Beyond glycemia: Comparing tirzepatide to GLP-1 analogues

Clinical effectiveness of tirzepatide for patients with atrial fibrillation and type 2 diabetes: A retrospective cohort study

AIM

This study aimed to evaluate whether tirzepatide is associated with a reduced atrial fibrillation (AF) burden in patients with type 2 diabetes (T2D).

METHODS

A retrospective cohort study was conducted using the TriNetX database. Adults with both AF and T2D diagnosed between January 2022 and February 2025 were included. The primary outcome was a composite of cardioversion, intravenous antiarrhythmic drug use, and AF ablation. Secondary outcomes included each component of the composite, heart failure, ischemic stroke, and all-cause mortality. Propensity score matching and Cox models were used. Subgroup analyses were conducted based on AF type, coronary artery disease, chronic kidney disease, heart failure, and obesity.

RESULTS

After matching, 11,194 patients were analyzed. Tirzepatide use was associated with a significantly lower risk of the primary outcome (HR: 0.65; 95 % CI: 0.55-0.76; P < 0.001). Significant findings were also observed across all secondary outcomes, including cardioversion, intravenous antiarrhythmic therapy, atrial fibrillation ablation, heart failure, ischemic stroke, and all-cause mortality. These associations remained consistent across prespecified subgroups and multiple sensitivity analyses.

CONCLUSION

Tirzepatide was significantly associated with reduced AF burden in patients with T2D and AF. These findings suggest a potential therapeutic role, supporting further prospective evaluation. Condensed abstract Tirzepatide, a dual GLP-1/GIP receptor agonist, has shown metabolic and cardiovascular benefits, but its impact on AF burden remains unclear. Using the TriNetX database, this study analyzed 11,194 patients with AF and T2D and found that tirzepatide use was significantly associated with a lower two-year risk of cardioversion, intravenous antiarrhythmic drug use, and AF ablation (HR: 0.65; 95 % CI: 0.55-0.76; P < 0.001). These findings suggest that tirzepatide may offer therapeutic benefits in this high-risk population, warranting further investigation through randomized clinical trials.

Effectiveness of tirzepatide in patients with HFpEF using a target trial emulation retrospective cohort study

Tirzepatide, a dual agonist of glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptors, has shown promise in improving metabolic and cardiovascular profiles in patients with obesity. However, its potential benefits in patients with heart failure with preserved ejection fraction (HFpEF) remain unclear. We conducted a real-world, retrospective cohort study using the TriNetX global database. A total of 14,154 patients with HFpEF were included after 1:1 propensity score matching. Tirzepatide use was associated with significantly lower risks of the primary composite outcome of heart failure exacerbation and all-cause mortality (HR 0.52), as well as reductions in major adverse cardiovascular events (HR 0.64) and major adverse kidney events (HR 0.44). Subgroup analyses demonstrated consistent benefits across different strata. Sensitivity analyses using alternative exposure definitions confirmed the robustness of the findings. These results support the potential clinical utility of tirzepatide in HFpEF management and warrant further investigation in randomized controlled trials.

Blood pressure lowering efficacy of dual glucose-dependent insulinotropic polypeptide/glucagon-like peptide-1 (GIP/GLP-1) receptor agonists compared to glucagon-like peptide-1 (GLP-1) receptor agonists

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To compare the blood pressure effects of dual glucose-dependent insulinotropic polypeptide/glucagon-like peptide-1 (GIP/GLP-1) receptor agonists with the blood pressure effects of glucagon-like peptide-1 (GLP-1) receptor agonists.

Tirzepatide and major adverse limb events: Insights from a multicenter real-world analysis in PAD and diabetes patients

AIMS

Peripheral artery disease (PAD) is a major diabetic complication and a leading cause of amputation. While GLP-1 receptor agonists (GLP-1 RAs) provide cardiovascular and limb protection, the impact of tirzepatide, a dual GLP-1/GIP receptor agonist, on major adverse limb events (MALEs) remains unclear. This study assessed tirzepatide's association with MALE risk in patients with PAD and diabetes using real-world data.

