The Type 1 Diabetes Medication that works: GLP1 - Dr. Diana Isaacs

Is it safe to use GLP1 in T1D? In this episode of The Diabetes Diaries, Rachael Sood sits down with Dr. Diana Isaacs, Pharmacist and Director of Education and training in Diabetes Technology, and co-Director of endocrine disorders in pregnancy at the Cleveland clinic. Dr. Isaacs shares her expertise and clinical insights when it comes to starting Glp1 medications in people living with type one diabetes. We discuss the science behind why it works, including reduced burden, insulin needs, and how the hormone glucagon comes into play. She describes cases where people need much less insulin, and are finally able to lose weight. Learn about adjustments needed for automated insulin delivery system users that are adding in glp1 to their regimen. 

https://youtube.com/@thediabetescollective?si=6gvVGtd5Um9XSb4u

https://www.instagram.com/thediabetescollective?igsh=bGI5bno2NnUwNmp3&utm_source=q

https://www.facebook.com/share/14mrAd3kbVj/?mibextid=wwXIfr

https://www.tiktok.com/@thediabetescollective?_r=1&_t=ZT-97f3bZc8GU9

Transcript

SPEAKER_00 0:01

Welcome to the Diabetes Diaries. I am your host, Rachel Seude. Joining me today is Dr. Diana Isaacs, who is the Director of Diabetes Education and Clinical Research at the Cleveland Clinic, one of the top medical institutions in the world. Diana is widely regarded as one of the leading experts in diabetes pharmacology in the country, delivering talks to audiences of thousands around the world. Today she is here to talk about something that is changing the way we treat type 1 diabetes, GLP1 medication use. And the number she is about to share is going to stop you in your tracks. Diana, welcome to the show. Thank you so much for having me. Diana, there is a medication that can reduce insulin consumption by up to 30% for people living with type 1 diabetes. And most of them have never even heard of it. Before we get into like why that is, why don't you break it down for us?

SPEAKER_01 0:56

Well, the medication class is GLP1 drugs. Those have the ability to majorly reduce the amount of insulin a person with type 1 diabetes needs. But many people don't know about it because those drugs are typically thought of as for people with type 2 diabetes.

SPEAKER_00 1:12

I see. So how does a GLP1 reduce insulin consumption? What is happening biologically or pathophysiologically that creates that 30, even 40 or 50% difference in that need of insulin?

SPEAKER_01 1:26

The idea of consumption is kind of funny to me because it makes it sound like we're eating insulin, which obviously we're not, right? People are injecting insulin, or in some cases, they're inhaling insulin. But what is happening? GLP1 drugs do a lot of really fascinating things in the body. And I think we're continuing to learn even more things that they do. At the heart of it, they actually stimulate insulin release. But you won't expect that in a person with type one. But the other amazing thing that they do is they reduce another hormone called glucagon. And glucagon actually causes the liver to put out excess glucose. So by stopping that, you're going to have less glucose. And then you need less insulin. In addition to that, though, they also reduce the appetite. And people tend to take in less food. If you're taking in less carbohydrates, less food, most likely you're also going to need less insulin.

SPEAKER_00 2:29

Wow. So it seems like it really helps, even like mealtime, high blood sugar, or it just helps people's appetite overall when they're living a type.

SPEAKER_01 2:37

I mean, there's really so many benefits. So for people that are overweight or that have obesity, it leads to weight loss. And that is true for people with type 1 diabetes and people without type 1 diabetes. And in fact, our major guidelines from the American Diabetes Association say that if someone has type 1 diabetes and they have obesity, we also should not be afraid to use this drug class because it will be able to help them with their weight, but we know it'll also be able to help them reduce their insulin needs.

SPEAKER_00 3:12

Why are doctors not prescribing this to people living with type 1 diabetes if the results are so significant?

SPEAKER_01 3:20

Well, I think the the data is really the big studies have been in people with type 2 diabetes or in people with overweight and obesity. And they haven't really included people with type 1. So when you look at the labeled indications, they don't mention type 1 diabetes. So that gives people some pause. Now, if we step back, we know that these drugs are now being studied in type 1 and there is some incredible data. And we know for those of us that are using it in our practice and the people that have been on it and experienced it, they're having really good results. They're often losing 10% of their body weight if they need to. And like you mentioned, like reducing insulin needs by 30%. I actually had someone that I went to pharmacy school with reach out to me just yesterday and he said he has type 1 diabetes. And he said, I just want you to know, I started this medication and my insulin needs went down by 100 units. Now I don't know how many units he was originally on. 100 units? That's a lot, right? So it's really, really significant the impact that these can have, especially in people that have insulin resistance. And many people with type one, like the rest of the population, have some insulin resistance and may struggle with some excess weight.

SPEAKER_00 4:41

Right. And I feel like, you know, insulin is not bad. And I think different people need different amounts of insulin. And we know that's so unique. But the more and more insulin you have to give and manage, the more likely there can be from complications. So it is nice to offload that burden of less insulin.

