GLP - 1 receptor agonists and diabetic ketoacidosis (DKA) when concomitant insulin was rapidly reduced or discontinued

Last edited 07/2019 and last reviewed 10/2021

GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued

Diabetic ketoacidosis has been reported in patients with type 2 diabetes on a combination of a GLP-1 receptor agonist and insulin who had doses of concomitant insulin rapidly reduced or discontinued

• GLP-1 receptor agonists are not substitutes for insulin, and any reduction of insulin should be done in a stepwise manner with careful glucose self-monitoring
• abrupt discontinuation or reduction in insulin doses can lead to poor glycaemic control, with a risk of diabetic ketoacidosis

Advice for healthcare professionals (1):

• serious and life-threatening cases of diabetic ketoacidosis have been reported in association with exenatide, liraglutide, and dulaglutide, particularly after discontinuation or reduction of concomitant insulin
• blood glucose self-monitoring is necessary when adjusting the dose of insulin, particularly when GLP-1 receptor agonist therapy is initiated and insulin is reduced
• if the insulin dose is to be reduced, a stepwise approach is recommended
• discuss with patients the risk factors for and signs and symptoms of diabetic ketoacidosis and advise them to seek immediate medical advice if these develop

Reference:

• MHRA (June 2019). GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued.