Who benefits? Match the person to the authorised indication
Source-checked guidance · 21 October 2026
Eligibility depends on the medicine, formulation, treatment goal and jurisdiction. Type 2 diabetes, weight management, cardiovascular prevention and MASH are not interchangeable prescribing routes. Avoid using a single HbA1c, BMI or eGFR threshold as a universal GLP-1 eligibility rule.
Current UK Wegovy injection information includes adult weight management, adolescent weight management from age 12 with specified criteria, cardiovascular risk reduction in eligible adults, and non-cirrhotic MASH with F2–F3 fibrosis in adults. Mounjaro weight management remains an adult indication; its T2DM indication extends from age 10. Wegovy UK SmPC · Mounjaro UK SmPC
Source check: 21 October 2026. Licence, trial eligibility and NHS access are assessed separately below.
A patient-centred selection framework
Source-checked guidance · 21 October 2026
- Define the goal. Choose the relevant clinical pathway and outcome evidence, rather than the largest reported weight-loss percentage.
- Assess safety. Review pregnancy plans, gastrointestinal disease, pancreatitis history, hydration, nutritional status, retinopathy and interacting medicines; use the exact product SmPC.
- Check access and formulation. Confirm the UK-authorised brand and dose, current NICE recommendation, formulary and administration requirements.
- Agree review. Discuss treatment burden, expected benefit, adverse effects, affordability, preferences and the relevant stopping conditions. Do not promise indefinite NHS treatment or guaranteed outcomes.
Type 2 diabetes — current NICE selection
Source-checked guidance · 21 October 2026
NICE NG28 (18 February 2026) uses comorbidity-led initial and further-treatment pathways. In adults with T2DM and atherosclerotic cardiovascular disease, it offers modified-release metformin, an SGLT-2 inhibitor and subcutaneous semaglutide up to 1 mg weekly, with alternatives when metformin cannot be used. NICE initial medicines
For people living with obesity who need further glucose lowering, a GLP-1 receptor agonist or tirzepatide may be considered after at least 3 months of the specified initial treatment. Individualised targets, benefits, frailty and stopping recommendations matter. NICE further medication
| Selection question | Clinical implication |
|---|---|
| Cardiovascular outcomes | Choose an agent with evidence and recommendations for the relevant population. SURPASS-CVOT established tirzepatide non-inferiority to dulaglutide for MACE; cardiovascular superiority was not established. SURPASS-CVOT primary report |
| Renal function | No class-wide eGFR cutoff: use the exact brand/formulation SmPC. Advanced CKD and dehydration require careful assessment. Renal scenarios |
| Oral semaglutide | Rybelsus is a T2DM formulation; current UK strengths are 1.5, 4 and 9 mg once daily, replacing the older bioequivalent 3, 7 and 14 mg formulation. Wegovy tablets are a distinct weight-management product. MHRA Wegovy tablet approval |
| Retinopathy / insulin / sulfonylureas | Use product-specific monitoring and hypoglycaemia precautions. Insulin or sulfonylurea adjustment requires individual assessment. UK product precautions |
Weight management — licence and NHS eligibility differ
Source-checked guidance · 21 October 2026
UK Wegovy and Mounjaro adult weight-management licences have BMI thresholds of ≥30 kg/m², or ≥27 kg/m² with a weight-related comorbidity. NHS access criteria are narrower. Wegovy SmPC · Mounjaro SmPC
| Pathway | Selected appraisal conditions |
|---|---|
| Semaglutide · TA875 | Specialist multidisciplinary weight-management service; at least one weight-related comorbidity and BMI ≥35 kg/m², or BMI 30–34.9 kg/m² with specified specialist-referral criteria. Lower ethnicity-adjusted thresholds apply. Maximum 2 years; consider stopping for less than 5% weight loss after 6 months. |
| Tirzepatide · TA1026 | Initial BMI ≥35 kg/m² and at least one weight-related comorbidity, with lower ethnicity-adjusted thresholds. Phased NHS England implementation. Review continuation if less than 5% weight loss after 6 months on the highest tolerated dose. |
For semaglutide used to reduce cardiovascular events, consult TA1152 instead of assuming the weight-management appraisal is the only route. These summaries do not replace the full appraisal or local access check. TA1152
Cardiovascular prevention — established disease, specific evidence
Source-checked guidance · 21 October 2026
SELECT studied semaglutide 2.4 mg in adults aged 45 or over with established cardiovascular disease, BMI ≥27 kg/m² and no diabetes. It demonstrated a reduction in major cardiovascular events (HR 0.80 versus placebo). This was secondary prevention: participants already had cardiovascular disease. SELECT primary report
NICE TA1152, published 7 May 2026, covers semaglutide up to 2.4 mg weekly with diet and physical activity, for eligible adults with established CVD and BMI ≥27 kg/m². CVD includes previous MI, ischaemic or haemorrhagic stroke, or specified symptomatic peripheral arterial disease. Apply the appraisal and licence separately from trial eligibility. NICE TA1152
Semaglutide 7.2 mg is an adult obesity weight-management dose. TA1152 cardiovascular prevention uses up to 2.4 mg weekly. Wegovy SmPC
Visual reference for patient selection
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.
Decision frameworks
Patient selection algorithm
Image description
The illustration presents Stepwise approach from indication to agent choice.
Clinical interpretation
Start with indication (T2DM, obesity, ASCVD, CKD), assess product-specific UK contraindications and pregnancy status; MTC/MEN2 restrictions differ by jurisdiction, screen GI disease, then match agent to priorities (weight vs CV vs renal vs convenience).
Secondary selection criteria
Image description
The illustration presents Comorbidity-driven refinements.
Clinical interpretation
HFpEF obesity phenotype favours semaglutide/tirzepatide; advanced CKD may require dose review; pancreatitis history contraindicates class.
Metabolic pathways
Diabetes–obesity overlap pathway
Image description
The illustration presents Dual indication populations common in practice.
Clinical interpretation
Many patients meet criteria for both T2DM and obesity management — align dose (Ozempic 1.0 mg vs Wegovy 2.4 mg semaglutide) with primary treatment goal.
Adipose tissue biology
Image description
The illustration presents White vs brown adipose and GLP-1 effects on lipolysis.
Clinical interpretation
Weight loss reduces visceral adiposity — key driver of insulin resistance improvement; GLP-1 may modestly increase energy expenditure via central pathways.
Assessment
Metabolic assessment panel
Image description
The illustration presents Baseline tests before initiation.
Clinical interpretation
HbA1c, renal function, liver enzymes, lipids, calcitonin if MTC risk, pregnancy test, and thyroid symptoms review. Retinopathy screening in diabetes per national programme.
Body composition — DXA context
Image description
The illustration presents Monitoring lean mass during substantial weight loss.
Clinical interpretation
DXA substudies show lean mass loss proportional to total weight loss; exercise mitigation is guideline-consistent advice.
Clinical FAQs
Frequently asked questions
Who should not take GLP-1 receptor agonists?
Contraindications are product- and jurisdiction-specific. US labels include MTC/MEN2 restrictions for specified products; do not apply these as a universal UK class contraindication. Check the current UK SmPC for hypersensitivity, pregnancy and other exclusions, and assess pancreatitis history and severe gastrointestinal disease.
Example: current UK Mounjaro SmPC; check each product separately.