SPEAKER_01 4:58

Right. And the other thing with these drugs is we know they have a variety of other benefits as well. So cardiovascular, the benefits on being able to reduce heart attacks, reduce strokes in people. And granted, those studies have not been done specifically in people with type 1 diabetes, but they have been done in people with type 2 and in people with obesity. And there's no reason to think, well, why wouldn't people with type 1 benefit? Also, we've seen benefits on the kidney. So being able to really improve kidney outcomes. And now, even with other things like liver health, osteoarthritis, even there's been benefits now for substance use for people that use a lot of alcohol, tobacco use, we are seeing emerging data. And so, why wouldn't people with type one also want to have these benefits from this really powerful drug class?

SPEAKER_00 5:55

That's amazing. How are you using GLP1 in type 1 diabetes in your practice right now?

SPEAKER_01 6:02

So we are using it. Um, I think it's really when somebody has overweight or has obesity, it's definitely easier to prescribe and get it through insurance because they have an indication for it. But that being said, I think many of us are using it, even in people that may not technically meet that classification. And what we're doing is we're labeling it that, hey, maybe they have some insulin resistance. They have characteristics of type one and type two. And in doing that, we're able to still get it approved. Now, I often in type one diabetes will start at a lower dose and go a little slower. Cause in my experience, some people have just been a little bit more prone to side effects or really have a pretty powerful effect on the lowest dose. And so I will start lower. Someone doesn't have side effects, great, we'll get them up. Some people do very well even on a very low dose. And one of the things we're very aware of is what to do with the insulin. So depending on what someone's current management looks like, how, you know, where their A1C is or where their time and range is will help us decide how much to cut back on the insulin. But generally, we will reduce the dose a little bit. If someone is on an automated insulin delivery system, we love those, right? That's first line for type one diabetes. I think with those systems is a little bit easier because often, right, they're going to be able to naturally decrease the dose, but we still may make adjustments to things like the carbohydrate ratio correction factor, certain settings just to reduce that risk of having low blood sugars.

SPEAKER_00 7:42

That makes sense that you're proactively adjusting things that way that, you know, decreases the risk of low blood sugar hypoglycemia. And you have to customize it, I'm sure, depending on the AID system or the pump system or the patient's needs, depending on their insulin sensitivity, right? Definitely. Definitely. Do you prefer injectable GLP ones or tablet versions for people with type 1 diabetes?

SPEAKER_01 8:05

So I think it really should be individualized and allow the person to decide. I think many people, a weekly injection isn't, you know, like they like the convenience of that versus having to take a daily pill. I think also the daily pills are kind of a new emerging area. So we've had, for example, oral oral semaglatide for a while, but that specific drug does need to be taken in a specific way, meaning like on an empty stomach, you have to separate it from other pills, other drinks, even your coffee by 30 minutes. So sometimes when people hear that, they're like, yeah, I would rather take an injectable. There is now another oral pill that doesn't have all of those extra things you have to do. So that's another option. And I give people the choice to decide what is gonna work best for them. Also, depending on how much weight someone would benefit from losing, we might choose to use a more powerful agent. So all of that kind of goes into consideration. And of course, like also what's their insurance covering as well? Or is there a cost savings program where it's cheaper to pay cash? So kind of all of that goes into the decision about what to take.

SPEAKER_00 9:12

Yeah. So what does life actually look like for a person living with type 1 diabetes when they finally start on a GLP one? They get this into their hands and they start it. What does it, what is it like those first few weeks?

SPEAKER_01 9:24

Well, I think the first few weeks are exciting, right? You're trying something new, and often people will find pretty quickly that their insulin needs will go down. The other thing is not just the insulin needs, but the management. People also find that their time and range usually improves, especially after meals. They find they don't spike up as much because again, it's suppressing that glucagon. And so they find their time and range will go up. And that often feels good, right? They're like, wow, I've added this drug. I'm finding my management's working a little bit better. And so often people feel very, very good. There is, of course, the chance of some side effects, especially like the GI, the nausea. And so that's something we really educate on. There are certain things a person can do, like just trying to limit how much is eaten at one time, being careful about higher fat, super oily or spicy foods. And so often being a little bit careful about that. But often people feel very good and it makes an improvement pretty quickly.

SPEAKER_00 10:25

That's amazing. I love having the capability to prescribe these medications for people with both type 1 and type 2 diabetes. What do you want every person living with type 1 diabetes watching this to do after seeing this and hearing about the use of GLP1 and T1D?

SPEAKER_01 10:42

So, my big thing, and it's not even just with GLP1, but I'd say you got to advocate for yourself. And I wish it wasn't that way. I wish every healthcare professional would offer you all of the different tools out there. Unfortunately, not everyone is aware of all the tools, is a aware of the latest research and benefits. So I would encourage you to really try to stay up to date, really try to, you know, watch things like this and bring it up to your healthcare team. Let them know you heard about this. Could this be beneficial for me so you can stay informed? Of course, there are certain people that they may have certain conditions where this is not going to be a good fit. In no way am I saying every single person with type one should take this. Right. But I think it it is, it warrants a conversation. And so I'd really encourage you to bring this up to your healthcare team and see if this is something that could benefit you.

SPEAKER_00 11:39

Yeah. Thank you so much for all of those insights on the use of GLP1 and T1D.

SPEAKER_01 11:45

Thank you so much for having me. It's a pleasure to be here.