Type 2 diabetes and cardiometabolic therapy
Glucose-lowering therapy chosen by organ protection, not by HbA1c: the three questions at diagnosis, what NICE NG28 changed in February 2026, the even-handed UK toolkit from SGLT2 inhibitors and incretins to metformin and deprescribed sulfonylureas, and the safety repertoire every prescriber must hold: euglycaemic ketoacidosis, sick-day rules, pancreatitis, hypoglycaemia and kidney dosing. About 60 minutes, for GPs, GP trainees, pharmacists, nurses and advanced clinical practitioners. A 10-item knowledge check is marked on our learning platform; pass at 70% and a numbered, verifiable Certificate of CPD (1 hour) from New Vision University (UK) is issued to you.
Living Certificate · reviewed and kept current
Last editorial review: awaiting clinical sign-off · Next scheduled refresh: 12 months after sign-off.
The Golden Triangle for the topic taught here: fixed to the topic, and re-examined when its knowledge, evidence or real-world sources change.
Golden Triangle
Type 2 diabetes
Knowledge Green · Evidence Green · Real-world Amber
Not yet at the Equinox · UK (NHS England) · as of 7 October 2026 · How the triangle works
A 58-year-old taxi driver with a stent and a new HbA1c of 64
Mr A, 58, drives a taxi. Eighteen months ago he had a non-ST-elevation infarct treated with a drug-eluting stent; he is on aspirin, ticagrelor, atorvastatin 80 mg, ramipril 10 mg and bisoprolol 5 mg. His annual bloods show HbA1c 64 mmol/mol, repeated at 63: type 2 diabetes. BMI 31, BP 134/82, eGFR 78, ACR 1.8 mg/mmol. He is asymptomatic and would rather not inject.
Ten years ago the answer was metformin and a recall. The 2026 answer starts with three questions: does he have atherosclerotic disease (yes), heart failure (no), or CKD (no)? One "yes" chooses the first drug for its organ protection, whatever the HbA1c: empagliflozin 10 mg with modified-release metformin, and NG28 1.15.1 also offers subcutaneous semaglutide up to 1 mg weekly in established atherosclerotic disease, all introduced one at a time (1.20.2). He would rather not inject, so he starts metformin and empagliflozin and semaglutide is revisited at each review as a shared decision (1.9.3). The pre-start ketoacidosis check is done (no previous ketoacidosis, current illness, dehydration or very low carbohydrate diet, 1.21.1). He is given the sick-day card (pause the SGLT2 inhibitor, metformin and ramipril during dehydrating illness; test ketones if unwell) and told why a glucose of 11 does not rule out ketoacidosis on his new tablet. His HbA1c target is 48 mmol/mol, neither drug causes hypoglycaemia, and neither carries a DVLA notification duty; he checks his taxi licensing authority's standard. At three months he is at 54. If he reaches 58, NG28 1.5.8 says reinforce, aim for 53 and intensify; with a BMI of 31 a GLP-1 receptor agonist or tirzepatide can be considered for glycaemia after 3 months of initial therapy (1.29.2), and otherwise 1.27.2 lists a sulfonylurea, pioglitazone or insulin. Aspirin for primary prevention never arises; he already has disease. That logic, with the safety rules that keep it safe, is this module.
By the end of this module you will be able to…
From glucocentric to organocentric
The three questions at diagnosis, the February 2026 NICE update, and the HbA1c targets that still apply.
The defining shift in type 2 diabetes care, codified in the ADA–EASD consensus, the ESC/EASD 2023 guideline, NICE NG28 (updated February 2026) and DCRM 2.0, is that drug choice follows organ protection rather than glucose lowering. For a person with atherosclerotic disease, heart failure or CKD, an SGLT2 inhibitor is offered regardless of HbA1c, with subcutaneous semaglutide added in atherosclerotic disease (NG28 1.14, 1.15, 1.18).