METHODS

This retrospective cohort study analyzed 8,046 propensity score-matched PAD patients with diabetes (4,023 on tirzepatide, 4,023 controls) from the TriNetX database. The primary outcome was MALEs, with secondary outcomes including all-cause mortality, acute stroke, acute myocardial infarction (AMI), and major adverse cardiovascular events (MACEs). Cox models and Kaplan-Meier curves were used for analysis.

RESULTS

Tirzepatide significantly reduced MALE risk (HR: 0.44, 95 % CI: 0.33-0.59, p < 0.001) and was associated with lower mortality, stroke, and MACEs. AMI risk was similar between groups (HR: 0.85, p = 0.29). Subgroup analyses confirmed consistent findings, except in those with prior stroke.

CONCLUSIONS

Tirzepatide significantly lowered MALE risk in PAD patients with diabetes, suggesting a potential therapeutic role. Further prospective studies are needed to validate these findings.

Gastrointestinal safety of semaglutide and tirzepatide vs. placebo in obese individuals without diabetes: a systematic review and meta analysis

INTRODUCTION

Semaglutide and tirzepatide are newly approved glucagon-like peptide-1 receptor agonists for weight management in adults without diabetes. However, safety concerns regarding gastrointestinal (GI) adverse outcomes have been raised. This review comprehensively evaluates their GI safety profile in randomized controlled trials (RCTs).

METHODS

Thirteen RCTs involving 26 894 obese participants without diabetes were analyzed. Pooled analysis assessed the risks for GI, biliary, hepatic, and pancreatic adverse events.

RESULTS

Overall GI adverse events were 1.86 times higher with *both* agents (95% CI=1.56, 2.21), with tirzepatide showing a greater risk (RR 2.94, 95% CI=2.61, 3.32) than semaglutide (RR 1.68, 95% CI=1.46, 1.94). Semaglutide increased gallbladder-related disorders, particularly cholelithiasis, by over 2.6 times (95% CI=1.40, 4.82), while tirzepatide showed no significant biliary risk. Neither agent significantly increased hepatic or pancreatic adverse events.

CONCLUSION

Compared to placebo, both Semaglutide and tirzepatide are associated with increased GI adverse outcomes, with most cases being mild. Clinicians should carefully monitor patients for potential adverse outcomes.

Appendicitis After Initiation of Tirzepatide

Tirzepatide is a GLP1/GIP receptor agonist that is used to treat type 2 diabetes and promote weight loss. Common side effects of Tirzepatide include nausea, vomiting, and diarrhea. More severe side effects include pancreatitis, cholelithiasis, thyroid cancer, and cholecystitis. With the increased use of these medications, additional side effects are being discovered. Delayed gastric emptying associated with GLP1/GIP receptor agonists can increase the risk of developing appendicitis due to changes in gastrointestinal motility. There is minimal data on the risk of developing appendicitis with Tirzepatide. This novel case report presents a 73-year-old female patient, without typical risk factors or obvious triggers, who developed appendicitis one week following the initiation of Tirzepatide. Once Tirzepatide was stopped, the patient's symptoms dramatically improved and there was improvement also demonstrated on CT imaging. The patient eventually got an outpatient appendectomy. Appendicitis is not frequently reported as a GLP1/GIP receptor agonist side effect in clinical studies. There seems to be a temporal association between Tirzepatide and the onset of appendicitis. This case report highlights the importance of considering appendicitis as a potential adverse effect of Tirzepatide, a GLP1/GIP receptor agonist.

