GLP-1 receptor agonists and dual agonists lower glucose in a glucose-dependent way and cause little hypoglycaemia on their own. Combined with a sulfonylurea or insulin, the risk rises, and appetite loss in the first weeks adds to it.
The usual approach is to reduce or stop the sulfonylurea, or lower basal insulin, when starting, particularly where HbA1c is already near target. Ask patients to check glucose more often during dose escalation and to report hypos. Recheck the need for the sulfonylurea at each dose step.
- Review every sulfonylurea and insulin dose before starting a GLP-1 receptor agonist or dual agonist.
- Where HbA1c is close to target, consider stopping the sulfonylurea rather than reducing it.
- Ask for extra glucose checks during the escalation weeks, when appetite falls fastest.
- Reassess the remaining doses at each escalation step, not only at the next HbA1c.
Why it matters
Most hypoglycaemia on incretin therapy comes from the drugs it is added to, not the incretin itself.
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