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For the first time, we have data comparing SGLT-2i and GLP-1 RA for kidney protection. The results are not what you might expect.

That's one story this week. We've also got a year's worth of NICE guidance changes distilled into one place, the latest HRT evidence reviewed across 30+ publications, and a look at why rare disease awareness campaigns keep missing the mark. Here's what's inside:

You're already getting plenty of NHS politics and contract noise from every direction. That's not what we're here for.

Medicine Central exists because clinical evidence keeps moving and it's genuinely hard to keep up alongside everything else. We're focusing on the clinical evidence, the prescribing guidance and changes that impact your day to day. We want to send you info that you would print off and give to a collegue! We'll leave the politics to others.

So tell us where to focus:

A lot has changed in NICE guidance over the past few months. A few days ago we published a full breakdown of the all the changes from 2025-2026. You can download the resource and stay up to date with all the latest guidance changes at https://www.medicinecentral.co.uk/nice-guidelines

Cardiometabolic prescribing

The biggest shift is in NG28, the type 2 diabetes guideline, updated in February 2026. This is the biggest shake-up in diabetes care in a decade.

We've already published a full breakdown of the NG28 changes - everything you need to know about the new prescribing pathways, who they apply to, and what it means for your patients.

The headline change: SGLT-2 inhibitors move from second-line to first-line treatment. For most adults with type 2 diabetes, the new recommendation is to start metformin first, confirm tolerability, then add an SGLT-2 inhibitor. The rationale has shifted beyond HbA1c control. These drugs are now recommended explicitly for their cardiovascular and renal protective effects, not just glucose lowering.

GLP-1 receptor agonists and tirzepatide also come in earlier for specific groups. Adults with established atherosclerotic cardiovascular disease should now be offered triple therapy including a GLP-1 receptor agonist as part of initial treatment. Early-onset type 2 diabetes (diagnosed before age 40), obesity, CKD, and heart failure all have tailored pathways under the new guidance.

NG136, the hypertension guideline: Also updated in February 2026, the change is more modest - a new recommendation to offer healthy lifestyle advice to people with raised blood pressure who have not yet received a formal hypertension diagnosis. Worth having a read if you haven't already, particularly given how often this group sits in a grey zone in practice.

Cancer recognition and referral

NG12 has had two clinically relevant updates.

Safeguarding

CG89, the child maltreatment guideline, was updated in December 2025 with a change that looks small on paper but matters considerably in practice. NICE has added a formal definition of "independently mobile" for the first time.

This term underpins recommendations on when to suspect maltreatment in the context of bruising, lacerations, abrasions, burns and scalds. Until now, the absence of a definition had led to real inconsistency in how clinicians and safeguarding teams were applying the same guidance. The update clarifies that a child should be considered independently mobile if they can roll, sit, crawl, bottom shuffle, pull to stand, cruise or walk.

These aren't the only updates worth knowing about. The past year has also brought new standalone sepsis guidelines, a significantly updated heart failure guideline (NG106) with recommendations for HFmrEF and HFpEF for the first time, a new consolidated pneumonia guideline, and updates to falls assessment, obesity management, and gambling-related harms. Plain English summaries of all of them are on the Medicine Central website.

Both SGLT2 inhibitors and GLP-1 receptor agonists protect the kidneys in type 2 diabetes. We know that. But nobody has run a head-to-head trial to tell us which one does it better.

A large new study in JAMA Internal Medicine is the closest we have got to an answer - the results are not as straightforward as you might expect…

Jensen and colleagues used Danish national registry data to compare over 55,000 adults with metformin-treated type 2 diabetes who started either an SGLT2 inhibitor or a GLP-1 receptor agonist between 2014 and 2020, with follow-up running to October 2024.

They used a target trial emulation design, which is the gold standard for observational comparative effectiveness research. It mimics the structure of a RCT as closely as the data allow. After weighting for baseline differences, the two groups were well-matched for age (median around 62), diabetes duration, eGFR and urine albumin-creatinine ratio.