NICE NG28, February 2026, at a glance. For most adults starting treatment, an SGLT2 inhibitor is offered together with modified-release metformin (1.13.1), no longer reserved for those with established cardiovascular or renal disease. Start metformin first, then add the SGLT2 inhibitor once metformin is at the maximum tolerated dose (1.20.2); an SGLT2 inhibitor alone if metformin is contraindicated or not tolerated (1.13.2). Variations: diagnosed under 40, consider adding a GLP-1 receptor agonist or tirzepatide (1.16.1); frailty, an SGLT2 inhibitor only if frailty does not put the person at risk of volume depletion or hypotension (1.19.1); eGFR 20 to below 30, dapagliflozin or empagliflozin with a DPP-4 inhibitor (1.18.2), and below 20 consider a DPP-4 inhibitor (1.18.3). In established atherosclerotic disease NG28 also offers subcutaneous semaglutide up to 1 mg weekly (1.15.1); other GLP-1 receptor agonists have outcome evidence but are not named by NG28. Targets: 48 mmol/mol on healthy living or an initial medication regimen not associated with hypoglycaemia; 53 on a medicine that can cause it; at 58 or more reinforce, aim for 53 and intensify (1.5.7-1.5.8). The numbers are unchanged; the wording was amended in February 2026. NG28 1.5.9 supports relaxing the target case by case in older or frailer people, with high hypoglycaemia risk or significant comorbidity, but gives no number; DCRM 2.0 cites an A1C goal of about 7.5% (58 mmol/mol) or higher for older adults with complex comorbidities, and the ADA Standards of Care use a less stringent goal of below 8.0% (64 mmol/mol) for older adults with complex health (not DCRM 2.0 or NG28 wording).
Three questions at diagnosis
1 · Atherosclerotic disease or high risk?
Yes (established disease): an SGLT2 inhibitor with proven cardiovascular benefit (empagliflozin, dapagliflozin, canagliflozin) and, in the UK, subcutaneous semaglutide up to 1 mg weekly with metformin (NG28 1.15.1), whatever the HbA1c. Dulaglutide and liraglutide have outcome evidence and are ESC/ADA-supported alternatives but are not the NG28 recommendation.
2 · Heart failure, any ejection fraction?
Yes: SGLT2 inhibitor (DAPA-HF, EMPEROR-Reduced and -Preserved; NICE TA679/773, TA902/929). Avoid pioglitazone and saxagliptin. F4 holds the pillars.
3 · CKD — eGFR below 60 or ACR of 3 mg/mmol or more?
Yes: ACE inhibitor or ARB at the highest tolerated dose plus an SGLT2 inhibitor (dapagliflozin TA1075 or empagliflozin TA942; eGFR 20 or more). Finerenone (TA877) is an add-on to that optimised care, including an SGLT2 inhibitor unless unsuitable, in stage 3-4 CKD with persistent ACR of 3 mg/mmol or more and eGFR 25 or more. FLOW (Perkovic, NEJM 2024) showed kidney benefit with semaglutide and KDIGO 2024 (Rec 3.9.1) recommends a long-acting GLP-1 receptor agonist where glycaemic targets are not met on metformin and an SGLT2 inhibitor, or these cannot be used, but NICE NG28 (2026) did not recommend one for CKD because it was not cost effective. F5 holds the ladder.
| Population | HbA1c target | Note |
|---|---|---|
| Most adults on drugs that do not cause hypoglycaemia | 48 mmol/mol | NICE NG28; achievable with metformin, SGLT2 inhibitor and incretin combinations |
| On a sulfonylurea or insulin | 53 mmol/mol | The hypoglycaemia margin |
| Frailty, hypoglycaemia history, advanced CKD, limited life expectancy | Relax case by case | NICE NG28 1.5.9 supports relaxing the target but gives no number; DCRM 2.0 about 7.5% (58 mmol/mol) or higher; ADA Standards of Care below 8.0% (64 mmol/mol) in complex health |
| Preconception and pregnancy | Below 48 mmol/mol if safely achievable | NICE NG3: metformin with or instead of insulin; stop other oral agents (including SGLT2 inhibitors) before pregnancy; GLP-1 receptor agonists and tirzepatide per NG28 1.9.4 and the MHRA washout |
Checkpoint 1 · New type 2 diabetes, HbA1c 60, BMI 31, no cardiovascular, kidney or heart disease. Initial therapy under NICE NG28 (2026)?
Modified-release metformin plus an SGLT2 inhibitor (NG28 1.13.1), introduced one at a time with metformin first (1.20.2), alongside lifestyle. Target 48 mmol/mol. Not metformin alone, and not a sulfonylurea.
