In the past, if a person with type 2 diabetes can’t get blood glucose to target on oral meds, the next action would be to add basal insulin. However, the latest guidelines, found in the ADA 2023 Standard 9, encourages providers to consider adding a GLP-1 RA or GIP/GLP-1 RA before writing that prescription for basal insulin.
Diabetes pharmacologic management has dramatically changed over the past few years with the addition of Incretin Mimetics (GLP-1 RA and GIP/GLP-1 RAs) and SGLT2i’s to the medication landscape. The pathways and algorithms have been adjusted to incorporate these newer medication options, which significantly lower glucose without the risk of low blood sugar or weight gain like insulin or sulfonylureas.
GLP-1 RA or GIP/GLP-1 RA versus Insulin Therapy
The truth is, insulin will always lower blood glucose levels, but users may experience the side effects of hypoglycemia and unwanted weight gain. However, for some people, adding insulin is still the next best step. According to the ADA Standard 9, “health care professionals should consider insulin as the first injectable when there is evidence of ongoing catabolism, symptoms of hyperglycemia and when A1C levels >10% or blood glucose levels are 300mg/dL or very high, or a diagnosis of type 1 diabetes is a possibility.”
Insulin can be easily titrated up or down, depending on glucose profile and users can fine tune dosing to match carb intake and other factors. Insulin has been around for over 100 years and has been extensively studied and it’s action and side effects are well understood.
In spite of these benefits, insulin does have some disadvantages. Insulin doesn’t have the same cardiovascular benefits as the GLP-1 RA’s or GIP/GLP-1 RA’s, nor does it contribute to weight loss. Let’s explore some of the benefits of starting with these “Incretin Agonists” before adding insulin therapy.
Benefits of starting Incretin Mimetics; GLP-1 RA’s or GIP/GLP-1 RA’s, before adding insulin therapy
These 2 classes of incretin mimetics lower A1C from 1.6% to 2.4% when used at maximum dose, a significant glucose improvement. In addition, people experience weight loss that ranges from 6% to 13% when on maximum doses. (Please see PocketCard to the right and package inserts for more information)
Data from the CVOTs (Cardiovascular Outcomes Trials) demonstrate that three of the GLP-1 RAs (liraglutide, dulaglutide, semaglutide ) significantly reduce the risk of cardiac death, heart attack and stroke.
Given that the most people living with type 2 diabetes have elevated BMI’s and a high risk for CV disease, it makes sense, when feasible and clinically indicated, to start with GLP-1 RAs or GIP/GLP-1 RAs before initiating insulin therapy. Of course, when selecting GLP-1 RAs or GIP/GLP-1 RAs, we need to consider individual preference, insurance coverage, A1C lowering and weight-lowering effect and frequency of injection. In addition, for those on GLP-1 RA and basal insulin combination, we can consider using a fixed-ratio combination product (iDegLira or iGlarLixi) For more info on dosing and considerations for these two combination products, you can Download FREE Combo Injectable PocketCards.
For a step-by-step approach, please see the 2023 ADA Algorithm for Intensifying Injectable Therapy for People with Type 2 from ADA Standard 9. This algorithm provides a roadmap for health care professionals working to improve glucose levels for those living with type 2 diabetes.
When people with type 2 are not at their glucose targets using oral medications, we are encouraged to thoughtfully consider the next best pharmacologic injectable addition. Given the benefits listed above, the GLP-1RA and GIP/GLP-1 RA therapies may be the best choice for many people living with type 2 diabetes.
Thank you for collaborating with individuals to determine the next best step when needing to add injectables to their management plan. To learn more, you can view our recorded program, Meds for Type 2 Update; New ADA/EASD 2023 Consensus Statement.
We retyped this ADA Standards algorithm in a larger font and on 2 pages, to make it easier to read for studying and so you can post on the wall of your clinical practice.
View ADA 2023 Standard 9, Pharmacological Approaches to Glycemic Treatment here.
Plan on joining this exciting webinar that walks participants through the newly released, “Management of Hyperglycemia in Type 2 Consensus Report by the ADA and EASD”. These updated guidelines will be incorporated into the 2023 ADA Standards of Care, but you can get an early sneak peek by joining Coach Beverly on December 1st, 2022. She will highlight the revised guidelines with a focus on new elements and exciting changes in how we approach medication management for type 2 diabetes. Together, we will explore clinical factors to consider when determining the best strategy to improve glucose management in people with type 2 diabetes and other co-conditions. There will be a special focus on cardiovascular risk reduction and renal protection and addressing clinical inertia.
Intended Audience: A great course for healthcare professionals seeking evidence-based information that improves the quality of life and outcomes.
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