NG28 was the biggest NICE change in a decade. Here is what else moved this year.

Twelve months ago, most newly diagnosed adults with type 2 diabetes left the consultation on metformin alone.

Wait, recheck HbA1c, escalate if needed.

That sequence was written into every practice template and most GPs' muscle memory. On 18 February 2026, NICE ended it.¹

Looking back over the last year, NG28 stands alone for how much of a working day it touched. Four other updates deserve a place beside it. NG28 first.

NG28, part one: two medicines from day one

The February 2026 update moved SGLT-2 inhibitors from second-choice to first-choice treatment.¹ For most adults, an SGLT-2 inhibitor is now offered with metformin at diagnosis.

This is done in steps to confirm that metformin is tolerated before bringing in the second drug. For those who cannot tolerate metformin, an SGLT-2 inhibitor alone is the first option. HbA1c targets now refer to an initial medication regimen rather than a single drug.

The rationale is not glycaemic. NICE highlights evidence that SGLT-2 inhibitors lower the risk of cardiovascular death, hospitalisation for heart failure, and CKD progression. This benefit is seen regardless of HbA1c levels.

NICE's modelling estimated about 17,000 deaths avoided over three years from the update as a whole, including the wider access to GLP-1 receptor agonists and tirzepatide noted below.²

NG28, part two: 810,000 more people become eligible for incretin therapy

GLP-1 receptor agonists and tirzepatide were previously intended for people who had failed multiple oral agents. The update brings them into the initial treatment plan for three groups.¹ Adults with atherosclerotic cardiovascular disease are offered triple therapy from the start, with subcutaneous semaglutide up to 1 mg weekly as the preferred GLP-1 receptor agonist.

Adults diagnosed before 40 start with metformin and an SGLT-2 inhibitor. Then, a GLP-1 receptor agonist or tirzepatide may be considered because of higher cardiovascular and renal risks. Adults living with obesity have specific combination pathways.

NICE estimated around 810,000 more people could benefit.¹

NG28, part three: why now, and who is still missing out

The clinical evidence for earlier SGLT-2 inhibitor use had existed for years. What changed was generic dapagliflozin. NICE estimated cumulative NHS savings of £560 million across 2025/26 and 2026/27, which is why a guideline that increases prescribing was also scored as cost-saving.¹

The part that should shape implementation is the equity analysis. NICE reviewed nearly 590,000 anonymised records and found SGLT-2 inhibitors significantly under-prescribed to women, older people, and Black or Black British individuals, with the revised recommendations including provisions to monitor access.¹

For practices, the update is not only about what the new-diagnosis template says. It is about running the search for who already qualifies and is not receiving it.

The other important updates in 25-26

TA1152: semaglutide for cardiovascular risk, no diabetes required

TA1152, published on 7 May 2026, recommends semaglutide at doses up to 2.4 mg weekly.² This is for adults with established cardiovascular disease, like a previous MI, stroke, or symptomatic peripheral arterial disease, and a BMI of 27 kg/m² or more.

There is no requirement for diabetes. NICE did not specify a treatment setting, so initiation is a local commissioning decision.

TA1182: finerenone in heart failure with preserved ejection fraction

TA1182, published on 5 August 2026, states that finerenone can be used within its marketing authorisation as an option for symptomatic chronic heart failure with preserved or mildly reduced ejection fraction, which the marketing authorisation defines as an LVEF of 40% or above.³

Around 280,000 people in England may qualify, and ICBs must comply by 3 November 2026. It is a choice within the current NG106 MRA recommendation and not an addition to spironolactone. NICE also described the comparison with spironolactone as uncertain. Finerenone is the only non-steroidal MRA licensed in the UK, so class-level wording identifies a single product; it is named here because the appraisal does.

NG12 and NG23: the CA125 rules were rewritten and menopause guidance followed

The April 2026 update to NG12 replaced the universal CA125 cut-off of 35 IU/ml with age-adjusted thresholds for adults aged 40 and over.⁴

For adults aged 39 and under, CA125 is no longer recommended in isolation and direct access ultrasound is advised instead.

NG23 was amended in the same month: vaginal bleeding is recognised as a common side effect within the first six months of starting systemic HRT or within three months of a dose or preparation change, and prompt medical help is advised beyond those windows.⁵

NG106, NG250 and NG253: heart failure and acute infection guidance was rebuilt

In September 2025, NG106 reviewed evidence across the ejection fraction bands.⁶ Then it issued two clarifications for primary care: an ECG should be carried out before a beta-blocker is prescribed (October 2025), and advice on ARNI prescribing by primary care prescribers followed in December 2025.

The pneumonia guideline NG250 was published in September 2025.⁷ It shortened the antibiotic course for non-severe community-acquired pneumonia in children aged 3 months to 11 years from five days to three.

Then, two months later, the sepsis guideline divided into three documents for different age groups.⁸ It also introduced a smaller initial fluid bolus of 250 ml for adults.

What this means for primary care

Loads - and there is so much to remember.

NG28 changed the new-diagnosis consultation, the QOF searches, and the prescribing templates in one update. The others changed what a normal CA125 means by age, what your ICB has commissioned, and what a heart failure review looks like before a beta-blocker goes on. None of them arrived with a single press release you could file and forget.

That's why we track every NICE publication relevant to primary care each week on the Medicine Central NICE Guidelines page. You can read articles, download cheat sheets and much more.

References

1. National Institute for Health and Care Excellence. Type 2 diabetes in adults: management. NICE guideline NG28. London: NICE; 2015 (updated 18 February 2026). Available from: https://www.nice.org.uk/guidance/ng28

2. National Institute for Health and Care Excellence. Semaglutide for reducing the risk of major adverse cardiovascular events in people with cardiovascular disease and overweight or obesity. Technology appraisal guidance TA1152. London: NICE; 7 May 2026. Available from: https://www.nice.org.uk/guidance/ta1152

3. National Institute for Health and Care Excellence. Finerenone for treating chronic heart failure with preserved or mildly reduced ejection fraction. Technology appraisal guidance TA1182. London: NICE; 5 August 2026. Available from: https://www.nice.org.uk/guidance/ta1182

4. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NICE guideline NG12. London: NICE; 2015 (updated 15 April 2026). Available from: https://www.nice.org.uk/guidance/ng12

5. National Institute for Health and Care Excellence. Menopause: identification and management. NICE guideline NG23. London: NICE; 2015 (updated 15 April 2026). Available from: https://www.nice.org.uk/guidance/ng23

6. National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. NICE guideline NG106. London: NICE; 2018 (updated December 2025). Available from: https://www.nice.org.uk/guidance/ng106

7. National Institute for Health and Care Excellence. Pneumonia: diagnosis and management. NICE guideline NG250. London: NICE; 2 September 2025. Available from: https://www.nice.org.uk/guidance/ng250

8. National Institute for Health and Care Excellence. Suspected sepsis in people aged 16 or over: recognition, diagnosis and early management. NICE guideline NG253. London: NICE; 5 November 2025. Available from: https://www.nice.org.uk/guidance/ng253