This content originally appeared in everyday health. It was reissued with permission.
by I want a loss
Medical review Elise M. Brett, Maryland
New blockbuster GLP-1 drugs such as Ozempic and Mounjaro are probably the most effective drugs ever developed for type 2 diabetes and obesity. They can also have a transformational effect on the treatment of type 1 diabetes, but there are risks.
Satishugag, Maryland has bold predictions. “I have no doubt about this class of drugs going forward will be used by the majority of people with type 1 diabetes.”
Dr. Garg, a professor at the University of Colorado Barbara Davis Center in Aurora, has written two recent studies on the actual use of GLP-1 to treat type 1 diabetes in people who are overweight or obese. GLP-1 and GIP agonists.(1)(2) They show that these big hits have exceptional benefits, such as massive weight loss and a significant blood glucose reduction.
GLP-1 drugs are currently not approved by the US Food and Drug Administration (FDA) for the treatment of type 1 diabetes. But more and more clinicians are prescribing them outside of criticism, primarily to type 1 people who need to lose weight.
Ultimately, Garg believes that almost everyone with type 1 diabetes uses GLP-1. Even people who are overweight “good for a normal BMI (body mass index) beyond weight loss.”
“Lower doses of these drugs are used routinely in diabetic patients not for weight loss, but for the long-term benefits they may give — (reduce the risk of cardiovascular disease) — risk of kidney disease and kidney disease — because it greatly improves blood sugar (glycemic control).”
Type 1 diabetes, overweight, and obesity
Patients with classic stereotypes of type 1 diabetes are thin or debilitating children. Acute hyperglycemia, a characteristic of undiagnosed or uncontrolled diabetes, prevents the body from harvesting energy from food. Ultimately, the body begins to burn body fat and muscle for fuel, leading to weight loss that is not explained among other symptoms.
Thankfully, that stereotype is now almost obsolete, at least in developed countries. The latest insulin and glucose measurement technologies enable people with type 1 diabetes to live a longer and healthier life. For better or worse, it’s much easier to eat a standard meal. In other words, type 1 people are beginning to resemble their non-diabetic peers more and more. One drawback to the shift is that excessive weight gain is almost prevalent in the type 1 diabetes population, as well as the general population.(3)
Health changes associated with overweight and obesity can have negative consequences for both short-term glucose management and long-term health. “People with type 1 diabetes have the same problems as people with type 2,” Garg says. In some cases, patients develop double diabetes.(4)
In short, people with type 1 diabetes need an effective obesity treatment just like everyone else.
Semaglutide, tilzepatide, and type 1 diabetes: Data
A recent study from Garg evaluated the actual use of GLP-1 prescribed in patients with type 1 diabetes at the Barbara Davis Center. At this time, such drug use is largely limited to those with a clear medical need to lose weight.
Tilzepatide produced the most surprising results. Garg’s analysis assessed participants with mean diabetes duration of 40 and 24 years. At the start of the study, its average weight was 229 pounds. Most were white and women.
Tilzepatide appeared to cause major metabolism improvements across the board.
- Extraordinary Weight Loss: After a year, the average participant lost 18.5% of his weight at 46.5 pounds. Some patients lost as much as 200 pounds.
- A1C improvement: Average A1C fell by 0.67 percentage points. Mean blood glucose levels decreased by 23.5 milligrams (mg/dl) per deciliter.
- More time in range: Participants spent an additional 15% of the day within the target glucose range.
- Reduced glucose excursions: The amplitude of blood glucose variability was significantly reduced.
- Low insulin dosage: Volunteers averaged 24.7 units less insulin per day. The basal dosage was reduced by about 10 units and bolus insulin was about 15 units.
“The merits are incredible,” Garg says. “It really flattens all glucose excursions.” And weight loss exceeded his expectations.
Previous trials of Garg semaglutide also identified strong and comprehensive improvements, including weight loss, improvements in A1C, and increased distance. However, the results were less impressive than tilzepatide, especially when it comes to weight loss. Semaglutide users lost an average of 16 pounds.
