Can a type 2 diabetic on Ozempic (semaglutide) come off of insulin?

Can Type 2 Diabetics on Ozempic Discontinue Insulin?

Yes, many type 2 diabetics on Ozempic (semaglutide) can successfully discontinue insulin, particularly those on basal insulin alone or basal-bolus regimens, with approximately one-third able to completely stop insulin while maintaining glycemic control. 1

Evidence for Insulin Discontinuation with Semaglutide

Real-World Outcomes

The most compelling evidence comes from a large multicenter study of 674 patients previously on insulin who initiated semaglutide:

• 32.8% completely discontinued all insulin therapy, with 72.5% of these patients achieving HbA1c <7% 1
• Among patients on basal-bolus insulin regimens, 75% discontinued bolus insulin entirely, with 62% achieving HbA1c <7% 1
• Those who remained on insulin still achieved significant reductions in total daily insulin requirements 1
• Mean HbA1c decreased by 0.9% and body weight by 4.3 kg over 18 months 1

Predictors of Successful Insulin Discontinuation

Patients most likely to successfully discontinue insulin have: 1

• Shorter diabetes duration
• Lower baseline HbA1c levels
• Lower baseline insulin doses

Clinical Trial Evidence Supporting Insulin Replacement

Semaglutide vs. Insulin Glargine (SUSTAIN 4)

In insulin-naive patients, semaglutide demonstrated superiority over basal insulin: 2

• Semaglutide 1.0 mg reduced HbA1c by 1.64% vs. 0.83% with insulin glargine (difference -0.81%, p<0.0001)
• Weight loss of 5.17 kg with semaglutide vs. weight gain of 1.15 kg with insulin glargine
• Significantly fewer hypoglycemic episodes: 6% with semaglutide 1.0 mg vs. 11% with insulin glargine (p=0.0202)

Semaglutide as Add-On to Insulin

When added to existing insulin therapy rather than replacing it: 3

• Semaglutide 14 mg added to insulin reduced HbA1c significantly more than placebo at both 26 and 52 weeks
• Facilitated a decrease in total daily insulin dosage
• Did not increase hypoglycemia incidence despite improved glycemic control

Guideline-Based Approach to Insulin Discontinuation

When to Consider Insulin Discontinuation

Initiate GLP-1 RA (like semaglutide) before starting insulin in most patients, as current guidelines prioritize GLP-1 RAs over insulin for their cardiovascular and renal benefits, weight loss advantages, and lower hypoglycemia risk. 4

Consider discontinuing or reducing insulin when: 4

• Glucose toxicity has resolved after initial insulin therapy for severe hyperglycemia
• Patient was started on insulin for blood glucose ≥300 mg/dL or HbA1c ≥10% with symptoms, but these conditions have improved
• Patient is on basal insulin doses >0.5 units/kg (suggesting overbasalization) 4

Contraindications to Insulin Discontinuation

Do NOT discontinue insulin in patients with: 4

• Severe hyperglycemia (HbA1c >86 mmol/mol [>10%]) with weight loss or ketonuria/ketosis
• Suspected type 1 diabetes
• Acute glycemic dysregulation (hospitalization, surgery, acute illness)
• Underweight status

Practical Implementation Algorithm

Step 1: Assess Suitability

• Confirm type 2 diabetes (not type 1 or LADA)
• Evaluate current insulin regimen and doses
• Check recent HbA1c and weight trends

Step 2: Initiate Semaglutide

• Start semaglutide using standard dose escalation (0.25 mg weekly → 0.5 mg → 1.0 mg, with 2.0 mg available if needed) 5, 6
• Continue metformin if already prescribed 5
• Discontinue sulfonylureas immediately to prevent hypoglycemia 4

Step 3: Reduce Insulin Gradually

For patients on basal insulin only:

• Reduce basal insulin dose by 20-50% when starting semaglutide 7
• Monitor fasting glucose closely
• Consider complete discontinuation after 3-6 months if HbA1c <7% and fasting glucose controlled 1

For patients on basal-bolus regimens:

• First eliminate bolus insulin at meals with smallest glucose excursions 1
• Reduce basal insulin by 20% 7
• Progressively eliminate remaining bolus doses over 2-4 weeks
• Consider maintaining basal insulin if needed for fasting glucose control

Step 4: Monitor and Adjust

• Assess HbA1c at 3 months 4
• If HbA1c remains >7%, consider increasing semaglutide to 2.0 mg before reintroducing insulin 6
• Monitor for hypoglycemia, though risk is significantly lower with semaglutide than insulin 2

Important Caveats

Avoid therapeutic inertia: The progressive nature of type 2 diabetes should be explained objectively, and insulin should never be presented as "failure" or "punishment." 4 However, with effective GLP-1 RA therapy, many patients can delay or avoid insulin entirely.

Cost considerations: While semaglutide is expensive, the total cost may be offset by insulin discontinuation, reduced hypoglycemia episodes, and decreased monitoring requirements. 4 Discuss financial barriers openly with patients.

Glucose toxicity resolution: The ADA guidelines explicitly state that "as glucose toxicity resolves, simplifying the regimen and/or changing to oral agents is often possible" after initial insulin therapy for severe hyperglycemia. 4 This principle applies equally to GLP-1 RAs like semaglutide.

Cardiovascular and renal benefits: Beyond glycemic control, semaglutide provides cardiovascular risk reduction and renoprotective effects that insulin does not offer, making it a superior choice for most patients with type 2 diabetes. 8, 4