GLP-1 receptor agonists and dual incretin peptide drugs are increasingly prioritized over basal insulin for type 2 diabetes, though insulin remains essential for patients with advanced beta-cell failure.
Insulin role narrowingGLP-1 RAs and dual incretins are displacing basal insulin as first-line intensification due to superior weight, cardiovascular, and safety profiles
What the researchers found
GLP-1 receptor agonists and dual incretin agonists (like tirzepatide) are increasingly prioritized over basal insulin for type 2 diabetes due to superior efficacy, cardiovascular benefits, weight loss, and safety. However, basal insulin remains indispensable for patients with advanced beta-cell failure, severe hyperglycemia, or contraindications to newer agents. The review advocates personalized, pathophysiology-driven therapy selection including integration of new once-weekly insulin formulations.
Why it matters
The diabetes treatment hierarchy is rapidly being rewritten by peptide-based incretin drugs. This review captures a pivotal moment: GLP-1 agonists and dual incretins are displacing insulin from its decades-long position as the default treatment intensification option, fundamentally changing how type 2 diabetes is managed.
The numbers in context
GLP-1 RAs, SGLT2 inhibitors, dual incretin agonists vs basal insulin · once-weekly insulin formulations · personalized therapy selection
How the study worked
Expert review article with targeted PubMed literature search focusing on cardiovascular outcomes trials, head-to-head comparison studies, and major diabetes treatment guidelines comparing newer agents (GLP-1 RAs, SGLT2i, dual incretins) to basal insulin.
Who was studied
Review of treatment evidence for adults with type 2 diabetes
What this study cannot tell us
Expert opinion/editorial format rather than systematic review. Brief article (4 pages). Does not quantify specific outcome differences between drug classes. May not capture the full breadth of patient scenarios. Does not address cost-effectiveness or global access disparities.
How to read the evidence
This is an expert review article synthesizing evidence from major trials and guidelines, published in a specialist endocrinology journal. It provides clinical context and recommendations but is not a systematic review or meta-analysis.
When this study was published
Published in 2025, this captures the current state of the rapidly evolving diabetes treatment landscape, including the impact of tirzepatide and once-weekly insulin formulations.
The bigger picture
This review reflects a seismic shift in diabetes care driven by peptide drug innovation. GLP-1 receptor agonists and dual GLP-1/GIP agonists have moved from niche options to first-line contenders, fundamentally challenging insulin's 100-year reign. The emergence of once-weekly insulin (icodec) and insulin-semaglutide combinations (IcoSema) suggests the future may involve integrated peptide-insulin products rather than an either/or choice.
Questions still open
- Will basal insulin eventually be reserved only for late-stage type 2 diabetes, or will new formulations keep it competitive?
- How should clinicians decide between GLP-1 monotherapy, dual incretins, and insulin-peptide combinations?
- Will cost and access barriers limit the shift away from insulin in lower-income healthcare settings?
Common questions
Why are GLP-1 drugs now preferred over insulin for type 2 diabetes?
When is insulin still the right choice?
Read the original research
Basal insulin in the age of innovation: are diamonds still forever?
Expert review of endocrinology & metabolism, 20(6), 471-474
Citation
Koufakis, Theocharis; Patoulias, Dimitrios; Popovic, Djordje S; Tsimihodimos, Vasileios. (2025). Basal insulin in the age of innovation: are diamonds still forever?. Expert review of endocrinology & metabolism, 20(6), 471-474. https://doi.org/10.1080/17446651.2025.2580629