When is it time to add a GLP-1 RA in type 2 diabetes?

The often overlapping conditions of type 2 diabetes (T2D), obesity, chronic kidney disease (CKD) and cardiovascular disease (CVD) continue to place an enormous strain on Australia’s healthcare system.
 
With these conditions sharing common pathways and risks, and around 40% of people living with T2D developing CKD, there is a need for integrated, proactive management across these interlinked diseases.
 
For GPs, who are often at the centre of chronic disease management, this can present a challenge.
 
Many patients using SGLT-2is to protect kidney or heart function still experience suboptimal glycaemic control, with HbA1c levels remaining above target (>7%).
 
Studies show that up to one-third of these patients require additional glucose-lowering treatment within 6–12 months of starting an SGLT-2i.
 
Even when SGLT-2is are prescribed for cardiorenal protection, maintaining optimal glycaemic control remains critical.
 
However, GPs often face uncertainty about what to do next when HbA1c remains elevated despite SGLT-2i therapy.
 
Questions can arise around which additional glucose-lowering agents to use, how to balance competing clinical priorities, and how to navigate the Pharmaceutical Benefits Scheme (PBS).
 
Experts have recently labelled GLP-1 RAs as a ‘potential fourth pillar of therapy’ for diabetes-associated kidney disease, alongside RAAS inhibitors, SGLT-2is and finerenone.
 
GLP-1 RAs not only improve glycaemic control but have also demonstrated cardiovascular and kidney protection in clinical studies.
 
Their benefits also extend beyond glucose lowering, they promote weight loss and improve metabolic health, addressing two major drivers of disease progression in T2D and CKD.
 
The decision to introduce a GLP-1 RA should be guided by factors such as Therapeutic Goods Administration (TGA) indications and encompass assessment of estimated glomerular filtration rate (eGFR), albuminuria, cardiovascular comorbidities and obesity.
 
For patients already on an SGLT-2i, combining the two therapies may provide complementary benefits, further reducing residual risk.
 
Reflecting this broader shift towards comprehensive care, semaglutide now carries a new indication in Australia.
 
Semaglutide is approved as an adjunct to standard-of-care therapy to reduce the risk of sustained decline of kidney function and to reduce the risk of cardiovascular death in adults with T2D and CKD.

This expanded indication underscores the growing recognition of GLP-1 RAs as a key component of integrated diabetes care, not only for glucose management but also for protecting the heart and kidneys.
 
While GLP-1 RAs are generally well-tolerated, gastrointestinal side effects, such as nausea and vomiting, are common initially and typically diminish over time.
 
However, understanding the specific TGA and PBS indications and documentation requirements is key to ensuring timely access for eligible patients. Education and support around these evolving pathways will be essential to empower confident prescribing in general practice.
 
Currently PBS restrictions however do not support co-prescribing of SGLT-2i and GLP-1 RAs unless the SGLT-2i is used for renal or heart failure indications.
 
As the complexity of diabetes management grows, GPs play a pivotal role in bridging the gap between evidence and practice.
 
Ensuring awareness of evolving therapeutic options, including when to introduce GLP-1 RAs alongside SGLT-2is, will be vital to improving outcomes for the hundreds of thousands of Australians living with T2D and its complications.
 
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