However, GLP-1 carries a serious risk for people with type 1 diabetes
Despite strong results, there is a reason why experts are extremely cautious about recommending the use of semaglutide and tilzepatide in people with type 1 diabetes. These powerful drugs pose very real risks to people with this condition. This drug must be managed in its own way using new strategies that experts have not yet fully agreed to.
There are two fatal obstacles that everyone with type 1 diabetes needs to navigate at all times. It is a threat to severe hypoglycemia (hypoglycemia) and diabetic ketoacidosis (DKA). GLP-1 drugs are suspected to increase the risk of each drug.
GLP-1 and DKA
GLP-1 quickly became infamous for its bad gastrointestinal side effects. For example, at the highest dose, semaglutide causes diarrhea in 32% and vomits in 25% of users. For most people, these side effects fade away as your body gets used to the medication.
However, the risk has risen sharply for people with type 1 diabetes, as dehydration disorders such as vomiting and diarrhea can rapidly lead to DKA.(5) If a person with type 1 diabetes is unable to eat or drink due to stomach illness, inevitably uses less insulin, making it even more likely that DKA will develop.
People with type 1 diabetes should be particularly careful about GLP-1 drugs because of DKA. This condition is fatal without emergency treatment.
GLP-1 and hypoglycemia
Meanwhile, GLP-1 can also increase the risk of severe hypoglycemia as it fundamentally affects insulin requirements. Most people with diabetes who receive injections of GLP-1 drugs experience greater insulin sensitivity. GLP-1 itself often does not cause hypoglycemia, but if users with type 1 diabetes do not adjust their use of insulin quickly, they run the risk of lowering their blood glucose levels to dangerous levels.
At the Barbara Davis Center for Diabetes, Garg instructs patients to reduce insulin by 20% when they first start GLP-1. He and his colleagues continued to suggest a reduction in insulin administration as participants stepped up to a higher GLP-1 dose.
No one in this study was hospitalized with severe hypoglycemia or hyperglycemia. However, Garg had a scary experience with a patient who overcompensated and began taking insulin.
Garg took the potential danger seriously. “We closely monitored these patients.” All participants wore serial glucose monitors (CGMs) to allow doctors to remotely track their blood glucose levels. In the real world, clinicians cannot easily provide that level of guidance.
Garg is “absolutely” worried about using GLP-1 in situations that are not carefully controlled. “I’m definitely worried that these medications will be used left and right by people with type 1 diabetes.”
People with type 1 diabetes need less GLP-1
Garg says that the best way to manage these two risks is to take small amounts of GLP-1 medication in the first place. Lower doses and a more gentle dose escalation schedule can alleviate the effects of side effects and changes in insulin requirements.
That’s easier than that. This family of Ozempic, Mounjaro, and other injectable drugs are manufactured and distributed at accurate, discrete doses not designed for the more sensitive bodies of people with type 1 diabetes. However, there are creative and unapproved ways to inject less medication than the manufacturer intended.
For example, the starter dose for Ozempic is 0.25 milligrams (mg) per week. However, Garg thinks it’s too big for most people with Type 1. “We launch them with 0.1 mg and gradually increase 1 or 2 mg per week in 3 months.” By counting delivery pens, we can make small amounts of semaglutide, as described in Daily Health Network Site Diabetes, a technology that neither FDA nor manufacturers support.
Tilzepatide comes in pen devices that do not allow custom dosing in the same way. For small tilzepatide doses, Garg occasionally asks the patient to take the dose every 10 days rather than every 7 days. Some of his patients also use an insulin syringe to extract the exact dose of tilzepatide from the pen.
The provider really doesn’t know how to properly use these medications. All guidelines must be created.
– Satish Garg, Maryland
Lower doses are not necessarily only in the first month of treatment. Clinicians may be wise to maintain type 1 patients with a smaller GLP-1 dose throughout treatment, Garg says. At the Barbara Davis Center, most of the study participants who were prescribed tilzepatide had progressed to higher doses available to date. And those who lose weight are less likely to need large doses.
