Viral Shah, MD

Diabetes Dialogue: Technology, Therapeutics, & Real-World Perspectives!

Diabetes Dialogue: Expanding GLP-1 Usage Into Type 1 Diabetes With Viral Shah, MD

In this episode of Diabetes Dialogue, recorded on-site at the American Association of Clinical Endocrinology (AACE) Annual Meeting 2026 in Las Vegas, Nevada, cohosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, welcome Viral Shah, MD, professor of endocrinology at Indiana University, for a discussion centered on the evolving role of GLP-1 receptor agonists and broader diabetes classification in type 1 diabetes care. Shah challenges the traditional distinction between type 1 and type 2 diabetes, emphasizing that type 2 diabetes lacks a definitive diagnostic test and is instead a diagnosis of exclusion based on phenotypic characteristics. He explains that patients with type 1 diabetes can also exhibit features of type 2 diabetes, making these categories non–mutually exclusive and supporting the rationale for dual diagnoses when clinically appropriate.

The group explores how this framework informs the use of GLP-1 receptor agonists in type 1 diabetes, particularly for patients with obesity, cardiovascular disease, heart failure, or chronic kidney disease. Shah notes that while obesity provides a clear indication for GLP-1 therapy, he is also comfortable using these agents in patients with lower BMI when cardiovascular or renal protection is the primary goal, with careful attention to dose adjustment and avoidance of excessive weight loss or muscle mass reduction. He adds that SGLT2 inhibitors may be preferable in some leaner patients, particularly when renal indications predominate, and highlights recent clarification that SGLT2 inhibitor use for CKD in type 1 diabetes is not considered off-label when prescribed for kidney protection rather than glycemic control.

The conversation then shifts to Shah’s broader view that type 1 and type 2 diabetes differ more in pathophysiology than in long-term disease course. He argues that both conditions share progressive beta cell dysfunction and overlapping complication risks, suggesting the field should move away from rigid separation and toward a more unified understanding of diabetes progression.

This perspective leads into a discussion of “prediabetes,” a term Shah critiques as outdated and insufficient. He reviews its historical origins as a label for intermediate hyperglycemia and argues that it has unintentionally minimized urgency by framing the condition as merely a risk factor rather than part of the disease continuum. Citing evidence of significantly elevated cardiovascular, kidney, and mortality risk in people with prediabetes, he advocates for staging type 2 diabetes similarly to type 1 diabetes, rather than maintaining an artificial threshold between “no disease” and diabetes. He notes that while therapies such as metformin, semaglutide, and tirzepatide have demonstrated benefit in delaying progression, regulatory limitations persist because prediabetes is not formally recognized as a disease state.

The episode concludes with a discussion of autoantibody screening in adults labeled with prediabetes. Shah supports broader antibody testing, particularly in younger adults, to identify individuals with early-stage type 1 diabetes who may otherwise be misclassified and present later with DKA. He emphasizes that accessible antibody testing and therapies such as teplizumab make earlier identification increasingly meaningful, while also acknowledging the importance of patient preference and individualized decision-making. Across the discussion, Shah calls for greater flexibility in diabetes classification, earlier intervention across the disease spectrum, and a more proactive approach to preventing complications rather than waiting for traditional diagnostic thresholds to be crossed.

Editors’ Note: Isaacs reports disclosures with Dexcom, Abbott, Lilly, Novo Nordisk, Medtronic, Insulet, and others. Bellini reports disclosures with Abbott Diabetes Care, MannKind, Povention Bio, and others. Shah reports disclosures with Sanofi, Novo Nordisk, Lilly, Dexcom, Insulet, Tandem Diabetes Care, and others.

Shah V. Beyond Type 2: Evaluating GLP-1 Use in Type 1 Diabetes and Obesity. Presented at the American Association of Clinical Endocrinology Annual Meeting 2026 in Las Vegas, NV. April 22-24, 2026.

Podcasts

Viral Shah, MD, joins the show to break down his AACE 2026 presentation on the benefits of using GLP-1 RAs in patients with T1D.