The toolkit, even-handedly
What each class does, which trial earned its place, and where NICE puts it.
| Agent | Class · key evidence | UK position |
|---|---|---|
| Dapagliflozin · empagliflozin · canagliflozin · ertugliflozin | SGLT2 inhibitors · EMPA-REG, DECLARE, CANVAS; DAPA-HF, EMPEROR; DAPA-CKD, EMPA-KIDNEY (ertugliflozin neutral in VERTIS-CV) | NG28: offered with modified-release metformin for most adults, metformin first (1.13.1, 1.20.2); heart-failure and CKD appraisals (F4, F5); continue for organ protection even if the HbA1c target is not met (1.24.2) |
| Semaglutide (weekly SC or oral) · dulaglutide · liraglutide · exenatide · lixisenatide | GLP-1 receptor agonists · SUSTAIN-6, REWIND, LEADER (exenatide and lixisenatide neutral); FLOW for the kidney; STEP-HFpEF; SELECT in obesity | NG28 1.15.1: subcutaneous semaglutide up to 1 mg weekly in atherosclerotic disease, with metformin and an SGLT2 inhibitor (also 1.27.1); a GLP-1 receptor agonist (at class level NG28 means liraglutide, dulaglutide or semaglutide) or tirzepatide may be considered in early-onset disease (1.16) or obesity (1.29.2); exenatide and lixisenatide are outside the NG28 class definition. TA875 (overweight and obesity); TA1152: semaglutide 2.4 mg weekly to reduce MACE in established CVD with BMI 27 or more, distinct from NG28 1.15.1 |
| Tirzepatide | Dual GIP/GLP-1 · SURPASS-2, SURMOUNT-2, SURPASS-CVOT (established ASCVD; non-inferior to dulaglutide, HR 0.92, superiority not shown) | NG28 1.29.2 (consider after 3 months of initial therapy in obesity; not ranked against GLP-1 receptor agonists); TA924 funding (type 2 diabetes, after failed triple oral therapy), TA1026 (overweight and obesity); the largest HbA1c and weight effect against semaglutide 1 mg in SURPASS-2 |
| Metformin (modified-release preferred) | Biguanide · UKPDS | NG28: modified-release metformin with an SGLT2 inhibitor at eGFR 30 or more (1.18.1); SmPC: titrate to 2 g, maximum 1 g a day at eGFR 30-44, stop below 30 |
| Pioglitazone | Thiazolidinedione · PROactive, IRIS | Option in insulin resistance and after stroke; contraindicated in heart failure; bladder cancer and fracture cautions |
| DPP-4 inhibitors (sitagliptin, linagliptin, alogliptin, saxagliptin) | TECOS, CARMELINA (cardiovascular-neutral) | NG28 default add-on for most groups (no relevant comorbidity, heart failure, CKD, frailty); not with a GLP-1 receptor agonist or tirzepatide (1.24.6); saxagliptin and alogliptin: caution in heart failure (possible increase in HF hospitalisation); linagliptin needs no renal dose adjustment |
| Sulfonylureas (gliclazide, glimepiride) | Hypoglycaemia and weight gain | Demoted by DCRM 2.0; deprescribe in frailty and CKD (NG28 1.30.1 offers one only at eGFR 30 or more); consider reducing or stopping when adding a GLP-1 receptor agonist or tirzepatide |
| Insulin | Basal first | Option alongside a sulfonylurea or pioglitazone when a DPP-4 inhibitor is unsuitable or ineffective (1.25.1, 1.27.2); in CKD after a DPP-4 inhibitor (1.18.4); for symptomatic hyperglycaemia (1.8.1); hypoglycaemia and weight gain |
Reviewing (NG28 1.24). Consider continuing an SGLT2 inhibitor for organ protection even if the HbA1c target is not met; stop a GLP-1 receptor agonist or tirzepatide if BMI falls below 18.5, or if it does not help reach the individualised glycaemic target and is not being taken for cardiovascular benefit; do not offer a GLP-1 receptor agonist or tirzepatide together with a DPP-4 inhibitor.
