GLP-1 agonists are often called “the miracle drug” for diabetes and weight management. These medications have many benefits, including cardiovascular and renal protection, blood pressure reduction, and improvements in glucose levels. I’ve been taking the GLP-1 + GIP combination medication, tirzepatide, for the last six weeks and have learned a lot. Here are some key takeaways that may help you navigate using this medication with type 1 diabetes.
Benefits for T1D
There are both long and short-term benefits to using this class of medications for PWD, which often outweigh the challenges. Here are some of them, but the use of these medications is still being studied, and we need more longitudinal (long-term) data.1
- Long-Term: Protective of kidney function, reduced risk of cardiovascular complications.
- Short-Term: Reduction in insulin needs, weight loss, improved post-meal glucose levels, improved glucose levels overall, lower blood pressure and lipid levels.
Interestingly, these medications may have the potential to help those struggling with addiction and substance use disorders.2 Other data has been conflicting on whether it improves or worsens symptoms of depression.
This is my Dexcom Clarity data from the month before starting GLP1s to the most recent 30 days.
Challenges for T1D
For PWD who experience severe side effects of these drugs, there is an increased risk of ketosis – even without high blood sugar levels.3 This is due to starvation ketones and the inability of the body to compensate when you have insulin-dependent diabetes. Determining the appropriate insulin dose adjustments can also be difficult, causing more lows and variability. Lows can also be difficult to treat for multiple reasons – nausea makes it difficult to consume glucose and treatment of lows may be delayed since gastric emptying is slowed.
Changing relationship with food
Food is the center of many cultures and social events for people, but taking a medication that decreases your appetite can change how you feel about food. I’ve been taking tirzepatide for the last month and have had various experiences with it so far. The first couple days of weeks one and three proved incredibly difficult. I experienced significant nausea and vomiting along with some stubborn low blood sugars. This caused me to have an aversion to many foods due to fear of worsening these side effects.
I was not anticipating this, and I wish I had been better prepared for the challenge of consuming enough calories during the early weeks of GLP1 usage. There were days when I was afraid to eat anything and even afraid to drink too much water. Regular Sprite seemed to be something that consistently settled my stomach, so I now make sure I always have it at home. Crackers, plain chips, and bland cereal were all I could stomach for the first couple of weeks. These did not help with the side effect of constipation, which also goes along with GLP1s.
Other psychological impacts of GLP1s
Given modern society’s preference for thinness, many are concerned with the psychological effects of GLP1s as it relates to body image. I have watched friends and acquaintances who take GLP1 agonists and lose weight speak about weight in ways that make me uncomfortable. All seem happier with their body image but also speak negatively about their past selves. It makes me worry about how weight is tied to people’s self-worth. Given the enormity of the challenge of obesity and the lack of adequate treatment options, it seems unfair to consider weight as an indicator of personal value.
One woman discussed fat stigma and her personal experience with weight loss with Ozempic and shared that she noticed people treating her better when she lost weight—more people opened the door for her, and her student evaluations improved.4 She wanted people to remember that no matter what your physical body looks like, you are still you, and setting expectations related to the medications is important. Additionally, if you seek food for comfort and are no longer comforted by food, you will need to develop new habits to accommodate.
Mitigating challenges
Throughout the last six weeks, I’ve learned a lot about managing the side effects of GLP1s, and I will try to summarize my key learnings briefly. I’m still learning, and if I ever increase my dose, I’m sure I’ll learn more through that process as well.
For Ketones –
Make sure on the days when you cannot eat or drink well, you are monitoring for ketones. So far, I’ve only had small ketones once and have been fine otherwise. If you plan to start one of these meds, make sure you have ketone test strips that are not expired.
For Lows –
Prevention: Work with your healthcare team to reduce your insulin doses as soon as you start taking the medications and with any increase in dosage. The focus usually starts with reducing meal-time insulin dosing, and as you lose weight, you will likely need to reduce your basal doses as well.
Treatment: Try to absorb some of it in your cheeks (buccal absorption) because this will help you more quickly than absorbing it in your intestines. Personally, I typically use honey or suck on fruit snacks. Other recommendations are glucose gels, icing, or dextrose powder.
For Nausea or Vomiting –
I received a recommendation to take omeprazole in the morning, take famotidine in the evening, and have plenty of ondansetron on hand. I would highly recommend doing these things. Additionally, I received some really great advice while I was at ISPAD 2024 from FFL Faculty Pantea Minnock. She recommended getting some physical food in your stomach first thing in the morning to help avoid a “sour stomach.” She also recommended the following, which is the advice they give their patients at Children’s Hospital of Philadelphia —
Tips to avoid nausea and promote a well-balanced diet:
- Eat small frequent meals – Try to eat 4-5 small meals every 3-4 hours
- Eat slowly, over 15-20 minutes
- Eat thoughtfully:
- Avoid distractions such as electronics while eating
- Chew food well
- When you start to feel a little bit full, put down your fork and walk away.
- Do not eat past the point of starting to feel full, as this may cause GI distress.
- Add fiber to your diet. – this will help prevent constipation. Fiber-rich foods include fruits, vegetables, legumes, nuts, seeds, and whole grains.
- Drink plenty of fluids
- Make sure to include plenty of protein and choose foods lower in fat.
For Constipation –
I’ve found that adding a daily docusate regimen has significantly helped me stay regular. There were times in the first couple of weeks when I needed more aggressive help and got some over-the-counter laxatives. The dietary recommendations above are likely the most helpful for prevention, but you may have to treat it at some point in your journey.
For Concern of Nutritional Deficiency –
Due to the significant change in appetite and food consumption, most providers recommend taking a daily multivitamin. This can be challenging if you cannot get enough food in your stomach to handle the vitamin, so I have been taking them when I am able to eat enough and, honestly, when I remember. I have also found that taking some kids gummy multivitamins when I’m not eating as much is easier on my stomach.
Overall, would recommend
My experience has not been without its ups and downs, but I feel that it has been well worth it. My total daily insulin dose has been cut in half, and my time in range (TIR) and standard deviation have improved significantly. I have had many days recently with 100% TIR, which has been very rewarding (Celebrate the wins!). Traveling during the first few weeks of using GLP1s has added complexity and glucose variability, without a doubt. So maybe try to start it when your schedule is clear, if that ever happens.
- Mechanistic Pathways and Clinical Implications of GLP-1 Receptor Agonists in Type 1 Diabetes Management
- IUPHAR review – Glucagon-like peptide-1 (GLP-1) and substance use disorders: An emerging pharmacotherapeutic target
- Type 1 on a GLP-1 Drug? Watch for Hypoglycemia and DKA
- Fat Stigma, Disordered Eating, and Ozempic
Written and clinically reviewed by Marissa Town, RN, BSN, CDCES