When children use these medications, the need for lower doses is most important. Garg argues that many physicians and endocrinologists are prescribing GLP-1 in children with overweight and type 1 diabetes despite lack of full research and formal guidance on the issue. Of course, children are small, but adolescence can also be a particularly difficult time in blood glucose control. Hormonal changes tend to cause dramatic changes in insulin sensitivity every day with each diabetes, making it even more important to actively manage risk. (Semaglutide is approved for weight loss in adolescents over the age of 12, but there is some controversy as to how often it should be prescribed. Tilzepatide is not approved for people under the age of 18.)(6)
New guidelines are needed
Garg says that using GLP-1 to treat type 1 diabetes is already very common. However, we don’t know if it is safely prescribed and used in the real world. “Providers really don’t know how to properly use these drugs. They need to write all the guidelines.”
In a recent editorial, Garg and his colleagues shared best practices regarding the safe and effective use of GLP-1 in people with type 1 diabetes. Some of the most important takeaways for clinicians are:
- Starting GLP-1 treatment reduces the insulin dose by 20-30%.
- Adjust the insulin dose as the patient rises to a larger GLP-1 dose.
- Titration of GLP-1 is administered slowly than the manufacturer recommends, stepping up every two months rather than every month.
- Patients can “count clicks” and use small amounts of semaglutide.
- Patients may use tilzepatide less frequently every 7 days.
- Make sure the patient has glucagon rescue medication at home.
- Instruct patients to test ketone levels regularly.(7)
Although these recommendations are based on solid clinical experience, Garg and his colleagues only make educated speculations about phenomena that are not yet predominantly non-executed. There has been a lot of research into old and powerful drugs in the GLP-1 class, such as Liraglutide, but semaglutide and tilzepatide represent new realms.
“To learn the best ways to use these drugs, you need to do the right research, which are definitely necessary for people with type 1 diabetes.”
Questions to ask your doctor
- Am I a good candidate for GLP-1 drugs?
- Do you think these medicines are safe for me?
- Will weight loss help ease my diabetes management?
- Did insulin gain me weight?
- Are you at a high long-term risk of cardiovascular disease?
- If I need to change my insulin administration, how can I help?
- When should I call your office or visit the ER if I experience serious side effects?
- Is there a prescription for emergency glucagon rescue medicine now?
- Are you worried about the long-term effects of GLP-1 drugs in patients with type 1 diabetes?
- Are there safer or cheaper alternatives to GLP-1 for weight loss and lowering glucose?
- How can I check if my insurance plan covers these treatments?
Should I take GLP-1 forever?
It is widely believed that GLP-1 should be used indefinitely or that it will no longer benefit.
At the Barbara Davis Center, many patients with type 1 use GLP-1 medications to lose weight. Of the hundreds who stopped using drugs, only three managed to keep their weight down. Perhaps semaglutide and tilzepatide are lifelong drugs.
Nevertheless, Garg made highly conservative recommendations and repeatedly advised that after the patient had achieved his weight loss goal, the patient would tapered and attempted to discontinue GLP-1. “We don’t know the long-term effects of these drugs. No one has done any type 1 studies.”
Of course, patients may have different ideas. “Dr. Garg, you’ve never left me out of this drug,” several people told him.
I have no doubt. In the future, this class of drugs will be used by the majority of people with type 1 diabetes.
– Satish Garg, Maryland
According to diabetes, a recent study by diabetes market research firm Thrivable demonstrates that people with type 1 diabetes who use GLP-1 drugs are far more likely to think positively about the future of diabetes treatment. The results suggest that the new drugs are so effective that some people with type 1 diabetes will completely change their outlook for life in this chronic condition. “This drug changed everything for me,” one respondent said.
Use GLP-1 for people who don’t have excessive weight
How about two-thirds of people with type 1 diabetes who are not obese?
Health experts have repeatedly warned that people who have not demonstrated medical care to use anti-obesity drugs should not use them. The use of GLP-1 in lean patients has not been studied. There are also some indications that it can pose special risks, including excessive muscle loss.
However, lean adults with type 1 diabetes have multiple special reasons for taking GLP-1 medications.
- Strengthening blood glucose control. GLP-1 may significantly improve glycemic outcomes.