Translational pearl: the eight-agent prescription. A patient with type 2 diabetes, atherosclerotic disease, CKD and HFpEF is on metformin, an SGLT2 inhibitor, a GLP-1 receptor agonist or tirzepatide, a high-intensity statin, ezetimibe where LDL-C remains above goal, an ACE inhibitor or ARB, a beta-blocker if indicated, and finerenone. Eight agents, each covering a defined spoke of the same disease; metformin stops below an eGFR of 30, and an ACE inhibitor or ARB with finerenone needs potassium monitoring. Reviewed against a four-pillar checklist, that looks rational, not excessive; what is excessive is a sulfonylurea in a frail patient with CKD.
Checkpoint 2 · HbA1c 71 on metformin and dapagliflozin, BMI 38, no cardiovascular disease, wants a weekly injection for glucose and weight. Best licensed option?
Tirzepatide 10–15 mg weekly (NICE NG28 1.29.2): the largest combined glycaemic and weight effect, ahead of semaglutide 1 mg in SURPASS-2. TA924 funding needs failed triple oral therapy, which this patient has not yet had. SURPASS-CVOT (established atherosclerotic disease) was non-inferior to dulaglutide for cardiovascular events, and NG28 recommends tirzepatide for glycaemic, not cardiovascular, benefit.
The safety repertoire, part 1: SGLT2 inhibitors and metformin
Euglycaemic ketoacidosis, sick-day rules, the eGFR dip, lactic acidosis and dosing by kidney function.
Euglycaemic ketoacidosis
Glucose may be only moderately raised (for example below 14 mmol/L) in SGLT2-inhibitor ketoacidosis (MHRA Drug Safety Update, April 2016). Triggers: restricted intake or dehydration, acute illness, surgery, alcohol misuse and a sudden reduction in insulin; NG28 1.21 adds very low carbohydrate and ketogenic diets. Test capillary ketones in any unwell patient on an SGLT2 inhibitor, whatever the glucose; abdominal pain, rapid breathing, vomiting or raised ketones on an SGLT2 inhibitor is suspected DKA: emergency assessment, and stop the drug immediately. Before starting, ask about previous ketoacidosis, current illness, dehydration or volume depletion risk and any very low carbohydrate or ketogenic diet; address these first and delay if needed (NG28 1.21.1-1.21.2), and advise anyone on an SGLT2 inhibitor to speak to you before starting such a diet (1.21.3). In hospitalised patients having major surgery or with serious illness, interrupt the drug and monitor blood ketones (MHRA, March 2020); for elective surgery follow local peri-operative policy. Restart once ketones are normal and the person is stable and eating and drinking (MHRA, March 2020); do not restart after ketoacidosis unless another cause was identified and resolved (MHRA Drug Safety Update, April 2016).
The eGFR dip and the RAAS combination
A fall in eGFR of up to about 30% in the first 2–4 weeks is haemodynamic and reverses on stopping; do not stop unless the fall exceeds 30%, is symptomatic, or comes with hyperkalaemia. Combined ACE inhibitor or ARB plus SGLT2 inhibitor can unmask acute kidney injury during dehydration; the sick-day card covers both.
Metformin and lactic acidosis
Rare but devastating; risk rises with eGFR below 30, acute illness, iodinated contrast in unwell patients and severe liver disease. NG28 continues modified-release metformin with an SGLT2 inhibitor while eGFR is 30 or more and treats it as contraindicated below 30 (1.18.1, 1.9.3). The SmPC sets the ceiling: 1 g a day at eGFR 30–44; stop below 30; withhold during dehydrating illness and at the time of iodinated contrast imaging, restarting at least 48 hours later once renal function is stable. Assess renal function at least annually, and every 3–6 months if it is falling or the person is at risk or older. Modified-release improves gastrointestinal tolerance; check B12 with symptoms or anaemia.
SADMANS: the sick-day card
Sulfonylureas · ACE inhibitors and ARBs · Diuretics · Metformin · ARNI · NSAIDs · SGLT2 inhibitors. Withhold during vomiting, diarrhoea or fever with poor intake; reinstate once eating, drinking and passing urine normally for 24 hours. Insulin is not on the card: do not stop it in illness; keep taking it, check glucose and ketones more often and get advice on dose adjustment (NG28 1.10.1), and follow the MHRA ketone advice when an SGLT2 inhibitor is interrupted. Give it in writing (Diabetes UK and kidney-charity wallet cards) and embed it in the practice template.