Beyond Insulin: GLP-1 Receptor Agonists in Type 1 Diabetes

 has centered almost exclusively on insulin delivery. Even as automated insulin delivery (AID) technology has advanced, a substantial proportion of patients fail to achieve time in range > 70%, driven in part by rising rates of 

, which increase insulin resistance and total daily insulin requirements. Insulin alone also does not address 

, which in T1D is 6 to 8 times greater than in people without diabetes.

These limitations have fueled interest in adjunctive pharmacotherapy, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RAs). Accumulating data from observational studies and randomized controlled trials point to clinically meaningful improvements in HbA1c, time in range, and weight in T1D patients, without a demonstrated increase in severe hypoglycemia risk. Regulatory trials are now underway, raising the prospect of a formal T1D indication.

At the American Association of Clinical Endocrinology (AACE) 2026 Annual Meeting, Viral Shah, MD, a professor of medicine in the division of endocrinology & metabolism and director of Diabetes Clinical Research at the IU Center for Diabetes and Metabolic diseases at Indiana University, led a session on this topic, drawing on data from the ADJUST-T1D trial, which evaluated semaglutide in people with T1D, alongside other observational and controlled studies.

Across these data sources, HbA1c reductions ranged from approximately 0.4% to 1.0%, translating to time in range improvements of roughly 5% to 10% depending on baseline glycemic status. Weight loss outcomes appeared comparable to those observed in type 2 trials, though Shah noted that head-to-head comparisons have not been conducted.

He emphasized that the clinical benefit of GLP-1 RAs in T1D is inseparable from appropriate insulin titration. Initiating semaglutide at 0.25 mg or tirzepatide at 2.5 mg typically necessitates a 20% to 30% insulin reduction, but the appropriate degree of down-titration depends on baseline HbA1c and time in range.

Patients with an HbA1c of 8.5% to 9% may not require immediate insulin reduction, as the GLP-1 RA effect is needed to bring glycemia down. Conversely, patients already near target require proactive down-titration to avoid hypoglycemia. Shah recommended follow-up within 1 to 2 weeks of initiation and monthly thereafter to monitor and adjust.

Regarding safety, available data have not shown an increased rate of diabetic ketoacidosis (DKA) with GLP-1 RAs in T1D, though Shah noted that longer-duration trials will be needed to definitively characterize this risk. Gastrointestinal tolerability generally mirrors what is seen in type 2 populations, with one important distinction: patients with T1D appear to tolerate lower maximum doses, and clinicians should calibrate titration accordingly using established GI mitigation strategies.

Shah closed with a direct challenge to industry stakeholders, arguing that obesity in T1D deserves the same clinical priority it receives in type 2, and that the field has been too slow to generate the large-scale regulatory evidence needed to make these therapies available to T1D patients.

“Through your platform, I want to say that all industry, I want them not to ignore type 1 space and do something more so that we can utilize those drugs safely in people with type 1 diabetes as well,” Shah concluded

Editors’ note: Shah reports relevant disclosures with Sanofi, Novo Nordisk, Lilly, Dexcom, Insulet, Tandem Diabetes Care, Medtronic, Sequel Med Tech, Abbott Diabetes, Roche, Biomea Fusion, and T1D Scout.

 The emergence of obesity in type 1 diabetes. 

https://doi.org/10.1038/s41366-023-01429-8

Shah VN, Akturk HK, Kruger D, et al. Semaglutide in Adults with Type 1 Diabetes and Obesity. NEJM. doi:10.1056/EVIDoa2500173

Shah VN. Beyond Type 2: Evaluating GLP-1 Use in Type 1 Diabetes and Obesity. Presented at the American Association of Clinical Endocrinology (AACE) Annual Meeting 2026 in Las Vegas, Nevada, April 22-24, 2026.

Videos

Shah discusses the potential of GLP-1 receptor agonists as adjunctive therapy in type 1 diabetes, from glycemic control to cardiometabolic risk.

