Anything other than insulin? Adjuvant treatments: drugs, bariatric surgery

Abstract

Treatment of obesity in T1D is essential for better glycemic control and prevention of the development of complications. It involves a multidisciplinary approach that includes insulin therapy as the gold standard of treatment for T1D and lifestyle interventions with diabetes education¹.

Intensive insulin therapy, repeated hypoglycemia with a tendency to frequent defensive intake of simple carbohydrates and increased caloric intake are the main factors that condition a weight gain in T1D and become the limitations to achieve optimal glycemic control.

The use of antihyperglycemic drugs as complementary therapies that promote weight loss and favor the reduction of the daily dose of insulin, could provide health benefits for people with T1D who are obese with improvements in metabolic control^1,2.

There is currently only one non-insulin agent approved (FDA) for long-term use in people with T1D, pramlintide³.

There is evidence that sodium-glucose cotransporter 2 (ISGLT2) inhibitors and dual SGLT1/SGLT 2 inhibitors demonstrated high efficacy in glycemic control and less variability in T1D but with higher rates of ketoacidosis so their indication has been discontinued³.

Clinical trials with glucagon-like peptide 1 receptor agonists in T1D have been conducted with liraglutide 1.8 mg daily, showed weight and insulin dose reduction. Its clinical use has not been approved due to the increase in hypoglycemia and ketosis³.

The risks and benefits of adjuvant agents continue to be evaluated, and consensus statements provide guidance on patient selection and precautions². Adding non-insulin agents offers the ability to address other pathophysiological abnormalities of T1D1.

There is an unmet need to simultaneously address the dual problems of hyperglycemia and obesity in T1D. Weight loss medications are not contraindicated in T1D, but data on their use are limited².

Bariatric surgery in people with T1D and obesity achieves significant weight loss, resolution of comorbidities and reduction of insulin doses, but sustained glycemic control is not observed in a large proportion of patients⁴.

The knowledge gap in the effective treatment of T1D and obesity is due to the absence of systematic studies in this population.