The SA Journal Diabetes & Vascular Disease Vol 11 No 4 (November 2014)

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VOLUME 11 NUMBER 4 • NOVEMBER 2014 169
SA JOURNAL OF DIABETES & VASCULAR DISEASE LEARNING FROM PRACTICE
Key messages
In patients with type 1 diabetes and co-existent obesity, GLP-1
agonists
• are currently unlicensed
• can potentially reduce body weight and reduce insulin
requirements
• treatment requires close monitoring
measure of the changes in units/kg. Perhaps disappointingly,
attainment of glycaemia, did not improve. This at least allowed the
true potential for weight loss to emerge independent of changes
that might have resulted from sharp improvements or deteriora-
tions in glycaemic control. The magnitude of weight loss in this
group appeared to exceed that expected in type 2 diabetes,18 pos-
sibly because of the interplay of GLP-1 effects together with the
reduced pro-obesity effect of falling insulin dosage. It is possible
that weight loss might not have been so good if we had simultane-
ously achieved a significant HbA1c reduction, and it is known that
intensification of insulin therapy to attain good control is associated
with weight gain.2 Interestingly, we observed a similar amplifica-
tion effect when adding GLP-1 agonist therapy to those already on
insulin therapy in type 2 diabetes.19
The individual variation of responses was of clinical importance.
One patient had poor tolerability. Otherwise it can be seen that an
effective response was clearly evident very early in the use of GLP-1
agonist therapy and, equally, non-responsiveness in a single patient
was similarly obvious by three months.
Ethical issues around unlicensed uses of liraglutide in type
1 diabetes must focus on safety. Our preliminary experience is
reassuring, but it is small scale and provides no more than a cautious
‘proof of concept’ among the few other small-scale trials that
have been published.11-13, 20,21 There are no currently available data
to suggest harm over and above the standard cautions and side
effects understood and observed in mainstream clinical practice.
Large, prospectively randomised studies have started to explore
the role of liraglutide as additional treatment in type 1 diabetes.22,23
Until they report, we would urge colleagues not to embark on
this therapy without due regard to all local clinical governance
processes, tight systems of clinical supervision, clear mechanism
for independent peer review and a fully informed and consented
patients, who have appropriate (and assessed and documented)
levels of self-care proficiency.
We conclude that, under the appropriate conditions, and with
appropriate patient selection, GLP-1 agonist therapy in type 1
diabetes may be advantageous where weight reduction becomes
both a constraint and a therapeutic objective.
Conflict of interest None
Funding None.
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