Over five years, people who started an SGLT2i had a lower risk of developing CKD (defined as a 40% drop in eGFR, severe albuminuria, or kidney failure) compared with those who started a GLP-1 RA. The five-year CKD risk was 6.7% vs 8.2%, giving a risk ratio of 0.81. In plain terms, roughly one in every 67 patients treated with an SGLT2 inhibitor instead of a GLP-1 receptor agonist avoided a CKD event over five years.

SGLT2 inhibitors was also associated with fewer acute kidney injury episodes per person over the five-year follow-up period (25.2 vs 28.7 events per 100 individuals).

But here is where it gets interesting. GLP-1 RA was also associated with slightly lower rates of albuminuria and mortality. So this is not a clean sweep for either drug class. It is a genuine split decision.

The most striking finding was in the subgroup analysis. The SGLT2 inhibitor advantage for CKD and AKI was most pronounced in patients who did not already have kidney disease.

A few important caveats. This is an observational study, not a randomised trial. The target trial emulation design is rigorous, but it cannot eliminate unmeasured confounding the way randomisation can. The population was Danish and overwhelmingly white European, so we should be cautious about applying these findings directly to more diverse UK populations. Plus, urine albumin-creatinine ratio data were missing for a proportion of participants, which could have affected the albuminuria findings in particular.

What does this add to the picture?

Until now, we have had strong trial data for each drug class individually but no comparison for kidney outcomes. This study provides the first large-scale evidence. It suggests the two classes may offer different types of kidney protection: SGLT2 inhibitors were more strongly associated with preserving eGFR and reducing AKI, while GLP-1 receptor agonists were associated with lower albuminuria and mortality. The FLOW trial separately showed that the kidney benefits of GLP-1 receptor agonists were consistent regardless of background SGLT2 inhibitor use, adding to the evidence on how these classes relate to each other.

NICE NG28 and KDIGO 2024 set out where each class sits in the current treatment pathway for type 2 diabetes with cardiovascular or renal risk. This study does not change that guidance, but it adds real-world comparative data to a question the guidelines have not yet been able to answer directly.

We are still waiting for a randomised head-to-head trial. Until it arrives, this is the best comparative evidence we have.

For international women’s day we took a deep dive into the latest evidence on HRT, reviewing over 30 publications from 2025-2026.

The latest research confirms HRT is still the most effective treatment for vasomotor symptoms, genitourinary syndrome of menopause, and early postmenopausal bone loss. But the benefit-risk profile is highly dependent on how and when you prescribe it.

The timing window matters. Starting within 10 years of menopause, or before age 60, is associated with a much more favourable risk profile. After that window, cardiovascular risk rises.

Formulation matters too. Transdermal estradiol with micronized progesterone carries lower VTE and breast cancer risk than oral regimens or synthetic progestogens. Combined estrogen-progestogen increases breast cancer risk in a duration-dependent way. Estrogen-only regimens (post-hysterectomy) carry a lower breast cancer risk.

Cognitive benefits remain inconsistent. Some evidence suggests possible protection with early initiation; started after 65, there may be increased dementia risk.

The bottom line: individualised prescribing, lowest effective dose, and regular reassessment. Get the PDF here to share with your colleagues.

For rare disease day we asked ourselves the question - does education actually make a difference in rare disease?

Having worked with pharma for many years, I have seen the same message on repeat - “provide more training for primary care to improve diagnosis in rare diseases”

Now while the evidence is clear that when primary care is actively involved, diagnostic delays shorten, emergency admissions fall, and quality of life improves. But the system is not set up to support that role.

A UK survey found that only 12-14% of rare disease patients had a care coordinator, just 32-33% were seen at a specialist centre, and only 2-5% had all three elements of a basic care plan in place. These aren't gaps in GP knowledge. They're gaps in infrastructure.

The mental health picture is equally striking. Over 90% of patients in one UK survey reported anxiety or low mood. 36% had experienced suicidal thoughts. One of the key drivers: not being believed by clinicians.

More education helps, but it isn't the answer on its own. What actually moves the needle: EHR-embedded case-finding tools, clear referral pathways, concise clinical resources accessible at the point of care, and pathway templates for specific conditions.

Download the full article here

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