Despite the strong results, there’s a reason why experts are very cautious about recommending the use of semaglutide and tirzepatide for people with type 1 diabetes. These powerful drugs carry very real risks for people with the condition. The drugs need to be managed in a unique way, using a new strategy that experts have not quite agreed on yet.
There are two deadly obstacles that all people with type 1 diabetes constantly need to navigate around: The threats of severe low blood sugar (hypoglycemia) and diabetic ketoacidosis (DKA). GLP-1 drugs are suspected to raise the risk of each.
GLP-1s and DKA
GLP-1s have quickly become infamous for their bad gastrointestinal side effects. At its highest dosage, for example, semaglutide causes diarrhea in 32 percent of users and vomiting in 25 percent. For most people, these side effects disappear as their bodies become accustomed to the medication.
The risks, however, are sharply elevated for people with type 1 diabetes, because dehydrating illnesses like vomiting and diarrhea can lead rapidly to DKA, which is ultimately caused by a critical lack of insulin. When people with type 1 diabetes cannot eat or drink due to a stomach ailment, they will inevitably use less insulin, which only makes DKA even more likely to develop.
People with type 1 diabetes need to be especially cautious with GLP-1 medications because of DKA. The condition can be fatal without emergency treatment.
GLP-1s and Hypoglycemia
On the other hand, GLP-1s can also increase the risk of severe low blood sugar because they radically impact insulin requirements. Most people with diabetes who take an injection of a GLP-1 drug will experience greater insulin sensitivity.
GLP-1s themselves don’t often cause hypoglycemia because they work in a glucose-dependent manner, but if users with type 1 diabetes don’t rapidly adjust their insulin usage, they’re at risk of using too much and plunging their blood sugar down to unsafe levels.
At the Barbara Davis Center for Diabetes, Garg instructs his patients to reduce their insulin by 20 percent when they start a GLP-1 for the first time. He and his colleagues continued to suggest insulin dosing reductions as participants stepped up to higher GLP-1 dosages.
Nobody in the study was hospitalized with severe low or high blood sugar. But Garg has had some scary experiences with his own patients who overcompensated and began taking even less insulin than he advised “because they were scared of getting hypoglycemia. And that results in a high risk of DKA.”
Garg took the potential dangers seriously: “We closely monitored these patients.” All participants wore a continuous glucose monitor, allowing doctors to remotely follow their blood sugar levels. In the real world, clinicians can’t easily provide that level of guidance.
Garg is “absolutely” worried about the use of GLP-1s in less carefully controlled circumstances. “I am definitely worried that these drugs are going to be used left and right in people with type 1 diabetes,” he says.
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