The new guidelines related to the use of GLP-1 drugs in people with Type 1 Diabetes (T1D), whose publication is planned for later in 2026, will focus on assessing safety and defining optimal ways of use where they are currently used outside approved indications.
Despite their “off-label” status, the use of these drugs has increased in recent years, especially as an adjunct to insulin therapy in patients with T1D who also have obesity and cardiovascular comorbidities.
This trend was highlighted by Satish K. Garg, professor of medicine and pediatrics at the Barbara Davis Diabetes Center at the University of Colorado in Denver, during a presentation of the guideline review at the 19th ATTD 2026 International Conference.
As Garg emphasized, the traditional understanding that people with Type 1 Diabetes are typically thin and not prone to obesity is no longer applicable in modern practice, erasing one of the earlier clinical distinctions between Type 1 and Type 2 Diabetes.
The forthcoming paper, known as “Adjunctive therapy with GLP/GIP agonists in patients with T1D: a consensus report and guidelines for safe use, “will be published in the June 2026 issue of the journal Diabetes Technology and Therapeutics, with Gard as editor-in-chief.
“I would especially emphasize the importance of ‘adjunctive’, which are already emphasized in the title, given that their use in people with Type 1 Diabetes is being considered,” he said.
Go Slow, Adjust Insulin
According to Garg, the upcoming consensus guidelines – based on earlier publications from 2024 – emphasize a cautious, individualized approach to introducing GLP-1/GIP agonists in people with Type 1 Diabetes.
Application of these therapies begins with low doses with gradual titration, bearing in mind that the maximum doses traditionally used in Type 2 Diabetes and obesity are often neither necessary nor tolerable in the T1D population.
Clinical observations indicate that therapeutic goals, including weight reduction and metabolic benefits, are achieved in most patients at moderate doses (approximately 7.5-10mg), while higher doses may be associated with poorer tolerance.
At the same time, careful adjustment of insulin is necessary, with the aim of minimizing the risk of hyperglycemia, ketosis, diabetic ketoacidosis, and hypoglycemia. Although an initial reduction of the total insulin dose of about 20% is often cited as a rough recommendation, therapy must be individualized. It is particularly noteworthy that most corrections involve prandial insulin, whereas the basal regimen typically requires only minor changes.
Experts emphasize the key role of continuous glucose monitoring and remote patient monitoring given the limited frequency of direct clinical contact. Patient education and monitoring of the therapeutic effect are considered outcomes while minimizing potential side effects.
Baseline Labs, Monitor and Treat Side Effects
Garg outlined a number of recommendations aimed at optimizing safety and clinical monitoring during these applications of medicines:
- Initial laboratory evaluation: Before starting therapy, it is crucial to perform a comprehensive laboratory evaluation, including TSH, uric acid level, albumin excretion rate, albumin/creatinine ratio, and estimated eGFR. During ongoing monitoring, dose adjustments of drugs such as thyroxine, statins, and antihypertensives may be required in response to changes in metabolic status.
- Control of gastrointestinal side effects: special attention should be paid to the prevention and relief of gastrointestinal symptoms, including nausea, vomiting, constipation, and diarrhea. Available pharmacological options can significantly improve the therapy tolerance.
- Ophthalmological monitoring: Before the introduction of therapy, a basal ophthalmological examination is recommended, with the possibility of an earlier examination (before the end of 12 months) in high-risk patients. This stems from the possibility of progression of diabetic retinopathy after initiation of GLP-1 or GLP/GIP therapy, most often in the context of a sudden improvement in glycemic control – a phenomenon that has already been documented. In patients with existing retinal damage, more intensive monitoring is necessary.
Additional recommendations include:
- Assessment of sarcopenia and nutritional support: Although sarcopenia is rarely reported in randomized studies, its assessment, along with adequate nutritional counseling, is recommended. The emphasis is on maintaining an adequate intake of nutrients, without restrictive interventions.
- Prevention of metabolic decompensation: Provision of glucagon and ketone test strips is advised, with consideration of future use of ketone monitoring should such technologies become available in clinical practice.
- Adjustment of therapy after achieving the goals: After reaching the target body weight, a dose reduction of GLP-1 or GLP/GIP agonists and a transition to maintenance can be considered. However, the optimal protocols for dose reduction and definition of maintenance therapy in T1D are still not clearly established and remain the subject of further research.
Insurance Coverage for Patients with T1D
Garg pointed out an important clinical aspect that requires attention:
- Financial and socioeconomic barriers: It is necessary to consider the availability of therapy and the limitations imposed by the health insurance system.
In a 2024 paper, Garg addressed insurance issues, noting that claims for off-label use in people with T1D are often denied. In some cases, approval of reimbursement requires prior authorization with detailed documentation indicating insulin resistance, increased insulin requirements, and hypertriglyceridemia – clinical features reminiscent of Type 2 Diabetes and often described as “double diabetes.”
Insurance companies often require proof of an inadequate response to previously applied therapeutic options, leading to significant delays in the approval of treatment with GLP analogues.
Kaufman said she began using a similar approach in specific older adolescents with T1D and obesity, indicating the presence of features related to Type 2 Diabetes. In these patients, increased insulin requirements may indicate insulin resistance, facilitating the clinical justification of therapy.
However, success in obtaining coverage is significantly lower when the indication is based on obesity alone, as such requests are often denied on the grounds that they are for patients with Type 1 Diabetes, who are not covered by the indication.
