Navigating the New Consensus: What People With Type 1 Diabetes Need to Know About GLP-1 Medications

Management of type 1 diabetes has evolved drastically in recent years. We have seen breakthroughs in closed-loop insulin pump systems, continuous glucose monitors (CGMs) and new medications designed to help support insulin. One of the most-discussed topics in the diabetes community recently has been the use of glucagon-like peptide-1 (GLP-1) receptor agonists, such as semaglutide and tirzepatide.

While these medications have transformed the treatment of type 2 diabetes and obesity, their role in type 1 diabetes is still a bit complex. Because they are not officially U.S. Food and Drug Administration (FDA)-approved for type 1 diabetes, many clinicians have been hesitant to prescribe them.

A new international consensus statement has recently addressed this uncertainty. This statement was created to provide clinicians with a framework for the safe and appropriate use of GLP-1s in people with type 1 diabetes.

If you are curious about what this means for your care or how to approach a conversation with your health care team, here is a breakdown of the key takeaways from these new guidelines.

Why Do We Need a Consensus Statement?

Even though GLP-1s are not yet approved by the FDA for type 1 diabetes, many patients with type 1 diabetes are already taking them off-label, often for weight management or to improve insulin sensitivity and blood sugar control.

Without formal guidelines, clinicians have been left to navigate this on their own, leading to confusion and significant variations in practice. Some providers avoid them entirely because of fears of side effects, while others prescribe them without standardized monitoring protocols.

This approach can be dangerous. The new consensus statement helps standardize how these medications are started, monitored and managed in the context of type 1 diabetes.

Benefits vs. Risks

The expert consensus acknowledges that GLP-1s can offer several key benefits for some people with type 1 diabetes, including:

• Weight management: Reducing weight gain, which is sometimes associated with taking insulin.
• Improved blood sugar control: A potential for lower hemoglobin A1c levels and improved time in range.
• Reduced insulin requirements: For some, these medications help lower the total daily dose of insulin needed, which can simplify daily management.

However, the consensus is equally clear about the risks. The primary concern in those with type 1 diabetes is the risk of diabetic ketoacidosis (DKA). GLP-1s slow gastric emptying and can decrease appetite, which, when combined with reduced insulin doses, can increase the risk of DKA if not carefully managed. If the insulin reduction is too aggressive, or if the patient is fasting or sick, DKA can occur even if blood sugar levels do not appear dangerously high (this is known as euglycemic DKA).

Recommendations for Safe Use

The consensus statement emphasizes that these medications should only be used under the close supervision of a diabetes specialist. The guidelines address the following recommendations to prioritize safety:

1. Careful Patient Selection

Not everyone with type 1 diabetes is a candidate for a GLP-1. The experts recommend careful screening to exclude those with contraindications, such as a history of gastroparesis or a personal or family history of medullary thyroid cancer.

2. Gradual Dose Titration

"Start low and go slow" is the golden rule of the new guidelines. Aggressive dosing increases the risk of gastrointestinal side effects and low blood sugar risk. A slow titration schedule allows the body to adjust and gives more time to evaluate how the medication interacts with the existing insulin regimen.

3. Proactive Insulin Adjustment

The most critical part of the consensus is the requirement for proactive insulin dose adjustment. Those with type 1 diabetes cannot simply add a GLP-1 to their existing regimen. Many experts recommend reducing the daily insulin dose, particularly the mealtime insulin, at the start of GLP-1 therapy to reduce the risk of low blood sugar.

4. Monitoring for DKA

The consensus places a high priority on ketone monitoring. People with type 1 diabetes using GLP-1s must be educated on the signs and symptoms of DKA, and they must have the tools to test for ketones if they feel sick, even if their blood sugar levels are in range.

If you have type 1 diabetes and have been wondering whether a GLP-1 might be right for you, this consensus statement is a step in the right direction. It moves the conversation from speculation to clinical practice. It provides your diabetes care team with a road map to support you safely if you decide to explore this option.