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Specifically, NICE suggests considering a DPP-4 inhibitor as a second agent when: The patient has a high risk of hypoglycaemia (making sulfonylureas less suitable) Weight management is a concern and a sulfonylurea's weight-gaining effects are undesirable An SGLT-2 inhibitor is contraindicated or not tolerated NICE NG28 recommends that in patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, an SGLT-2 inhibitor should generally be prioritised often alongside or instead of metformin due to its organ-protective benefits