Who deserves GLP-1 drugs?

Dr Paula Diab gives an overview of GLP-1 drugs, their approved uses, and who might benefit the most. She also explores newer combinations, oral formulations, and clinical trials shaping the future.

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Over the past decade, GLP-1 receptor agonists (GLP-1 RAs) have revolutionised the management of Type 2 diabetes and obesity. These medications, initially developed to improve blood glucose control, have since demonstrated profound benefits for weight loss, cardiovascular health, and even emerging possibilities in treating other metabolic conditions. With their widespread availability and increasing popularity, one key question remains: who should receive GLP-1 drugs?

What are GLP-1 drugs?

GLP-1 receptor agonists mimic the action of a natural hormone called glucagon-like peptide-1 (GLP-1), which is released in response to eating. They regulate blood glucose and appetite by:

• Stimulating insulin secretion.
• Slowing gastric emptying (keeping food in the stomach longer, which helps you feel full).
• Suppressing glucagon, a hormone that raises blood glucose.
• Reducing appetite through signals to the brain. 

GLP-1 drugs available today

There are several GLP-1 receptor agonists available currently (not all on the South African market). Each has its own unique formulations, dosing schedules, and benefits. Here’s a breakdown of the most commonly used medications:

1. Exenatide (Byetta, Bydureon)

• Indication: Type 2 diabetes.
• Form: Byetta, a twice-daily injection, was previously available in SA. Bydureon, the weekly injection isn’t available in SA.

• Highlights: One of the first GLP-1 drugs, effective for blood glucose control but less commonly used today due to newer options with greater weight-loss benefits.

2. Liraglutide (Victoza, Saxenda)

• Indication:
  • Victoza: Type 2 diabetes and cardiovascular risk reduction.
  • Saxenda: Obesity or overweight with comorbid conditions (e.g. hypertension, sleep apnoea).
• Form: Daily injection.
• Availability: Both available and licensed in SA.
• Highlights: A proven option for weight loss and diabetes, though some patients find daily dosing inconvenient.

3. Dulaglutide (Trulicity)

• Indication: Type 2 diabetes and cardiovascular risk reduction.
• Form: Weekly injection.
• Availability: Available and licensed in SA.
• Highlights: Convenient once-weekly dosing, widely used for both blood glucose and heart health benefits.

4. Semaglutide (Ozempic, Wegovy, Rybelsus)

• Indication:
  • Ozempic: Type 2 diabetes and cardiovascular risk reduction.
  • Wegovy: Obesity or overweight with comorbid conditions.
  • Rybelsus: Oral form for Type 2 diabetes.
• Form: Weekly injection (Ozempic and Wegovy) or daily oral tablet (Rybelsus).
• Availability: Only Ozempic is currently available in SA, others may become available later in the year.
• Highlights: Semaglutide has set a new standard for weight loss, with Wegovy often leading to 15% or more body weight reduction in clinical trials.

5. Tirzepatide (Mounjaro)

• Indication: Type 2 diabetes (with anticipated obesity indication approval).
• Form: Weekly injection.
• Availability: Available in SA as of February 2025.
• Highlights: A dual-action drug targeting both GLP-1 and GIP (another gut hormone), delivering remarkable weight loss and glucose control.

Who can benefit from GLP-1 drugs? 

1. People with Type 2 diabetes

For individuals struggling with blood glucose control, GLP-1 drugs offer a highly-effective option. Beyond lowering HbA1c levels, these medications often reduce cardiovascular risks and may even slow the progression of kidney disease in people with diabetes.

2. Individuals living with obesity

Obesity is now recognised as a chronic, multi-factorial disease, not simply a result of willpower. GLP-1 drugs like semaglutide brand 2 and liraglutide brand 2provide a powerful tool for weight loss by addressing the biological mechanisms driving appetite and energy balance.

Eligible patients typically have:

• A body mass index (BMI) ≥ 30 (obesity), or
• A BMI ≥ 27 (overweight) with weight-related health conditions like high blood pressure or Type 2 diabetes.

3. People with cardiovascular risk

Several GLP-1 drugs, including liraglutide, semaglutide, and dulaglutide, have demonstrated benefits in reducing the risk of heart attack, stroke, and cardiovascular death in people with Type 2 diabetes and existing heart disease.

4. Those with prediabetes

Emerging evidence suggests that GLP-1 drugs could help prevent or delay the onset of Type 2 diabetes in individuals with prediabetes by improving insulin sensitivity and promoting weight loss.

5. Individuals facing plateaus with lifestyle changes

For those who have struggled with diet and exercise alone, GLP-1 drugs can offer an additional boost. These medications complement healthy lifestyle choices and provide sustainable weight-loss results.

New combinations and oral GLP-1 options

The field of GLP-1 therapies is rapidly evolving, with exciting developments that enhance convenience and efficacy.

Combination therapies

• Tirzepatide: Combines GLP-1 and GIP receptor agonism for dual-action benefits.
• Next-generation therapies: Ongoing trials are exploring triple-action drugs targeting GLP-1, GIP, and glucagon receptors, potentially amplifying weight-loss effects.

Oral formulations

• Oral semaglutide: The first and only oral GLP-1 drug, offering an alternative for patients who prefer not to use injections.
• Future options: Researchers are investigating improved oral formulations to increase bioavailability and effectiveness.

Current clinical trials and future directions

Several clinical trials are expanding the potential uses of GLP-1 drugs. Studies, such as STEP and SURMOUNT, are investigating the weight loss potential in non-diabetic populations. Other studies are looking into the use of GLP1 medications to reduce liver fat and treat liver disease associated with diabetes and obesity.

Certainly, there is also great interest in looking into the cardiovascular benefits of GLP1 medications not only in diabetic populations but also in people without diabetes who exhibit risk factors for cardiovascular disease.

Finally, early research suggests GLP-1 drugs might also have protective effects in diseases like Alzheimer’s and Parkinson’s, but further investigation is required.

Are GLP-1 drugs right for you?

 Not everyone is a candidate for GLP-1 drugs. These medications are generally reserved for people who:

• Have Type 2 diabetes or obesity.
• Are unable to achieve sufficient results with lifestyle changes alone.
• Have no contraindications, such as a history of medullary thyroid cancer or pancreatitis.

It’s also important to consider cost. While some medical aid plans cover GLP-1 drugs, others may not, particularly for obesity treatment. Speak to your doctor to determine your eligibility and explore various options that may be available.

Overview

GLP-1 receptor agonists are reshaping how we approach Type 2 diabetes and obesity, offering hope to millions worldwide. From improved blood glucose control to life-changing weight loss, these medications address the biological underpinnings of chronic conditions that were once considered unsolvable.

If you are interested in knowing more or think that these drugs might be right for you, please consult your doctor. Together, you can explore your health goals, treatment options, and the exciting possibilities these ground-breaking medications provide.

Diabetes breakthroughs

This year Dr Paula Diab will present a series of articles that address various new breakthroughs in diabetes management. These will focus mainly on medications that are becoming available – different ways of using old medications, new formulations, and new drugs in the pipeline.

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