When to Add a GLP-1 Receptor Agonist in Type 2 Diabetes
19 Nov 2025
Type 2 diabetes (T2D) commonly overlaps with obesity, chronic kidney disease (CKD) and cardiovascular disease (CVD)—a cluster of conditions that together create significant pressure on Australia’s healthcare system. With around 40% of people with T2D developing CKD, coordinated and proactive management has become essential.
For GPs, who sit at the centre of chronic disease care, treatment decisions can become complex, especially when glycaemic control remains suboptimal.
When SGLT2 inhibitors aren’t enough
Many patients prescribed SGLT2 inhibitors for kidney or heart protection continue to have HbA1c levels above target (>7%). Evidence shows that up to one-third of patients require an additional glucose-lowering therapy within 6–12 months of starting an SGLT2i.
Even when the primary goal of an SGLT2i is cardiorenal protection, maintaining glycaemic control remains crucial. This raises practical questions for GPs:
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What should be added next?
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Which therapy provides the best balance of glucose control, weight management and organ protection?
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How should TGA indications and PBS rules be navigated?
Why consider a GLP-1 RA?
Experts increasingly describe GLP-1 receptor agonists as a “fourth pillar” of therapy in diabetes-associated CKD—alongside RAAS inhibitors, SGLT2 inhibitors and finerenone.
GLP-1 RAs provide multiple benefits:
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Improved glycaemic control
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Cardiovascular protection
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Kidney protection
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Weight loss and improved metabolic health
These effects directly address key drivers of disease progression in T2D and CKD.
Choosing when to introduce a GLP-1 RA
The decision should reflect:
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TGA indications
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eGFR and albuminuria levels
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Presence of CVD or high cardiovascular risk
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Obesity and metabolic factors
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Current use of SGLT2 inhibitors
For patients already on an SGLT2 inhibitor, combination therapy may offer complementary organ-protective effects and reduce residual risk.
Updated indication: Semaglutide
Semaglutide is now approved in Australia as an adjunct to standard of care to:
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Reduce the risk of sustained kidney function decline
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Reduce cardiovascular death in adults with T2D and CKD
This reinforces the expanding role of GLP-1 RAs beyond glucose lowering.
Tolerability and PBS considerations
GLP-1 RAs are generally well-tolerated, though gastrointestinal effects such as nausea and vomiting are common early on and often improve with time.
Importantly, current PBS restrictions do not allow co-prescribing an SGLT2 inhibitor and a GLP-1 RA for diabetes alone, unless the SGLT2 inhibitor is being used for renal or heart failure indications. Clear documentation and understanding of criteria are essential for timely access.
The GP’s role moving forward
As diabetes management becomes increasingly complex, GPs are vital in translating emerging evidence into practice. Knowing when to add a GLP-1 RA—particularly alongside SGLT2 inhibitors—will be central to improving outcomes for Australians living with T2D and its complications.
Source: Racgp