- Beta cell protection. One very small trial suggests that small amounts of semaglutide can dramatically reduce the need for insulin in new type 1 diabetic patients. This drug may somehow slow down the progression of type 1 diabetes after diagnosis.
- GLP-1 could uniquely benefit people with type 1 diabetes by correcting for alpha cell dysfunction, a secondary feature of the condition that leads the liver to release excess glucose into the bloodstream.(8)(9)
- Cardiovascular protection. Wegovy has recently established cardiovascular disease and has been approved by the FDA for the prevention of heart attacks and strokes in adults, either obese or overweight. Both of these serious consequences are more common in people with type 1 diabetes.
- Kidney protection. The FDA has not yet approved GLP-1 for the prevention of kidney disease, but it points out that early evidence of diabetes is very encouraging. Kidney disease is also very common in people with type 1 diabetes.
For now, Garg does not recommend GLP-1 in patients who are not overweight. The risk is too unknown. However, some of his more adventurous and determined patients persuaded him to give him a try.
“I have a few patients with lean body who are using these drugs. No. No. But it keeps my glucose profile very flat.
Garg hopes to develop a long-term development of continuous ketone monitors, as well as Abbott, the manufacturer of continuous glucose monitors from Freestyle Ribble, will be working on development. “It will change the way we use these drugs.”(10)
“We see amazing results as these few people use (GLP-1). There is no doubt that these drugs are used by people with normal BMI because of their overall glycemic effect.”
Does insurance cover Ozempic for type 1 diabetes?
At this time, it is unlikely that insurers will cover Ozempic and other GLP-1, particularly for the treatment of type 1 diabetes. Insurance companies tend to adhere to FDA guidelines, and family drugs are not approved for use in this condition.
However, some people with type 1 diabetes may be eligible for compensation if they meet other health standards. Wegovy is currently FDA-designated for reduced cardiovascular risk. Insurance companies can cover the costs of adults who are overweight and are at high risk of heart attacks and stroke. Zepbound is indicated for overweight adults with at least one weight-related health condition, including high blood pressure, high cholesterol, and sleep apnea.
Important exams may never happen
Garg’s experience provides valuable insight into the risks and benefits of GLP-1 in type 1 diabetic patients, but large, long, rigorous, randomized controlled trials are required to truly understand the impact of these drugs. The same exam is also essential to convince insurance companies that GLP-1 should cover many Type 1 people.
Such a test can cost hundreds of millions of dollars. And so far, according to Garg, the makers of semaglutide and tilzepatide, Novo Nordisk and Eli Lily have said they “do not want” and “do not show desire” to organize major trials for type 1 treatments.
There are 10 million people worldwide with type 1 diabetes, but there is little compared to 500 million people with type 2 diabetes and 2 billion people who are overweight or obese.(11)(12)(13) In contrast to the broader potential markets of Ozempic-Wegovy and Mounjaro-Zepbound, individualism with type 1 diabetes is very little significant.
Type 1 Diabetes Research and Advocacy Group JDRF and other nonprofits of diabetes may help advance science by funding academic research research. However, there are currently only pharmaceutical companies that have the financial weight to pay for the exams the FDA wants to see.
The FDA could force pharmaceutical companies to act. If off-label use of GLP-1 for type 1 diabetes is so widespread that it becomes impossible to ignore, the FDA may “require companies to do and do these research,” Garg said. But that day, if it came, we’ll probably be away for years.
“We don’t know what the future holds, but these drugs can stay here,” Garg says.
Take home
The hit GLP-1 drugs have the incredible potential to help people with type 1 diabetes and overweight or obese, providing weight loss, reduced blood glucose levels, and perhaps long-term heart and kidney protection. Ultimately, GLP-1 can be important in the treatment of almost anyone with type 1 diabetes.
However, much is still unknown about the use of GLP-1 to treat type 1 diabetes. It may take years for rigorous testing to lead to official clinician guidelines. Patients and doctors alike need to be very careful about this powerful class of medication. These drugs pose an inherent risk for people with type 1 diabetes.
Resources we trust
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