An oral GLP-1 finds its place on top of basal insulin

The edition in brief

Today's edition is dominated by two trials that answer questions clinics actually face. ACHIEVE-5 randomised 546 adults with type 2 diabetes already on titrated insulin glargine to orforglipron, an oral non-peptide GLP-1 receptor agonist, or placebo for 40 weeks. All three doses beat placebo: HbA1c fell 1.58%, 1.88% and 1.82% with 3 mg, 12 mg and 36 mg against 0.79% with placebo, from a baseline of 8.50%. This matters because it is the first description of an oral GLP-1 added to basal insulin, a combination that until now meant an injection alongside an injection. Second, an exploratory analysis of FINE-ONE asked whether finerenone's kidney benefit in type 1 diabetes depends on how well controlled the diabetes is. Over six months in 242 adults with albuminuric CKD, median UACR fell from 575 to 374 mg/g on finerenone versus 506 to 476 mg/g on placebo, a 25% placebo-corrected reduction. The effect was consistent across HbA1c tertiles and across diabetes duration, with no signal that hyperkalaemia risk varied. HbA1c itself did not change, confirming finerenone works on the kidney rather than through glycaemia. Elsewhere, two phase 3 CagriSema trials published together signal that dual amylin/GLP-1 agonism is now a late-stage diabetes proposition, not only an obesity one. Regulatory watch flagged one new FDA biologics approval whose structured record does not yet carry an indication. The practical thread running through the lead trial is unglamorous but important: adding incretin therapy to insulin is a de-escalation opportunity for the insulin, not just an addition.