Re-introducing GLP-1 RAs to patients with type 2 diabetes
08 Mar 2023
For patients with type 2 diabetes, GLP-1 RAs (glucagon-like peptide-1 receptor agonists) have been an effective treatment option for controlling blood glucose levels.
However, the medication became unavailable in 2022 due to global supply issues, prompting many GPs to change treatment approaches for their patients with type 2 diabetes.
With the shortage having recently been resolved, RACGP Specific Interests Diabetes Chair Dr Gary Deed told newsGP there are a number of considerations GPs need to take into account before reintroducing GLP-1 RAs particularly semaglutide (Ozempic) in patients with uncontrolled blood glucose levels.
‘The absence of semaglutide means that a “reset” is needed, so patients may have already understood injection techniques etcetera, but a reminder may be needed to introduce the medication again at lower dose of 0.25 mgs weekly before escalating after one month to 0.5 mgs. and then a further increase to a maximum of 1 mgs as required individually and described in the product information,’ he said.
‘On introduction, nausea/GIT upsets may re-appear and educating patients again may be useful.’
Dr Deed also reiterated that patient-centred care underpins diabetes management, and so GPs should reinforce healthy lifestyle choices and assess the patient’s needs, questions and goals, as well as record a physical examination including patient weight, waist circumference and BMI.
‘If a GLP1-RA is to be considered, ensure the patient understands the steps in commencing including combining with other diabetes therapy, the details for injection technique, needle attachment/disposal [semaglutide, but not needed for dulaglutide], and how to escalate slowly as mentioned earlier,’ he said.
‘It is also important to discuss possible side-effects such as nausea, and other gastro-intestinal upsets and explain the need for interval assessments and investigations such as HbA1c, kidney health and cardiovascular health.’
GLP-1 RAs are included as a ‘second line’ option for diabetes management in Australian therapeutic guidelines after metformin, but Dr Deed said the advice also recognises their non-glycaemic benefits in patients with existing cardiovascular disease or high cardiovascular risk.
‘The PBS allows for early utilisation in combination with metformin or a sulphonylurea, and where clinical judgment finds a combination of these are contraindicated or not tolerated [when HbA1c remains over 7% or 53 mmol/mol],’ he said.
While GLP-1 RAs have returned to Australia, the Therapeutic Goods Administration (TGA) has noted that initial supplies will not be sufficient to meet demand from all patients with current valid prescriptions for type 2 diabetes. As such, the regulator has asked that clinicians refrain from prescribing it off-label for other conditions, such as obesity, a position supported by Dr Deed.
‘GPs should reflect on the TGA indications focused on using these in adults with type 2 diabetes,’ he said.
‘If utilising it off-label for weight management, know that the weight loss indicated form [Wegovy] is yet to become available in Australia.’
Additional resources
- Management of type 2 diabetes: A handbook for general practice
- Early and tight glycaemic control the key to managing type 2 diabetes
- GLP-1 receptor agonists in the treatment of type 2 diabetes
- Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)
This content has been commissioned by Novo Nordisk and written and reviewed by newsGP.