The GLP-1 receptor agonist that will be funded is dulaglutide, which is given as a once-weekly subcutaneous injection via a device very similar to an insulin pen. GLP-1 receptor agonists also reduce cardiovascular and likely renal disease over and above their effect on glycaemic control. They probably lead to greater weight loss and glycaemic control than SGLT2 inhibitors but they have no benefit for heart failure, and hard renal outcomes (eg, reduction in renal replacement therapy) are awaited.
If patients have heart failure, an SGLT2 inhibitor will be the preferred agent. For other patients, there is no clear-cut decision. The renal benefits for SGLT2 inhibitors are probably greater than with GLP-1 agonists; so, for a patient with renal disease or heart failure, a SGLT2 inhibitor is a good option. If a patient is very overweight or obese, or has cerebrovascular disease, the tendency may be more toward prescribing a GLP-1 receptor agonist.
PHARMAC will have one Special Authority for both new agents, so it will be straightforward to switch from empagliflozin to dulaglutide when it is available. It will be beneficial to start patients on empagliflozin if there are no contraindications, rather than just waiting a few months and not doing anything. They can be switched to dulaglutide later if indicated. GLP-1 receptor agonists are often a good alternative to basal insulin, and more educational material will be available later in the year when it is expected their place in treatment will be discussed in more detail.