Deprescribing in type 2 diabetes and cardiovascular disease: Recommendations for safe and effective initiation of glucagon-like peptide-1 receptor agonists in patients on insulin therapy

Abstract

Select glucagon-like peptide-1 (GLP-1) receptor agonists have demonstrated cardiovascular benefits in both primary and secondary prevention populations and are recommended in multiple guidelines for cardiovascular risk reduction in people with type 2 diabetes (T2D). Despite this, uptake of GLP-1 receptor agonists in clinical practice has been lagging. While the etiology of their underuse is multifactorial, lack of comfortability in adding a GLP-1 receptor agonist to established insulin regimens is a common barrier. Adjustments to basal and bolus insulin doses upon initiation of GLP-1 receptor agonists in trials have varied. When recommending empiric dose adjustments during initiation of GLP-1 receptors agonists, the most recent A1C and the current blood glucose levels, if available, should be taken into consideration. When initiating in a person being managed with basal-only insulin regimens, an empiric 20 % dose reduction is recommended if the baseline A1C is ≤8 %. For individuals using intensive insulin regimens, empiric dose reductions of up to 25 % in basal and 50 % in bolus therapy were implemented and summarized further in this review. Overall, initiation of GLP-1 receptor agonists can decrease insulin requirements and may permit deintensification of antihyperglycemic therapy through the reduction or discontinuation of bolus insulin therapy. As a result, this simplified regimen promotes increased adherence, reduces glycemic variability and hypoglycemia, and improves overall glycemic management and quality of life. This review aims to serve as a guide for clinicians to facilitate the initiation of GLP-1 receptor agonists and deintensification of insulin by providing suggested dose adjustments based on available literature.