Adjunctive diabetes therapies and cardiovascular protection in type 1 diabetes: tackling the challenging Tchaikovsky piece.

PURPOSE OF REVIEW: This review aims to discuss the cardiometabolic-renal-glycaemic effects of adjunctive diabetes agents in the management of type 1 diabetes.

RECENT FINDINGS: Recent studies have investigated the effectiveness and safety of adjunctive diabetes agents such as metformin, SGLT2 inhibitors and GLP-1 receptor agonists in individuals with type 1 diabetes. A rising trend of use of diabetes technology, notably continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) devices, with improvement of glycaemic control, is observed. Questions arise whether these adjunctive diabetes agents and technologies confer cardiometabolic protective effects in patients with type 1 diabetes.

SUMMARY: The most widely studied adjunctive diabetes agent for type 1 diabetes is metformin. Meta-analyses suggest that metformin modestly improves glucose control, weight, lipid profile, and carotid intima-media thickness in patients with type 1 diabetes and mild obesity. SGLT2 inhibitors have been shown to modestly improve glycaemic control, weight, and blood pressure but are associated with increased risk of diabetic ketoacidosis in individuals with type 1 diabetes. The use of GLP-1 RA in type 1 diabetes with mild obesity provided modest HbA1c and weight reduction, but gastrointestinal side effects were common. The results of the ongoing phase 3 clinical trial of finerenone study in type 1 diabetes on chronic kidney disease progression are awaited. Observational studies suggest that CSII and CGM may also reduce cardiovascular events and hospitalizations in patients with type 1 diabetes.