Other SGLT2 inhibitor points: genital mycotic infection is common and treatable; volume depletion warrants a diuretic review in the euvolaemic; use caution in frailty where volume depletion or hypotension is a risk (NG28 1.19.1); Fournier's gangrene is rare but reportable.
Checkpoint 3 · On empagliflozin, two days of vomiting, abdominal pain, rapid breathing, glucose 11. Reassure?
No. Check ketones now; this is euglycaemic ketoacidosis until proven otherwise. Stop the SGLT2 inhibitor, metformin and ramipril, and arrange immediate emergency hospital assessment.
The safety repertoire, part 2: incretins and hypoglycaemia
Pancreatitis and gallstones, dose reductions on combination, the three levels of hypoglycaemia, and who gets a glucose sensor.
GLP-1 receptor agonists and tirzepatide
Nausea and vomiting settle with slow titration; gallbladder and biliary disease is more common on GLP-1 receptor agonists: about 1.3-fold overall and in diabetes trials (RR 1.27–1.37), and more than doubled at weight-loss doses (RR 2.29), rising with dose and duration (He et al., JAMA Intern Med 2022). Acute pancreatitis is rare but real, and necrotising and fatal cases have been reported (MHRA, January 2026): new persistent abdominal pain, especially radiating to the back, is not normal; lipase and imaging, stop the drug, and no re-challenge after proven pancreatitis. Semaglutide has very rarely been associated with non-arteritic anterior ischaemic optic neuropathy: sudden loss of vision, even partial, needs urgent ophthalmological referral and semaglutide is stopped if NAION is confirmed (MHRA, February 2026). Ask about privately supplied products in anyone with severe persistent abdominal pain or sudden visual loss. Avoid in a personal or family history of medullary thyroid cancer. Counsel on dehydration and acute kidney injury with vomiting, and on diabetic retinopathy review with rapid HbA1c falls. Before any procedure under general anaesthesia or deep sedation, make sure the anaesthetist knows about GLP-1 receptor agonist or tirzepatide use, including privately obtained supply: delayed gastric emptying means fasting may not empty the stomach, so pre-procedure instructions or the anaesthetic technique may need modifying; advise the person not to stop the medicine without first discussing it with their doctor, and make sure the anaesthetic team knows (MHRA, January 2025). Use effective contraception while taking a GLP-1 receptor agonist or tirzepatide (NG28 1.9.4); tirzepatide can reduce the effectiveness of oral contraceptives (Lesson 5).
Dose reductions on combination
GLP-1 receptor agonists do not cause hypoglycaemia alone but potentiate sulfonylureas and insulin, and the SmPCs advise considering a lower dose: consider reducing the sulfonylurea (commonly by half, or stopping it) and basal insulin (about 10–20% where the HbA1c is below 64 mmol/mol) on starting semaglutide or tirzepatide, then titrate to readings; the figures are MD Acumen course practice, not NICE or DCRM 2.0. Reduce insulin in steps guided by capillary glucose, never abruptly: diabetic ketoacidosis has been reported when insulin was rapidly reduced or stopped on starting a GLP-1 receptor agonist, and these agents are not a substitute for insulin; tell the person the symptoms of ketoacidosis and to seek urgent help (MHRA, June 2019). Better still, use the opportunity to deprescribe the sulfonylurea.
Hypoglycaemia levels 1–3
Level 1: glucose 3.0–3.9 mmol/L; level 2: below 3.0; level 3: needing another person's help, whatever the glucose. DCRM 2.0 advises considering stopping the sulfonylurea after documented hypoglycaemia and prescribing glucagon to everyone on insulin; the MD Acumen course treats level 3 as an event to be designed out (course framing, not DCRM wording). After one: review the sulfonylurea and insulin, relax the individualised target where appropriate (NG28 1.5.9 gives no number), check renal function, and give the family a plan. Group 1 drivers on insulin or a sulfonylurea with 2 or more severe episodes (needing another person's help) while awake in 12 months must stop driving and notify DVLA, which then makes medical enquiries; Group 2 drivers must notify after every severe episode.
Monitoring and technology
NG28 1.7.1 offers intermittently scanned continuous glucose monitoring to adults with type 2 diabetes on multiple daily insulin injections with recurrent or severe hypoglycaemia, impaired awareness, a disability preventing finger-prick testing, or 8 or more tests a day; 1.7.2 covers insulin-treated adults who need a care worker or healthcare professional to help monitor. Once-daily basal insulin with family support may not qualify. Capillary self-monitoring is not offered routinely; NG28 1.6.2 offers it if on insulin, with evidence of hypoglycaemic episodes, on tablets that may cause hypoglycaemia while driving or operating machinery, or in pregnancy or pre-conception; short-term with corticosteroids or to confirm suspected hypoglycaemia (1.6.3). HbA1c every 3–6 months until stable, then 6-monthly.
Checkpoint 4 · Frail 76-year-old on glargine and gliclazide, two level 3 hypoglycaemic episodes in a fortnight, eGFR 45. Immediate priority?
Stop the gliclazide, reduce the basal insulin, relax the individualised target (NG28 1.5.9), review glucose monitoring (isCGM if NG28 1.7.1 or 1.7.2 criteria are met), and address driving and the family plan.
The whole picture: aspirin, lipids, blood pressure, pregnancy, frailty
What the diabetes consultation must cover beyond glucose, and where the ladder bends.
Aspirin for primary prevention: no
ASCEND (2018, n = 15,480 with diabetes and no cardiovascular disease): a small absolute reduction in vascular events offset by an equivalent excess of major bleeding. NICE advises against it in type 2 diabetes without cardiovascular disease (NG28 1.45.1; NG238 1.2.1). DCRM 2.0 is more permissive and allows aspirin in selected people with two or more risk factors and low bleeding risk after discussion, so in UK practice NICE applies. The levers with net benefit are statin intensification (LDL-C below 1.8 at high risk, F2), blood pressure, the SGLT2 inhibitor, weight and smoking.
Blood pressure and lipids
NICE NG136 (its tables reproduce NG203 for CKD): clinic below 140/90 under age 80 (below 150/90 from age 80), or below 130/80 in CKD with an ACR of 70 mg/mmol or more. Offer an ACE inhibitor or ARB at step 1 to adults with type 2 diabetes of any age or family origin (NG136 1.4.32), including where there is albuminuria; do not combine an ACE inhibitor with an ARB (1.4.34). Atorvastatin 20 mg for primary prevention at a 10-year QRISK3 of 10% or more (NG238 1.6.7); do not rule it out below 10% on informed preference or if risk may be underestimated (1.6.8); aim for more than 40% non-HDL-C reduction (1.6.1); atorvastatin 80 mg with established CVD (1.7.2). Annual ACR, eGFR, retinal screening and foot check are the organ-protection audit.
Pregnancy and preconception
NICE NG3: metformin may be used with or instead of insulin; stop other oral glucose-lowering agents (including SGLT2 inhibitors) before pregnancy and use insulin; aim for an HbA1c below 48 mmol/mol if achievable without problematic hypoglycaemia; folic acid 5 mg until 12 weeks; stop statins and ACE inhibitors or ARBs before conception or as soon as pregnancy is confirmed. Use effective contraception while taking a GLP-1 receptor agonist or tirzepatide and for the MHRA washout before trying to conceive (NG28 1.9.4): at least 2 months for semaglutide, at least 1 month for tirzepatide, none for liraglutide. Tirzepatide can reduce the effectiveness of oral contraceptives: switch to a non-oral method or add a barrier method for 4 weeks after starting and after each dose increase. Do not take these medicines in pregnancy or while breastfeeding. Contact the joint diabetes–antenatal clinic immediately once pregnant (NG3 1.3.37). After delivery, metformin and insulin can continue (insulin needs fall and hypoglycaemia risk is higher, especially while breastfeeding); while breastfeeding, other oral glucose-lowering agents and medicines stopped for safety before conception, including statins, ACE inhibitors and ARBs, stay stopped (NG3 1.6.4–1.6.5). If not breastfeeding, review each agent on its merits.