Biotechnology Revolution Shaping the Future of Diabetes Management

INTRODUCTION

Diabetes mellitus (DM) has a millennia-long history, with early references dating back to ancient Egypt and India. However, it was not until the 20th century that the connection between diabetes and insulin was fully understood. The sequencing of insulin in the 1950s initiated the convergence of biotechnology and diabetes management, leading to the development of recombinant human insulin in 1982. This marked the start of peptide-based therapies in DM. Recombinant peptides for DM treatment: Numerous recombinant peptides have been developed since, starting with modified insulin molecules, with the aim of bettering DM management through fine-tuning the glycemic response to insulin. Peptide-based therapies in DM have expanded substantially beyond insulin to include agonists of Glucagon-like peptide-1 receptor and Glucose-dependent insulinotropic polypeptide receptor, glucagon receptor antagonists, and even peptides exerting multiple receptor agonist effects, for better metabolic control. Insulin pumps, continuous glucose monitoring, and automated insulin delivery systems: The development of modern delivery systems combined with real-time glucose monitoring has significantly advanced diabetes care. Insulin pumps evolved from early large devices to modern sensor-augmented pumps with automated shutoff features and hybrid closed-loop systems, requiring minimal user input. The second-generation systems have demonstrated superior outcomes, proving highly effective in diabetes management. Islet cell transplantation, organoids, and biological pancreas augmentation represent innovative approaches to diabetes management. Islet cell transplantation aims to restore insulin production by transplanting donor beta cells, though challenges persist regarding graft survival and the need for immunosuppression. Organoids are a promising platform for generating insulin-producing cells, although far from clinical use. Biological pancreas augmentation relies on therapies that promote beta-cell (re)generation, reduce stress, and induce immune tolerance. Further biotechnology-driven perspectives in DM will include metabolic control via biotechnology-enabled tools such as custom-designed insulin hybrid molecules, machine-learning algorithms to control peptide release, and engineering cells for optimal peptide production and secretion.

Improvement of Recalcitrant Folliculitis Decalvans With Tirzepatide: A Case Report

Folliculitis decalvans (FD) is a chronic inflammatory alopecia characterized by painful, scarring lesions and recurrent flares, often complicated by secondary bacterial infections. Despite the use of topical and systemic anti-inflammatory or antimicrobial therapies, FD remains challenging to manage, with limited therapeutic advancements. We report a case of recalcitrant FD in a man in his 40s who experienced significant symptom improvement and hair regrowth following the initiation of tirzepatide for weight management. This case highlights a previously unreported therapeutic benefit of tirzepatide in FD, potentially mediated through its anti-inflammatory and immunomodulatory effects. As glucagon-like peptide 1 (GLP-1) receptor agonists gain recognition for their efficacy in other inflammatory skin conditions, such as psoriasis and hidradenitis suppurativa, this case supports further exploration of their role in managing FD and other refractory dermatologic diseases.

Anti-Diabetic Therapies and Cancer: From Bench to Bedside

Diabetes mellitus (DM) is a significant risk factor for various cancers, with the impact of anti-diabetic therapies on cancer progression differing across malignancies. Among these therapies, metformin has gained attention for its potential anti-cancer effects, primarily through modulation of the AMP-activated protein kinase/mammalian target of rapamycin (AMPK/mTOR) pathway and the induction of autophagy. Beyond metformin, other conventional anti-diabetic treatments, such as insulin, sulfonylureas (SUs), pioglitazone, and dipeptidyl peptidase-4 (DPP-4) inhibitors, have also been examined for their roles in cancer biology, though findings are often inconclusive. More recently, novel medications, like glucagon-like peptide-1 (GLP-1) receptor agonists, dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) agonists, and sodium-glucose co-transporter-2 (SGLT-2) inhibitors, have revolutionized DM management by not only improving glycemic control but also delivering substantial cardiovascular and renal benefits. Given their diverse metabolic effects, including anti-obesogenic properties, these novel agents are now under meticulous investigation for their potential influence on tumorigenesis and cancer advancement. This review aims to offer a comprehensive exploration of the evolving landscape of glucose-lowering treatments and their implications in cancer biology. It critically evaluates experimental evidence surrounding the molecular mechanisms by which these medications may modulate oncogenic signaling pathways and reshape the tumor microenvironment (TME). Furthermore, it assesses translational research and clinical trials to gauge the practical relevance of these findings in real-world settings. Finally, it explores the potential of anti-diabetic medications as adjuncts in cancer treatment, particularly in enhancing the efficacy of chemotherapy, minimizing toxicity, and addressing resistance within the framework of immunotherapy.

Risk of major adverse cardiovascular events and all-cause mortality under treatment with GLP-1 RAs or the dual GIP/GLP-1 receptor agonist tirzepatide in overweight or obese adults without diabetes: a systematic review and meta-analysis

Background

Among the currently approved antiobesity medications, the glucagon-like-peptide-1 receptor-agonists (GLP-1 RAs) liraglutide and semaglutide, and the dual glucose-dependent-insulinotropic-polypeptide (GIP)/GLP-1 RA tirzepatide have been suggested to reduce cardiovascular-risk in overweight or obesity without diabetes.

