Even with the most advanced insulin preparations and delivery systems currently available, it is challenging for many people with type 1 diabetes (T1D) to achieve target levels of glycemic management. Adjunct therapy in T1D consists of adding glucose-lowering agents besides insulin with the aim of lowering hemoglobin A1c (HbA1c) and improving other health outcomes, including weight. It is an attractive potential strategy for achieving glycemic targets and other benefits in this T1D subpopulation. While not yet Food and Drug Adminstration (FDA)-approved for this use, incretin-based therapies (glucagon-like peptide-1 receptor agonist-based therapy) and sodium-glucose cotransporter-1/2 (SGLT-1/2) inhibitors are being prescribed off-label for T1D.
Sodium-glucose cotransporter inhibitors (SGLTi) as an adjunctive to insulin therapy may offer cardiometabolic and renal benefits in adults with type 1 diabetes (T1D). Their effective use depends on patient selection, education, and ketone monitoring to prevent diabetic ketoacidosis (DKA). Starting with the lowest effective dose, making appropriate insulin adjustments, and following structured protocols for ketone monitoring and DKA risk mitigation are essential for safe use of SGLTi in adults with T1D.
Sodium-glucose cotransporter inhibitors, glucagon-like peptide 1 receptor agonists and mineralocorticoid receptor blockers have revolutionized type 2 diabetes and by providing substantial cardiovascular and renal protection in this. This article summarizes the data for these newer agents in type 1 diabetes (T1D). Here we also emphasize the need for more long-term studies of these agents in T1D to assess their impact on cardiovascular risk.
Phase 2 clinical trials using daily injectable glucagon-like peptide-1 receptor agonists as adjunct therapy in type 1 diabetes showed promising signals for efficacy on glycemic control and weight. These effects were confirmed in larger phase 3 trials but accompanied by safety issues including hypoglycemia and ketosis. Of note, these trials were conducted before the availability of widespread continuous glucose monitoring (CGM) and used simple one size fits all rules for insulin dose titration. Attention has moved on to weekly injectable agents at present, with more individualized insulin titration and guided by CGM.
