| name | t2dm-comorbidity-medicine-selector |
| description | Guides comorbidity-stratified selection of initial and further glucose-lowering medicines for adults with type 2 diabetes using the NICE NG28 (2026) framework, covering six clinical profiles: no relevant comorbidity, heart failure, atherosclerotic cardiovascular disease, early onset, obesity, chronic kidney disease, and frailty.
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| source_guideline | Type 2 Diabetes in Adults: Management (NG28) |
| publishing_body | National Institute for Health and Care Excellence (NICE) |
| year | 2026 |
| url | https://www.nice.org.uk/guidance/ng28 |
| specialty | Endocrinology / General Practice / Cardiology / Nephrology |
| version | 1.0 |
Type 2 Diabetes — Comorbidity-Stratified Medicine Selection
Based on: Type 2 Diabetes in Adults: Management (NG28) — NICE (last updated February 2026)
Reference: https://www.nice.org.uk/guidance/ng28
PURPOSE
Use this skill when initiating or intensifying glucose-lowering treatment in an adult with
type 2 diabetes. The NICE NG28 framework stratifies medicine choice by the person's
comorbidity profile rather than a single universal algorithm. This skill identifies the
correct comorbidity category, maps it to the guideline-recommended initial regimen, and
specifies when and how to add further medicines if glycaemic targets are not met.
STEP 1 — GATHER INFORMATION
Collect the following before selecting a medicine regimen:
Glycaemic status
- Current HbA1c (mmol/mol and %)
- Individualised HbA1c target already agreed (or needs agreeing — see NICE NG28 Section 1.5)
- Current glucose-lowering medicines (drug, dose, duration, tolerability)
- Duration since diagnosis
Comorbidity screen — ask and document each:
- Heart failure? (any ejection fraction)
- Established atherosclerotic cardiovascular disease (ASCVD)? (coronary artery disease, stroke, peripheral arterial disease)
- Early onset type 2 diabetes? (defined by NICE as diagnosis before age 40)
- Obesity? (BMI ≥30 kg/m², or ≥27.5 kg/m² in South Asian / Black African or Caribbean groups)
- Chronic kidney disease (CKD)? If yes: current eGFR (ml/min/1.73 m²)
- Frailty? (if suspected, confirm with validated frailty assessment before prescribing)
Safety parameters
- eGFR — essential for metformin and SGLT-2 inhibitor dosing and contraindications
- Risk factors for diabetic ketoacidosis (DKA): previous DKA, intercurrent illness, very low carbohydrate / ketogenic diet, dehydration
- Hypoglycaemia risk: driving / machinery, fall risk, impaired hypoglycaemia awareness
- Current use of DPP-4 inhibitor (incompatible with GLP-1 receptor agonists / tirzepatide)
- Pregnancy status or intent (separate guidance applies)
Patient factors
- Preference regarding injection vs oral route
- Adherence concerns or previous intolerances
- Weight trajectory and weight target
STEP 2 — RULE IN / RULE OUT
Confirm this skill applies:
- Adult with confirmed type 2 diabetes (if treatment response is atypical, revisit diagnosis per NICE NG17 on type 1 diabetes)
