Prevention and remission of type 2 diabetes (SIGN)
Incretin-based therapies demonstrate the potential to treat obesity, type 2 diabetes and reduce cardiovascular disease risk.46-48
These medicines are licensed in the treatment of people living with obesity for use as an adjunct to a reduced-calorie diet and increased physical activity. Clinical trials demonstrated that when used alongside non-pharmacological therapies, incretin-based therapies were more effective for weight loss than non-pharmacological therapies alone.49, 50
Glucagon-like peptide-1 receptor agonists
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) mimic the GLP-1 hormone naturally produced in the body. They act by increasing insulin secretion, suppressing glucagon secretion, delaying gastric emptying so increasing satiety and acting via the central nervous system to reduce hunger and appetite. They can therefore be used to achieve and sustain weight loss for the prevention of type 2 diabetes.
Liraglutide (Saxenda) is accepted for restricted use by the SMC as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults.49
The SMC restriction is people with body mass index (BMI) of ≥35 kg/m2* with:
- Non-diabetic hyperglycaemia (prediabetes) at high risk of type 2 diabetes which is defined as having either:
- fasting plasma glucose level of 5.5–6.9 mmol/L or
- HbA1c of 6.0–6.4% (42–47 mmol/mol), and
- High risk of cardiovascular disease (CVD):
- total cholesterol >5mmol/L, or
- high-density lipoprotein (HDL) <1.0mmol/L for men and <1.3mmol/L for women, or
- systolic blood pressure (SBP) >140mmHg
Patients should be treated in a specialist weight management service.
Semaglutide (Wegovy) is accepted for restricted use by the SMC as an adjunct to a reduced-calorie diet and increased physical activity for weight management, including weight loss and weight maintenance, in adults.
The SMC restriction is people with BMI of ≥30kg/m2* in the presence of at least one weight-related comorbidity. Patients should be treated in a specialist weight management service.50
*A lower BMI cut-off may be more appropriate for those from minority ethnic groups known to be at equivalent risk of the consequences of obesity at a lower BMI than the white population (see Social determinants of health).
Liraglutide should be considered as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults with a BMI ≥35 kg/m2 with prediabetes (or lower for people from minority ethnic groups at increased risk of diabetes). Patients should be treated within a specialist weight management service.
Semaglutide should be considered as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults with a BMI ≥30 kg/m2 with prediabetes (or lower for people from minority ethnic groups at increased risk of diabetes). Patients should be treated in a specialist weight management service.
The Scottish Government has issued a statement to NHS boards on a phased approach to implementation of the SMC advice (see Implementing the guideline).
Glucose-dependent insulinotropic polypeptide dual receptor agonists
Glucose-dependent insulinotropic polypeptide dual receptor agonists (GLP-1/GIP RAs) are the most recent type of anti-obesity medicine to be approved for restricted use in Scotland.
Tirzepatide is accepted for restricted use by the SMC as an adjunct to a reduced-calorie diet and increased physical activity for weight management.
The SMC restriction is for use in adults with BMI ≥30 kg/m2* and at least one weight-related comorbidity (including prediabetes).51
*A lower BMI cut-off may be more appropriate for those from minority ethnic groups known to be at equivalent risk of the consequences of obesity at a lower BMI than the white population (see Social determinants of health).
Tirzepatide should be considered as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adults with prediabetes or type 2 diabetes with a BMI ≥30 kg/m2 (or lower for people from ethnic minority groups at increased risk of diabetes).
The Scottish Government has issued a statement to NHS boards on a phased approach to implementation of the SMC advice (see Implementing the guideline).