Beyond Insulin: Evaluating GLP-1 RAs as Adjunctive Therapy in Type 1 Diabetes, With Viral Shah, MD

The Future of GLP-1s in Type 1 Diabetes, with Viral Shah, MD

New data from the American Diabetes Association’s 85

 Scientific Sessions has highlighted the potential of semaglutide in people with type 1 diabetes. Given these developments, many in endocrinology – and healthcare at large – are wondering if this is the next frontier for glucagon-like peptide receptor agonists (GLP-1 RAs).

Named the ADJUST-T1D study and presented by Viral Shah, MD, professor of medicine in the division of endocrinology & metabolism and director of diabetes clinical research at the Center for Diabetes and Metabolic Diseases at Indiana University School of Medicine, these data showed a significant reduction in fat mass in patients with T1D who received semaglutide treatment, compared against placebo. Shah sat down with 

 to discuss the trial and the future of GLP-1 RAs in endocrinology.

Although insulin has long been considered the optimal treatment for T1D, only around 20% of patients achieve adequate glycemic control based on current targets. Weight gain is also a significant concern for patients with T1D on intensive insulin therapy. These patients are also experiencing a rapid increase in obesity prevalence.

GLP-1 RAs have an established safety profile in treating type 2 diabetes and result in hemoglobin A1C reduction, significant weight loss, and a decrease in long-term micro- and macrovascular complications. However, they are not recommended for use in treating T1D by any current guidelines. Past trials analyzing early GLP-1 RAs such as liraglutide found no consistent benefit in A1C reduction or insulin dose reduction. However, these studies do not account for more effective, modern GLP-1 RAs such as semaglutide.

Recently, with GLP-1 RAs rising in popularity in both the commercial and medical settings, many patients have begun to adopt them into treatment plans for T1D. This is an especially attractive option given their history of relieving cardio-renal diseases, which are the leading cause of mortality in T1D. However, these uses are distinctly off-label and contrary to national guidance, as limited research exists examining modern GLP-1 RAs in relation to T1D.

The ADJUST-T1D trial indicated a significant achievement of a composite primary endpoint of a time in range of >70%, time below range of <4%, and a 5% body weight reduction in the semaglutide cohort compared to placebo. This evidence indicates a successful reduction in obesity in patients with T1D.

Although the results indicate grounds for a potential US Food and Drug Administration (FDA) approval submission, sponsor Novo Nordisk has not yet confirmed intentions to do so. In the interview, Shah discusses the potential for the acceptance of these data, despite being positioned outside of the ADA.

“I don’t know whether it will happen or not, the American Diabetes Association standard of care always updates based on the evidence, and this is a level of evidence because it’s a double-blind randomized controlled trial,” Shah told 

. “And so hopefully that might be added into the ADA standard of care.”

Shah also discusses his personal belief regarding T1D treatments, calling for a wider scope to be taken. Insulin has long been the sole focus of T1D medication, and as its returns diminish, Shah believes that more options must be sought out and tested.

“I would just say that I think we spent 100 years on insulin delivery, which is good. It’s now time to think beyond that, and GLPs and future SGLT2s would be a great way to start,” Shah said. “Within the GLP-1 class, we saw at the ADA meeting that there are so many new classes; once monthly, monoclonal antibody, and so on. It’s such an amazing field, and I hope that people with type 1 diabetes could benefit from some of those. They open up an avenue to do a lot of research.”

Resnick O, Bril F, Beauchamp G. Glucagon-like peptide-1 receptor agonists and type 1 diabetes: a potential game changer?. Front Endocrinol (Lausanne). 2025;15:1520313. Published 2025 Jan 21. doi:10.3389/fendo.2024.1520313

Anson M, Zhao SS, Austin P, Ibarburu GH, Malik RA, Alam U. SGLT2i and GLP-1 RA therapy in type 1 diabetes and reno-vascular outcomes: a real-world study. Diabetologia. 2023;66(10):1869-1881. doi:10.1007/s00125-023-05975-8

Shah VN, Akturk HK, Kruger D, et al. Semaglutide in adults with type 1 diabetes and obesity. NEJM Evidence. Published online June 23, 2025. doi:10.1056/evidoa2500173

Shah discusses the stagnation of the T1D treatment landscape and the potential progress that GLP-1 RA research could present.