Objectives

The objective of this study was to evaluate the cardio- and neuroprotective potential of these novel agents in the nondiabetic overweight/obese adult population.

Data sources and methods

A systematic review and meta-analysis of randomized-controlled clinical trials (RCTs) was performed to estimate the risk of major adverse cardiovascular events (MACE), all-cause and cardiovascular mortality in overweight or obese adults without diabetes treated with GLP-1 or GIP/GLP-1 RAs (vs placebo). Secondary outcomes included the risk of myocardial infarction (MI) and stroke.

Results

Sixteen RCTs (13 and 3 on GLP-1 RAs and tirzepatide, respectively) comprising 28,168 participants were included. GLP-1 or GIP/GLP-1 RAs reduced MACE (odds ratio (OR): 0.79; 95% confidence interval (CI): 0.71-0.89; p < 0.01; I 2 = 0) and all-cause mortality (OR: 0.80; 95% CI: 0.70-0.92; p < 0.01; I 2 = 0), while there was a trend toward lower cardiovascular-mortality (OR: 0.84; 95% CI: 0.71-1.01; p = 0.06; I 2 = 0%) compared to placebo. Additionally, GLP-1 or GIP/GLP-1 RAs reduced the odds of MI (OR: 0.72; 95% CI: 0.61-0.86; p < 0.01; I 2 = 0%) and nonfatal-MI (OR: 0.72; 95% CI: 0.61-0.85; p < 0.01; I 2 = 0%); while no associations between antiobesity treatment and fatal-MI, stroke, nonfatal, or fatal stroke were uncovered.

Conclusion

GLP-1 and GIP/GLP-1 RAs reduce cardiovascular-risk and all-cause mortality in overweight or obese adults without diabetes. Additionally, GLP-1 RAs and GIP/GLP-1 RAs attenuate the risk of MI. Since data on stroke are still limited, future RCTs are warranted to evaluate the neuroprotective potential of these novel antiobesity agents.

Trial registration

PROSPERO CRD42024515966.

The Effect of Tirzepatide on Body Composition in People with Overweight and Obesity: A Systematic Review of Randomized, Controlled Studies

Tirzepatide (TZP) is a new anti-obesity drug, and little is currently known about its effect on body composition (BC) in people with overweight or obesity. The aim of this study is to conduct a systematic review on the impact of TZP on BC compartments in this population during weight loss programs. Literature searches, study selection, method development, and quality appraisal were performed. The data were synthesized using a narrative approach, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Of the 1379 papers retrieved, 6 randomized controlled trials met the inclusion criteria and were reviewed, revealing the following findings. Firstly, TZP was shown to result in a significant reduction in total fat mass (FM), visceral adipose tissue (VAT) and waist circumference (WC) between baseline and short as well as intermediate follow-ups. Compared to other anti-obesity medications (e.g., dulaglutide and semaglutide) taken over the same duration, TZP showed a superior decrease in body fat compartments (i.e., total FM, VAT and WC). Finally, the effect of TZP on fat-free mass (FFM) is still uncertain because the findings remain inconclusive. In conclusion, TZP appears to be an effective strategy for achieving significant improvements in body fat and its distribution, but additional investigations are still needed to determine the impact of TZP on lean mass in this population.

In vivo Antibody Painting for Next Generation Weight Loss Drugs

Peptide-based therapeutics are currently in great demand but often suffer from rapid clearance and accumulation in off-target tissues which continue to present barriers in their clinical translation. Here, we developed an electrophilic peptide for the attachment of therapeutics to native immunoglobulin (IgG) in vivo, enabling the bioorthogonal covalent linkage, or 'painting', of peptide drugs of choice to circulating IgGs directly in live animals. Native IgG painting with glucagon-like peptide-1 (GLP-1) results in sustained body weight loss and prolonged blood glucose management after one dose. Such technology might revolutionize the next generation of long-acting peptide-based medicines.