Frailty and advanced CKD
Frailty, assessed by clinical judgement (NICE NG28 sets no frailty-scale cut-off; a Clinical Frailty Scale of 6 or more, moderate frailty, is a commonly used working threshold), should prompt deliberate de-escalation: relax the individualised target case by case (NG28 1.5.9; the ADA Standards of Care use below 8.0% (64 mmol/mol) and DCRM 2.0 about 7.5% (58 mmol/mol) or higher; neither is a NICE figure), deprescribe sulfonylureas, review polypharmacy quarterly (NG28 1.19.3), and offer an SGLT2 inhibitor only if frailty does not put the person at risk of volume depletion or hypotension (1.19.1); statins retained for secondary prevention if life expectancy exceeds a year. In eGFR below 30 metformin is contraindicated; NG28 offers dapagliflozin or empagliflozin with a DPP-4 inhibitor at eGFR 20–29, a DPP-4 inhibitor alone below 20, and pioglitazone or insulin if a DPP-4 inhibitor is unsuitable (1.18.2–1.18.4); reduce insulin doses and watch for hypoglycaemia; continue an SGLT2 inhibitor already started (NG28 1.24.2; F5).
Checkpoint 5 · Type 2 diabetes, no cardiovascular disease, QRISK3 18%, on statin, ACE inhibitor and SGLT2 inhibitor. Daily aspirin?
No. NICE advises against it (NG28 1.45.1); in ASCEND the bleeding largely counterbalanced the benefit; intensify the lipid, blood-pressure, weight and SGLT2 levers instead.
Running it: the organ-protection search and the review that counts
Where the events are, who to deprescribe, and the annual review that is an audit of organ protection rather than a glucose check.
Three searches
The annual review as an organ-protection audit
Ask the three questions again (atherosclerotic disease, heart failure, CKD) and check the answer is reflected in the prescription. Record the HbA1c target and why; the sick-day card; the ACR and eGFR with the KDIGO band; blood pressure to target; the statin and non-HDL; weight and waist with the weight-management offer (F6); retinal and foot surveillance; vaccination; and, for women of childbearing age, contraception and preconception advice. Ten minutes, one template, every drug in it for a stated reason.
Practice task
Run search 1 this week and count the patients with type 2 diabetes and cardiovascular, heart-failure or kidney disease who are not on an SGLT2 inhibitor. Record the number and your first ten actions in the reflection box below; it prints on your certificate. Do not include patient names, NHS numbers, initials or any detail that could identify a patient or practice: record counts and actions only.
Checkpoint 6 · The one diabetes search that reduces events most?
The organ-protection gap: diabetes joined to the CVD, heart-failure and CKD registers, listing each missing SGLT2 inhibitor and, separately, atherosclerotic disease without subcutaneous semaglutide, plus the deprescribing list.
Ten items, marked on our learning platform
Answer all ten, add your details and reflection, and claim your certificate. Pass mark 70% (7 of 10). If you fall short you can read back and try again; your answers are kept.
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Reflection — for your CPD portfolio
Two short entries of at least 20 characters each. They are stored with your certificate record and printed on the certificate. Do not include patient names, NHS numbers, initials or any detail that could identify a patient or practice; record counts and actions only.
New Vision University (UK)
Acumen Focus · CVRM-HF Foundation series · delivered by MD Acumen Ltd
This certifies that
Your name will appear here
has completed
Acumen Focus F3 · Type 2 diabetes and cardiometabolic therapy
including its 10-item knowledge check
Authored by Prof Rajesh Varma · MD Acumen Ltd · mdacumen.com
CPD authorised by Prof Rajesh Varma, Convenor for CPD, New Vision University (UK)
Signed against: NICE NG28 (updated 18 February 2026) · NICE NG3 · NG136 · NG203 · NG238 · TA924 · TA1026 · TA877 · TA875 · TA1152 · DCRM 2.0 (2024) · MHRA Drug Safety Updates (April 2016, June 2019, March 2020, January 2025, January 2026, February 2026) and GLP-1 guidance (February 2026) · ASCEND (2018) · EMPA-REG OUTCOME (2015) · FLOW (2024) · KDIGO 2024 · DVLA · He et al. (2022) · SmPCs (metformin, dapagliflozin, Ozempic, Mounjaro)
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Keep learning
F3 is the diabetes pillar of the CVRM-HF Foundation series (F1 cardiometabolic risk · F2 lipids · F3 type 2 diabetes · F4 heart failure · F5 kidney disease · F6 obesity and MASLD). Complete all six for the series certificate (6 CPD); the series counts as recognised prior learning for the Certificate of Advanced Studies in CVRM-HF.
Key sources
Every clinical statement in this module is checked against the source below at each signed review. Where several licensed agents in a class exist they are presented even-handedly per their NICE technology appraisals.
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