When can insulin be stopped in a patient taking semaglutide (glucagon-like peptide-1 receptor agonist)?

When to Stop Insulin When on Semaglutide

Insulin can be discontinued in patients taking semaglutide when glycemic control is achieved (HbA1c ≤7.5%), particularly when the total daily insulin dose is ≤120 units/day, with most patients able to maintain good glycemic control after stopping prandial insulin while continuing basal insulin alongside semaglutide. 1

Decision Algorithm for Insulin Discontinuation

Candidates for Insulin Discontinuation

• Patients with well-controlled Type 2 diabetes (HbA1c ≤7.5% or ≤58 mmol/mol) 1
• Patients on stable semaglutide therapy (typically at maintenance dose of 1.0-2.4 mg weekly) 2, 1
• Patients showing significant weight loss response to semaglutide 1
• Shorter diabetes duration and lower baseline insulin requirements 2

Stepwise Approach to Insulin Discontinuation

1. First, discontinue prandial (bolus) insulin

   • 97.5% of patients can successfully stop prandial insulin when on semaglutide 1
   • Continue basal insulin alongside semaglutide 1, 3

2. Monitor for 3-6 months before considering basal insulin discontinuation

   • Approximately 33% of patients can completely discontinue all insulin therapy 2
   • 60% of patients can achieve HbA1c <7% on semaglutide therapy 2

3. Gradually reduce basal insulin doses

   • Patients on semaglutide can reduce total daily insulin dose by approximately 56% 1
   • Monitor for hypoglycemia during insulin reduction 1, 3

Monitoring During Transition

• Perform HbA1c testing quarterly during therapy changes 4
• Increase frequency of self-monitoring of blood glucose (SMBG) during transition (every 4-6 hours while awake) 4
• Consider continuous glucose monitoring (CGM) if available, especially during insulin reduction 4
• Watch for hypoglycemia, particularly if continuing sulfonylureas 4

Special Considerations

Predictors of Successful Insulin Discontinuation

• Shorter diabetes duration 2
• Lower baseline HbA1c 2
• Lower baseline insulin requirements 2
• Greater weight loss response to semaglutide 1

Cautions and Contraindications

• Discontinue sulfonylureas when starting insulin to avoid hypoglycemia 4
• Patients with Type 1 diabetes should never discontinue insulin 4
• Patients with severe hyperglycemia (HbA1c >10%) may need to continue insulin until glycemic control improves 4
• Consider temporarily stopping GLP-1 receptor agonists during acute illness 4

Common Pitfalls to Avoid

• Abrupt insulin discontinuation: Taper insulin gradually while monitoring glucose levels 1
• Failure to increase monitoring: Increase SMBG frequency during transition 4
• Overlooking hypoglycemia risk: Even with reduced insulin, hypoglycemia can occur, especially if sulfonylureas are continued 4
• Not adjusting other medications: Some medications may need dose adjustments when adding semaglutide 4

Clinical Evidence Summary

The most recent evidence from a 2025 randomized trial (TRANSITION-T2D) showed that 90% of patients maintained HbA1c ≤7.5% after replacing prandial insulin with semaglutide while continuing basal insulin. Additionally, 45% of patients achieved >10% weight loss, and 97.5% were able to completely stop prandial insulin 1.

A large real-world study of 674 patients found that 32.8% of patients were able to completely discontinue insulin therapy after starting semaglutide, with 72.5% of these patients achieving HbA1c <7%. Among patients on basal-bolus insulin, 75% completely discontinued bolus insulin 2.