Do You Still Need Insulin for Type 2 Diabetes in the Ozempic Era?

Insulin, a hormone medication used to regulate blood sugar, has long been one of the most important therapies for managing type 2 diabetes. But with the rise of semaglutide (Ozempic) and other glucagon-like peptide-1 (GLP-1) agonist drugs, which can lower blood sugar very effectively, insulin’s status is shifting.

For some people, however, insulin will remain an essential type 2 diabetes treatment.

Insulin for Type 2 Diabetes: Pros and Cons

Insulin is one of the most powerful therapies available to lower the blood sugar of people with type 2 diabetes. Keeping your blood sugar levels in a healthy range is one of the essential goals of diabetes treatment and is important for preventing diabetes complications such as kidney and vision problems.

As a medicine, insulin functions like the hormone insulin that the body naturally produces, allowing sugar in the bloodstream to flow into the body’s cells and be used for energy.

Insulin: The Pros

Insulin has other benefits. For example, insulin doses can be adjusted frequently to match an individual’s glucose patterns and account for factors such as illness, stress, and dietary intake, says Betul Hatipoglu, MD, director of Case Western Reserve University’s Diabetes, Obesity, and Metabolism Center in Cleveland.

“Insulin is the better choice when you need rapid, dependable, titratable control,” says Dr. Hatipoglu. It’s also necessary in some people with long-standing type 2 diabetes, whose bodies have begun to lose the ability to produce their own insulin. In such cases, blood sugar cannot be controlled adequately without insulin, she says.

Insulin: The Cons

• It may cause weight gain. Due to its tendency to naturally promote energy storage, insulin can worsen excess weight, one of the most common root causes of type 2 diabetes.
• It can lower blood sugar too much. This potentially dangerous side effect is named hypoglycemia. People who use insulin need to be prepared to consume sugar or use emergency glucagon to bring their blood sugar back into a normal range.

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• It may not support cardiovascular health. While insulin’s glucose-lowering effect can help reduce the incidence of complications like nerve or vision damage, prolonged use may increase the long-term risk of heart attack and stroke.

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• It is challenging to use properly. There’s a significant learning curve to insulin use, and many people struggle with the complex treatment burden.

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It’s especially important for insulin users to learn how to prevent and treat hypoglycemia. “If sugars are too low, it can lead to a dangerous, life threatening condition,” says Jennifer Cheng, DO, chief of endocrinology at Hackensack Meridian Health in Neptune, New Jersey. “It’s important to eat regularly when taking insulin injections to prevent low sugars.”

GLP-1s for Diabetes: Pros and Cons

GLP-1s: The Pros

• Lower blood sugar
• Weight loss
• Cardiovascular and kidney benefits

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• Improved insulin resistance

“Insulin remains one of the most potent glucose-lowering therapies we have, but it’s no longer accurate to imply that insulin is always a clearly superior choice to GLP-1–based therapy for lowering A1C in type 2 diabetes,” says Hatipoglu.

GLP-1 drugs are also much easier to use than insulin. They carry a low risk of hypoglycemia despite their ability to prevent glucose spikes, and administration is straightforward, typically with one injection per week. With insulin, many people must take multiple injections every day, varying doses depending on their meals and activity level.

For a person with type 2 diabetes who doesn’t need urgent treatment for high blood sugar, especially if they have obesity, heart disease, high cardiovascular risk, or kidney disease, a GLP-1 is often the more attractive first injectable option, says Hatipoglu.

“In those patients, the question is no longer which lowers sugar more but rather which improves glycemia while also helping weight, hypoglycemia risk, cardiovascular risk, and possibly kidney outcomes,” says Hatipoglu. “On that broader scorecard, GLP-1s often come out ahead.”

GLP-1s: The Cons

GLP-1 drugs aren’t entirely without their own risks.

Perhaps more importantly, for some people with type 2 diabetes, GLP-1 drugs just aren’t effective enough to discontinue insulin use.

Switching From Insulin to GLP-1s

Clinicians like Hatipoglu are switching some of their patients off insulin and onto GLP-1 drugs. “I prefer transitioning some patients from insulin to GLP-1 receptor agonists or GLP-1/GIP therapies if appropriate,” says Hatipoglu.

Dr. Cheng prescribes a gradual transition when switching patients from insulin therapy to GLP-1 therapy. “I typically start with a lower dose GLP-1 and titrate [adjust] upward while decreasing the insulin dosages,” says Cheng. “It’s sometimes possible for patients to get off insulin completely if sugars are well controlled with GLP-1 therapy.”

For those who are interested in transitioning from insulin therapy to GLP-1 therapy, it’s key to exercise regularly, follow a balanced diet that features plenty of protein, and hydrate well, says Cheng. These lifestyle factors can help mitigate side effects that may lead to potential muscle loss or kidney damage, she says.

Taking Insulin and GLP-1s Together

“I have switched many patients from insulin therapy to GLP-1 therapy, and I also regularly use insulin as an adjunctive therapy with GLP-1s,” says Cheng. “It’s another tool to help people get sugars under better control. I often use the GLP-1 medication to help decrease insulin resistance.”

The Takeaway

• While insulin therapy remains a vital tool for blood sugar stabilization in people with type 2 diabetes, using insulin can be a burden, and it comes with risks such as weight gain and hypoglycemia.
• GLP-1 medications are increasingly preferred by doctors because they offer comparable blood sugar control to insulin along with additional benefits like weight loss and heart and kidney protection.
• Insulin is still necessary for people with advanced type 2 diabetes whose pancreases can no longer produce enough insulin and for those facing certain medical situations, like surgery and pregnancy.
• Doctors can combine both therapies or use GLP-1s to transition their patients off insulin therapy, as the combination can improve insulin resistance while offsetting the weight gain typically associated with insulin therapy alone.