The best way to manage these two risks, Garg believes, is to take smaller doses of GLP-1 medications in the first place. Smaller doses and more gradual dose escalation schedules can soften the impact of side effects and insulin requirement changes.
That’s easier said than done. Ozempic, Mounjaro, and other injectable drugs in this family are manufactured and distributed in precise, discrete doses that were not designed for the more sensitive bodies of people with type 1 diabetes. But there are creative, albeit unapproved ways of injecting less medication than the manufacturers intended.
A starter dose of Ozempic, for example, is 0.25 milligrams (mg) per week. But Garg thinks that’s far too much for most people with type 1: “We would start them on 0.1 mg and then gradually over three months build them up 1 or 2 mg per week.”
It is possible to draw up smaller doses of semaglutide by counting clicks on the delivery pen, as explained by Everyday Health’s network site Diabetes Daily, a technique that neither the FDA nor the manufacturer endorses.
Tirzepatide comes in a pen device that does not allow for custom dosing in the same way. For smaller tirzepatide doses, Garg will sometimes ask his patients to take a dose every 10 days rather than every seven. Some of his patients go further and extract precise smaller doses of tirzepatide from the pen using an insulin syringe — a technique that Garg does not recommend.
The providers really don’t know how to use these drugs properly. All of the guidelines need to be written.
Smaller doses aren’t necessarily just for the initial months of treatment. Clinicians might be wise to keep patients with type 1 on smaller GLP-1 doses throughout their treatment, Garg says.
At the Barbara Davis Center, very few of the study participants who had been prescribed tirzepatide ever progressed to the higher available doses. And people with less weight to lose have even less need of large doses.
The need for smaller doses is most critical when children use these drugs. Garg says that many doctors and endocrinologists are already prescribing GLP-1s to children who are overweight and have type 1 diabetes, despite a complete lack of study or official guidance on the issue.
Children have smaller bodies, of course, but adolescence can also be a particularly challenging time for blood sugar management. Hormonal changes tend to introduce dramatic shifts in insulin sensitivity, per Diabetes Daily, making it even more important to proactively manage risk.