GLP-1 Prescribing Is Now a Minefield. Here's a Practical Route Through It

What You Need to Know in 60 Seconds

• Patients can now qualify for a GLP-1 RA under three separate indications at once: obesity (TA1026), type 2 diabetes (NG28/TA924), and cardiovascular risk reduction (May 2026 TA, based on SELECT).
• Pick the wrong pathway and you could have picked the wrong treatment and the wrong follow-up.
• Obesity pathway: via referral to ICB-commissioned local service; requires at least 5% weight loss at the highest tolerated dose to continue.
• If T2DM + obesity overlap → T2DM pathway → semaglutide (s.c.) up to 1 mg weekly under T2DM pathway, avoiding any ICB approval delay.
• If all three pathways apply → semaglutide (s.c.) up to 1 mg weekly under the T2DM pathway.
• Switch to CV pathway (semaglutide 2.4 mg weekly) only if CV risk reduction is primary goal and glycaemia is already controlled.
• Before issuing any prescription: contraception check (tirzepatide), oral HRT review (any GLP-1 RA), same-day action on any private prescription notification.
• Document the indication, not just the drug. Your review criteria depend on it.

Why This Feels Like a Minefield

Three NICE pathways for the same class of drug, each with its own eligibility criteria, funding route, and stopping rule. A patient with type 2 diabetes, BMI 41, and a stroke 18 months ago qualifies for all three. Nothing in NG28 tells you what TA1026 expects, nor how the May 2026 CV appraisal interacts with both. This has the potential to result in varying health outcomes for patients through inconsistency across prescribers, funding routes, and review dates.

At the Point of Prescribing: Three Questions

1. Which indications does this patient actually meet? Not "could a GLP-1 help" but which of the three eligibility sets (obesity comorbidity count, T2DM triple-therapy criteria plus BMI, or established CVD plus BMI ≥27) does the patient meet.
2. If more than one applies, what is the tiebreak? When T2DM and obesity overlap, prescribe under the T2DM pathway — and weight loss is already a built-in continuation criterion under TA924. All three: semaglutide (s.c.) up to 1 mg weekly under T2DM, switching to the CV pathway (semaglutide 2.4 mg weekly) only if cardiovascular risk reduction is the primary goal and glycaemia is already controlled.
3. Have you run the safety checks regardless of pathway? Tirzepatide requires barrier or non-oral contraception for four weeks after starting and after every dose increase. Any GLP-1 RA requires oral HRT review. Any private GLP-1 prescription requires same-day action on notification.

Document the Indication, Not Just the GLP-1

The pathway you choose sets your six-month review. TA924 requires HbA1c reduction of at least 11 mmol/mol and weight loss of at least 3% to continue. The obesity pathway requires at least 5% weight loss at the highest tolerated dose. The CV pathway has no mandated stopping criterion.

Document the indication as your rationale, not just the drug. "Started on semaglutide for T2DM, ASCVD-preferred agent per NG28" sets up a completely different review than "started on semaglutide" without recording a rationale.

In practice, we sometimes see local guidelines varying from NICE guidance, and that variation is important to account for in prescribing decisions.