The healthcare system in Australia is under immense pressure due to the complex interplay of type 2 diabetes (T2D), obesity, chronic kidney disease (CKD), and cardiovascular disease (CVD). These conditions often overlap, with approximately 40% of individuals with T2D developing CKD, creating a pressing need for integrated management strategies.
General Practitioners (GPs) are at the forefront of chronic disease management, but they face a challenging dilemma. Many patients taking SGLT-2is to protect kidney and heart function still struggle with suboptimal glycaemic control, with HbA1c levels persistently above the target (>7%). Studies reveal that up to a third of these patients require additional glucose-lowering treatment within 6-12 months of starting SGLT-2i therapy.
Even when SGLT-2is are prescribed for cardiorenal protection, maintaining optimal glycaemic control remains a critical aspect of care. However, GPs often encounter uncertainty when HbA1c levels remain elevated despite SGLT-2i treatment. Questions arise about the choice of additional glucose-lowering agents, balancing clinical priorities, and navigating the Pharmaceutical Benefits Scheme (PBS).
Experts have recently identified 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 offer more than just improved glycaemic control; they have demonstrated cardiovascular and kidney protection in clinical studies. Additionally, they promote weight loss and enhance metabolic health, addressing two major drivers of disease progression in T2D and CKD.
The decision to introduce GLP-1 RAs should be guided by Therapeutic Goods Administration (TGA) indications and consider factors such as estimated glomerular filtration rate (eGFR), albuminuria, cardiovascular comorbidities, and obesity. For patients already on SGLT-2is, combining these therapies may provide complementary benefits, further reducing residual risk.
Semaglutide, a GLP-1 RA, now carries a new indication in Australia. It is approved as an adjunct to standard-of-care therapy to reduce the risk of sustained kidney function decline and cardiovascular death in adults with T2D and CKD. This expanded indication highlights the growing recognition of GLP-1 RAs as a crucial component of integrated diabetes care, offering protection for the heart and kidneys, in addition to glucose management.
While GLP-1 RAs are generally well-tolerated, gastrointestinal side effects like nausea and vomiting are common initially but tend to diminish over time. Understanding the specific TGA and PBS indications and documentation requirements is essential for ensuring timely access for eligible patients. Education and support regarding these evolving pathways will empower GPs to prescribe confidently.
Currently, PBS restrictions do not support the co-prescription of SGLT-2is and GLP-1 RAs unless the SGLT-2i is indicated for renal or heart failure. As diabetes management becomes increasingly complex, GPs play a pivotal role in bridging the gap between evidence and practice. Ensuring awareness of evolving therapeutic options, including the appropriate timing of introducing GLP-1 RAs alongside SGLT-2is, is vital for improving outcomes for the hundreds of thousands of Australians living with T2D and its complications.
