Three experts will explore the pros and cons of using metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, and sodium-glucose co-transporter 2 (SGLT2) inhibitors in adult patients to help lower their insulin dosage and decrease the risks associated with type 1 diabetes during the Sunday morning symposium Adjunctive Glucose-Lowering Therapies for Adults with Type 1 Diabetes—Evidence, which will begin at 8:00 a.m. CT.
“It’s always the balance between what you gain in lowering the insulin dose, what you gain in weight loss, what you gain in more stable glucose control, and what you lose in side effects and risks,” said Chantal Mathieu, MD, PhD, who will present research on SGLT2 inhibitors during the session. “It’s a balance you need to weigh as a clinician, as a diabetes team, and as a patient.”
In type 1 diabetes patients, randomized trials indicate that metformin has a small impact on A1C, results in no increase in hypoglycemia and a decrease in insulin dosage by about two units, with very little effect on weight, according to Irene Hramiak, MD, FRCPC, MACP, who will examine results from the REMOVAL (REducing With MetfOrmin Vascular Adverse Lesions in Type 1 Diabetes) trial during the session. Dr. Hramiak is Professor of Medicine at the University of Western Ontario and Site Chief for Medicine at St. Joseph’s Hospital in London, Ontario.
GLP-1 receptor agonists have been shown in randomized trials to lower insulin doses and bring down weight, but the effect is transient, according to Dr. Mathieu, Professor of Medicine at the Katholieke Universiteit Leuven in Belgium. In one study, the insulin dosage wasn’t reduced quickly enough, so there was still an increased risk of hypoglycemia. But other studies have shown that if the insulin dose is lowered more rapidly, there can be reductions in A1C and weightloss without the risk of hypoglycemia.
Tina Vilsbøll, MD, DMSc, Professor of Medicine at the University of Copenhagen, will address the benefits of GLP-1 receptor agonists, as well as the side effects that can come with this drug class, including nausea and vomiting.
SGLT2 inhibitors, including dapagliflozin and empagliflozin and the mixed SGLT1/2 inhibitor sotagliflozin, have demonstrated positive results by bringing down A1C, insulin dose, and weight without the increase in hypoglycemia. “But all of the SGLT2 inhibitor programs show there’s a price to be paid, including an increased risk in genital infection,” Dr. Mathieu said. “It’s an issue, but it’s an issue we’re not very afraid of because we can deal with it with antifungal creams, or we can stop the agent and no harm done.”
Other risks associated with SGLT2 inhibitors include an increase in ketone formation, which can lead to diabetic ketoacidosis.
“This session will help practicing clinicians discuss the benefits and risks of using these adjunct therapies with their patients, and then come to an educated decision on whether or not to use or introduce these agents as therapies in their patients with type 1 diabetes,” Dr. Mathieu said.