Use of Semaglutide (Ozempic) in Obese Patients with Type 1 Diabetes
Semaglutide can be used in obese patients with type 1 diabetes as an adjunct therapy for weight management, with recent evidence showing significant benefits for weight loss and glycemic control when used alongside insulin therapy. 1
Evidence for Use in Type 1 Diabetes
While semaglutide is not FDA-approved specifically for type 1 diabetes, recent clinical evidence supports its use in this population:
- The 2025 American Diabetes Association (ADA) Standards of Care acknowledges that GLP-1 receptor agonists, including semaglutide, have been studied in type 1 diabetes with positive results 2
- A recent 26-week randomized controlled trial (ADJUST-T1D) demonstrated that semaglutide significantly improved a composite outcome of glycemic control and weight loss in adults with type 1 diabetes and obesity 1
- Real-world retrospective data shows that semaglutide effectively reduces body weight and BMI while improving glycemic metrics in overweight/obese patients with type 1 diabetes 3
Dosing and Administration
For obese patients with type 1 diabetes, the following approach is recommended:
- Initial dosing: Start with 0.25 mg subcutaneously once weekly for 4 weeks (titration dose) 4
- Titration schedule:
- Weeks 1-4: 0.25 mg weekly
- Weeks 5-8: 0.5 mg weekly
- Weeks 9-12: 1.0 mg weekly 4
- Administration: Inject subcutaneously in the abdomen, thigh, or upper arm, rotating injection sites 4
Expected Benefits
Patients with type 1 diabetes and obesity may experience:
- Weight reduction: Mean weight loss of 8.8 kg (compared to placebo) over 26 weeks 1
- Improved glycemic control:
Safety Considerations and Monitoring
When using semaglutide in patients with type 1 diabetes, be aware of these important safety considerations:
- Diabetic ketoacidosis (DKA) risk: Unlike SGLT2 inhibitors, semaglutide has not shown increased DKA risk in clinical trials of patients with type 1 diabetes 1
- Hypoglycemia: Monitor closely as insulin requirements may decrease with weight loss 3
- Gastrointestinal side effects: Nausea, vomiting, and diarrhea are common, especially during dose titration 4
- Contraindications: Do not use in patients with:
- Personal or family history of medullary thyroid carcinoma
- Multiple Endocrine Neoplasia syndrome type 2
- Known hypersensitivity to semaglutide 4
Practical Implementation
For successful implementation in obese patients with type 1 diabetes:
- Patient selection: Consider for patients with BMI ≥30 kg/m² or ≥27 kg/m² with weight-related complications 5
- Insulin adjustment: Be prepared to reduce insulin doses as weight decreases and insulin sensitivity improves 3
- Monitoring:
- Regular weight measurements
- Continuous glucose monitoring if available
- HbA1c every 3 months
- Screen for malnutrition in patients with significant weight loss (>20%) 2
Limitations and Caveats
Important considerations when prescribing:
- Semaglutide is not a substitute for insulin in type 1 diabetes 4
- FDA labeling specifically states that Ozempic "is not indicated for use in patients with type 1 diabetes" (off-label use) 4
- The ADA acknowledges that clinical trial data in type 1 diabetes population is limited 2
- Long-term safety data beyond 26 weeks is not yet available for this specific population 1
The 2025 ADA Standards of Care notes that "retrospective case series have revealed potential benefits on body weight and glycemic metrics with addition of semaglutide or tirzepatide for individuals with type 1 diabetes and obesity. Prospective studies using semaglutide are ongoing." 2
Human studies now provide stronger evidence for this approach, with the ADJUST-T1D trial showing that 36% of patients achieved the composite outcome of time in range >70%, time below range <4%, and ≥5% weight reduction with semaglutide versus 0% with placebo 1.