Development of Novel N-Acylhydrazone Derivatives with High Anti-obesity Activity and Improved Safety by Exploring the Pharmaceutical Properties of Aldehyde Group

The discovery of effective and safe antiobesity agents remains a challenging yet promising field. Our previous studies identified Bouchardatine derivatives as potential antiobesity agents. However, the 8a-aldehyde moiety rendered them unsuitable for drug development. In this study, we designed two series of novel derivatives to modify this structural feature. Through a structure-activity relationship study, we elucidated the role of the 8a-aldehyde group in toxicity induction. We identified compound 14d, featuring an 8a-N-acylhydrazone moiety, which exhibited significant lipid-lowering activity and reduced toxicity. Compound 14d shares a similar lipid-lowering mechanism with our lead compound 3, but demonstrates improved pharmacokinetic properties and safety profile. Both oral and injectable administration of 14d significantly reduced body weight gain and ameliorated metabolic syndrome in diet-induced obese mice. Our findings identify 14d as a promising antiobesity agent and highlight the potential of substituting the aldehyde group with an N-acylhydrazone to enhance drug-like properties.

GLP-1 receptor agonist improves metabolic disease in a pre-clinical model of lipodystrophy

Aims

Individuals with lipodystrophies typically suffer from metabolic disease linked to adipose tissue dysfunction including lipoatrophic diabetes. In the most severe forms of lipodystrophy, congenital generalised lipodystrophy, adipose tissue may be almost entirely absent. Better therapies for affected individuals are urgently needed. Here we performed the first detailed investigation of the effects of a glucagon like peptide-1 receptor (GLP-1R) agonist in lipoatrophic diabetes, using mice with generalised lipodystrophy.

Methods

Lipodystrophic insulin resistant and glucose intolerant seipin knockout mice were treated with the GLP-1R agonist liraglutide either acutely preceding analyses of insulin and glucose tolerance or chronically prior to metabolic phenotyping and ex vivo studies.

Results

Acute liraglutide treatment significantly improved insulin, glucose and pyruvate tolerance. Once daily injection of seipin knockout mice with liraglutide for 14 days led to significant improvements in hepatomegaly associated with steatosis and reduced markers of liver fibrosis. Moreover, liraglutide enhanced insulin secretion in response to glucose challenge with concomitantly improved glucose control.

Conclusions

GLP-1R agonist liraglutide significantly improved lipoatrophic diabetes and hepatic steatosis in mice with generalised lipodystrophy. This provides important insights regarding the benefits of GLP-1R agonists for treating lipodystrophy, informing more widespread use to improve the health of individuals with this condition.

Molecular mechanisms of semaglutide and liraglutide as a therapeutic option for obesity

Obesity, a chronic global health problem, is associated with an increase in various comorbidities, such as cardiovascular disease, type 2 diabetes mellitus, hypertension, and certain types of cancer. The increasing global prevalence of obesity requires research into new therapeutic strategies. Glucagon-like peptide-1 receptor agonists, specifically semaglutide and liraglutide, designed for type 2 diabetes mellitus treatment, have been explored as drugs for the treatment of obesity. This minireview describes the molecular mechanisms of semaglutide and liraglutide in different metabolic pathways, and its mechanism of action in processes such as appetite regulation, insulin secretion, glucose homeostasis, energy expenditure, and lipid metabolism. Finally, several clinical trial outcomes are described to show the safety and efficacy of these drugs in obesity management.

An imbalanced GLP-1R/GIPR co-agonist peptide with a site-specific N-terminal PEGylation to maximize metabolic benefits

Glycemic and body weight control gained from GLP-1R agonists remains an unmet need for diabetes and obesity treatment, leading to the development of GLP-1R/GIPR co-agonists. An imbalance in GLP-1R/GIPR agonism may extensively maximize the glucose- and weight-lowering effects. Hence, we prepared a potent and imbalanced GLP-1R/GIPR co-agonist, and refined its action time through a site-specific N-terminal PEGylation strategy. The pharmacological efficacy of these resulting long-acting co-agonists was interrogated both in vitro and in vivo. The results showed that peptide 1 possessed potent and imbalanced receptor-stimulating potency favoring GIP activity, but its hypoglycemic action was disrupted probably resulting from its short half-life. After PEGylation to improve the pharmacokinetics, the pharmacological effects were amplified compared to native peptide 1. Among the resulting derivatives, D-5K exhibited significant glycemic, HbA1c, body-weight, and food-intake control, outperforming GLP-1R mono-agonists. Based on its excellent pharmacological profiles, D-5K may hold the great therapeutic potential for diabetes and obesity treatment.