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Leszek Czupryniak, MD, PhD, is a professor of medicine and head of the Department of Diabetology and Internal Medicine at the Medical University of Warsaw, Poland. His areas of interest are type 1 diabetes, type 2 diabetes, diabetes accompanying other diseases, and chronic complications of diabetes, with special interest in oral antidiabetic agents and insulins.
In which clinical settings are there indications to initiate the treatment of type 2 diabetes with a glucagon-like peptide-1 (GLP-1) receptor agonist?
Leszek Czupryniak, MD, PhD: GLP-1 receptor agonists, or GLP-1 analogues, as we call them shorter, are the drugs that will change metabolic medicine forever, but I believe they will change the medicine overall and extend much greater than we can imagine today. These drugs entered the market in 2005, so almost 20 years ago. The first drug was called exenatide, and it was intended only to treat type 2 diabetes. But the producers, doctors, patients very quickly realized that these drugs are also very effective in lowering body weight, so nowadays we are using drugs like semaglutide or tirzepatide to treat obesity.
[Obesity] is the second name for GLP-1 analogues, virtually. If we have a patient with newly diagnosed diabetes who is obese, has a body mass index [BMI] >30 kg/m2, the patient should really be getting a GLP-1 receptor agonist. Moreover, if a person has—and that is what the European Association for the Study of Diabetes (EASD) together with the American Diabetes Association (ADA), these 2 associations [recommend]: they both publish a shared a consensus every 3 to 4 years, and the most recent addition was in 2022, in the autumn—so, if a patient is not just obese, may not really have to be obese, but if the patient has atherosclerotic cardiovascular disease, it’s also an indication for a GLP-1 analogue, because these drugs have been shown, for example, to decrease the risk of stroke and in general delay the progression of atherosclerosis. It takes time and doesn’t happen overnight, so the drugs should be taken, as we think today, life long, but they are also effective in this regard.
Semaglutide has been shown to reduce cardiovascular risk in people who are obese and do not have diabetes, so its scope of action is much wider than many people realize today. These drugs also help in chronic kidney disease and heart failure, although here the preference is given to sodium-glucose cotransporter-2 (SGLT-2) inhibitors. So, whenever we see a patient who is obese, or, let’s say, just overweight, as overweight is also a problem, this patient should really be treated with GLP-1 analogues. And the more obese the person is, the more they deserve to be treated with GLP-1 from the very beginning, not just of diabetes, but just when we diagnose a patient as a person suffering, or fighting, or living with obesity. So, these drugs, as they are so effective in reducing body weight, and 80% of patients treated with GLP-1 analogues do lose weight at different levels—some of them lose 5 to 10 kg, but some patients lose 30 kg and even more—these [drugs have] effects that we can compare with bariatric-metabolic surgery.
With these drugs being more and more present, more and more available, with new agents entering the market, we will see a real revolution, as I said, not just in metabolic medicine, but in medicine at large, because having an effective tool to control body weight, to fight obesity, and also, of course, to fight type 2 diabetes, will change our medical practice forever.
