When to use GLP-1 (Glucagon-like peptide-1) versus Insulin in diabetes management?

From the Guidelines

GLP-1 receptor agonists are generally preferred over insulin therapy in patients with type 2 diabetes due to their efficacy in improving glycemic control, promoting weight loss, and reducing cardiovascular risk 1.

Key Considerations

• Disease severity: Insulin therapy is typically reserved for patients with more severe hyperglycemia or those who have failed to achieve adequate control with GLP-1 receptor agonists 1.
• Comorbidities: The choice between GLP-1 and insulin ultimately depends on individual patient factors, including comorbidities and treatment goals 1.
• Treatment goals: A patient-centered approach should be used to guide the choice of pharmacologic agents, considering factors such as efficacy, hypoglycemia risk, effect on weight, side effects, cost, and patient preferences 1.

GLP-1 Receptor Agonists

• Liraglutide: 1.2-1.8 mg/day 1
• Semaglutide: 0.5-1.0 mg/week 1

Insulin Therapy

• Metformin plus basal insulin glargine: 10-50 units/day 1
• Premixed insulin aspart: 20-50 units/day 1

From the FDA Drug Label

OZEMPIC is a glucagon-like peptide 1 (GLP-1) receptor agonist indicated as: • an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (1). • to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease (1)

Not indicated for use in type 1 diabetes mellitus or treatment of diabetic ketoacidosis (1).

Hypoglycemia: When OZEMPIC is used with an insulin secretagogue or insulin, consider lowering the dose of the secretagogue or insulin to reduce the risk of hypoglycemia (5.5).

GLP-1 (e.g., semaglutide) versus Insulin:

• Use GLP-1 as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
• Use Insulin for type 1 diabetes mellitus or treatment of diabetic ketoacidosis.
• When using GLP-1 with insulin, consider lowering the dose of insulin to reduce the risk of hypoglycemia 2.

From the Research

GLP-1 versus Insulin in Diabetes Management

• GLP-1 receptor agonists (GLP-1 RAs) are recommended as the preferred first injectable glucose-lowering therapy for type 2 diabetes, even before insulin treatment, due to their similar or superior effectiveness for HbA1c reduction, additional weight reduction, and no intrinsic risk of hypoglycemic episodes 3.
• GLP-1 RAs can be combined with basal insulin in either free- or fixed-dose preparations, and are particularly recommended for patients with pre-existing atherosclerotic vascular disease 3.
• The choice between GLP-1 RAs and insulin depends on individual patient factors, such as the presence of cardiovascular risk factors, need for weight loss, and potential for hypoglycemia 4, 5.

Patient-Specific Factors

• Patients with high cardiovascular risk factors may benefit from GLP-1 RAs as first-line therapy, due to their positive effects on weight loss, blood pressure, hyperlipidemia, and glycemic control 6.
• Patients who are intolerant to metformin or have a high risk of hypoglycemia may also benefit from GLP-1 RAs as an alternative to insulin therapy 4, 7.
• The choice of GLP-1 RA should be based on individual patient preferences, potential adverse effects, and cost, as well as the specific characteristics of each medication, such as dosing frequency and efficacy 4, 7.

Comparison of GLP-1 RAs and Insulin

• GLP-1 RAs have been shown to have a more favorable risk-benefit profile compared to insulin, with a lower risk of hypoglycemia and weight gain 3, 5.
• Insulin therapy may be necessary for patients with more advanced diabetes or those who require more intensive glucose control, but GLP-1 RAs can be used in combination with insulin to improve glycemic control and reduce cardiovascular risk 3, 6.