with different devices and schedules.
Clinical interpretation
Weekly vs daily injection, oral option, weight loss magnitude, supply issues, and cost/access shape real-world selection as much as trial hazard ratios.
Clinical FAQs
Frequently asked questions
What do NICE guidelines say about GLP-1 prescribing?
NICE recommends GLP-1 receptor agonists for type 2 diabetes when specific criteria are met, and semaglutide (Wegovy) for weight management within a specialist service subject to BMI thresholds. Always check current NICE guidance and local formularies before prescribing.