ADJUST-T1D Suggests Semaglutide Efficaciously Treats Type 1 Diabetes, with Viral Shah, MD

 in Chicago, Illinois, Viral Shah, MD, professor of medicine in the division of endocrinology & metabolism and director of diabetes clinical research at the Center for Diabetes and Metabolic Diseases at Indiana University School of Medicine, presented data from the recent ADJUST-T1D trial investigating the efficacy of semaglutide in patients with 

Although T1D is a widespread disease requiring constant and lifelong insulin therapy, there are few alternative treatments for patients. The automated insulin delivery (AID) mechanism has streamlined the process of insulin delivery, but with GLP-1 RAs largely still in the pipeline, there is a surprising lack of treatments compared to the 

“About 100 years from insulin discovery, and we just focused on how to best deliver insulin,” Shah told 

. “Which includes the pump and the AID systems and other things, but nothing else. The only other drug that was approved was pramlintide, which is not used anymore. Versus the type 2 diabetes landscape, where there are so many different options available.”

Shah went on to describe the ADJUST-T1D trial, a double-blind, randomized, placebo-controlled study of adults with type 1 diabetes and a body mass index (BMI) >30 who were not meeting their weight loss goals with the AID system. The study was conducted across 4 centers across the US, and randomized patients to either semaglutide or a placebo.

ADJUST-T1D included 72 patients, with 36 in the semaglutide arm and 36 in the placebo arm. Each patient was followed for 6 months. The trial involved a composite endpoint; patients reaching this endpoint had to achieve continuous glucose monitoring (CGM)-based time between 70 and 180 mg/dL of >70%, time below 70 mg/dL of <4%, and weight reduction of ≥5%.

“We wanted to have a very holistic approach where you have real improvement in both time and range without increasing time below range and weight loss, so that it’s a more comprehensive health outcome,” Shah said. “This is the first trial that has that primary endpoint.”

Ultimately, a substantially larger portion of the semaglutide group achieved the composite outcome than the placebo group (36% versus 0%; between-group difference, 36 percentage points; 95% CI, 20.6 to 52.2; 

 <.001). The difference in least-squares mean change from baseline to week 26 for the semaglutide versus placebo group for glycated hemoglobin was -0.3% (95% CI, -.6 to -.05). Percentage of time with CGM glucose levels between 70 and 180 mg/dL had a difference of 8.8% (95% CI, 3.9 to 13.7), and body weight saw a difference of -8.8 kg (95% CI, -10.6 to -7).

The trial saw only 4 adverse events – 2 instances of hypoglycemia in each cohort. However, all of these were unrelated to semaglutide, as they occurred after the end of the study and due to a pump failure, respectively. No diabetic ketoacidosis was reported, and no decay occurred over the following 6 months.

“Again, it’s a short-term trial with a small sample size, but at least it’s reassuring that we didn’t have any safety concerns,” Shah concluded. “It’s not a head-to-head comparison, but if you think about the type 2 diabetes trials or obesity trial, it sounds like a pretty similar type of GI.”

Shah reports the following disclosures: Novo Nordisk, Dexcom Inc., Insulet Corporation, Tandem Diabetes Care, and others.

Infante M, Silvestri F, Padilla N, et al. Unveiling the Therapeutic Potential of the Second-Generation Incretin Analogs Semaglutide and Tirzepatide in Type 1 Diabetes and Latent Autoimmune Diabetes in Adults. J Clin Med. 2025;14(4):1303. Published 2025 Feb 15. doi:10.3390/jcm14041303

Shah discusses the results from the ADJUST-T1D trial comparing semaglutide to placebo, which saw a significant disparity in semaglutide’s favor.

Viral Shah, MD

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