The benefits of GLP-1 drugs beyond obesity

Obesity accelerates cardiovascular ageing

A global obesity pandemic, coupled with an increasingly ageing population, is exacerbating the burden of cardiovascular disease. Indeed, clinical and experimental evidence underscores a potential connection between obesity and ageing in the pathogenesis of various cardiovascular disorders. This is further supported by the notion that weight reduction not only effectively reduces major cardiovascular events in elderly individuals but is also considered the gold standard for lifespan extension, in obese and non-obese model organisms. This review evaluates the intricate interplay between obesity and ageing from molecular mechanisms to whole organ function within the cardiovascular system. By comparatively analysing their characteristic features, shared molecular and cell biological signatures between obesity and ageing are unveiled, with the intent to shed light on how obesity accelerates cardiovascular ageing. This review also elaborates on how emerging metabolic interventions targeting obesity might protect from cardiovascular diseases largely through antagonizing key molecular mechanisms of the ageing process itself. In sum, this review aims to provide valuable insight into how understanding these interconnected processes could guide the development of novel and effective cardiovascular therapeutics for a growing aged population with a concerning obesity problem.

Review Article: GLP-1 Receptor Agonists and Glucagon/GIP/GLP-1 Receptor Dual or Triple Agonists-Mechanism of Action and Emerging Therapeutic Landscape in MASLD

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is primarily managed through diet and lifestyle modifications. However, these behavioural interventions alone may not achieve disease regression or remission, and maintaining long-term adherence is challenging. Incretin mimetics and other gastrointestinal hormones targeting the pleiotropic pathophysiological pathways underlying MASLD have now emerged as promising disease-modifying therapies.

AIMS

This is a comprehensive review summarising the role of glucagon-like peptide-1 (GLP-1) receptor agonists and glucagon/glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor dual or triple agonists in the treatment of metabolic dysfunction-associated steatohepatitis (MASH).

METHODS

Only clinical trials with endpoints assessed by liver histology were included for a robust evaluation of therapeutic efficacy.

RESULTS

Recent evidence from phase 2 clinical trials for MASH demonstrated that pharmacological agents based on GLP-1 receptor agonism are effective in improving disease activity. Additionally, tirzepatide and survodutide showed potential clinical benefits in reducing fibrosis. Other cardiometabolic benefits observed include weight loss and improvements in glycaemic control and lipid profile. Adherence to treatment may be limited by gastrointestinal side effects, though they were found to be generally mild to moderate in severity. An interim analysis of the semaglutide phase 3 trial confirmed its efficacy in improving steatohepatitis and demonstrated its potential to improve fibrosis.

CONCLUSIONS

GLP-1 receptor agonists, alone or in combination with GIP and/or glucagon receptor agonists, represent promising, effective pharmacotherapies for the treatment of MASLD/MASH. Larger and longer-duration clinical trials are needed to further evaluate the efficacy and safety of GIP receptor and glucagon receptor agonism.

Body image and interest in GLP-1 weight loss medications

There has been extensive discourse about new weight loss medications, glucagon-like peptide 1 agonists (GLP-1s), and their potential to induce significant weight loss among users. Past research reveals strong associations between body size and body image, which may lead some users of GLP-1s to expect an increase in body satisfaction. To date, no research has explored the relationship between body image and interest in using GLP-1s, which is the focus of the current study. Two hundred and twenty-five participants from a university in the Northeastern U.S. (Mage = 20.03; 71.2 % women) completed assessments of their awareness and interest regarding GLP-1s using questions developed specifically for this study. Participants also completed measures of body appreciation, body neutrality, self-objectification (body shame and surveillance), weight bias, concerns about weight, and attempts at weight loss; they self-reported their height and weight. Results indicated that participants who were most interested in trying GLP-1s and willing to tolerate their common side effects reported greater body shame, body surveillance, weight concerns, anti-fat bias, disordered eating behaviors, and higher BMIs, as well as lower body appreciation and body neutrality. Simultaneous regression analyses revealed that BMI and recent attempts at weight loss uniquely accounted for variance in interest in GLP-1 use and willingness to tolerate side effects of GLP-1s. Notably, body appreciation moderated one of these findings, suggesting that a higher appreciation for one's body may serve as a protective factor against interest in using GLP-1s for weight loss.

Building Comprehensive Care Networks to Support Lifestyle Change in Patients Taking Obesity Management Medications

There is a sizable proportion of the U.S. population taking obesity management medications (OMMs), accessed through their primary care provider or a specialist. If healthcare providers are prescribing the medications as directed, and patients are taking the medications as directed, they should be doing so in combination with healthy lifestyle behaviors. Specialists in nutrition therapy, physical activity, behavioral counseling, and medical management should work together as a network providing truly comprehensive care. When trained, educated and credentialed in obesity care, this network of providers can coordinate and collaborate to build trust, combat weight stigma and bias, support lifestyle change, and achieve improved health outcomes.

The Critical Role of Lifestyle With the Use of Contemporary Obesity Management Medications

The emergence of the latest generation of obesity management medications (OMMs) or commonly referred to as "GLP-1s," are proving to be highly efficacious for the reduction of excess body weight. A comprehensive obesity care strategy in which patients are prescribed both lifestyle and medication therapy to promote holistic health and well-being are recommended. Lifestyle modification, through changes in eating and exercise behaviors, has long been a cornerstone of obesity treatment; however, there is a lack of evidence to fully demonstrate the role that lifestyle plays with the latest generation of OMMs compared to previous obesity pharmacotherapies. While obesity continues to be a significant public health problem, medical treatments for obesity have entered a new era with a promising outlook. However, there are key aspects that warrant further consideration to treat patients with obesity in a comprehensive manner that includes medical management, lifestyle, and behavioral health. Highlighted throughout are evidence-based aspects of obesity care, areas where there are gaps in evidence and critical questions remain, and opportunities for enhancing comprehensive obesity treatment.

Association of glucagon-like peptide-1 receptor agonists with atrial fibrillation, cardiac arrest, and ventricular fibrillation: Casual evidence from a drug target Mendelian randomization

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have shown benefits for cardiorenal outcomes in patients with type 2 diabetes mellitus. Although some observational studies suggest that GLP-1RAs protect against arrhythmias, the evidence remains inconclusive.

METHODS

This study aimed to assess the causal relationship between GLP-1RAs and arrhythmias, including atrial fibrillation (AF), cardiac arrest, and ventricular fibrillation. We performed a two-sample Mendelian randomization (MR) analysis to examine the associations between genetically proxied GLP-1RAs and the risk of arrhythmias. Genetic instruments for GLP-1RAs were obtained from the cis-expression quantitative trait loci of the GLP1R gene, on the basis of data from the eQTLGen Consortium. Genome-wide association study (GWAS) data for AF were sourced from FinnGen10, whereas data for cardiac arrest and ventricular fibrillation came from the GWAS Catalog. Bayesian colocalization and multivariable Mendelian randomization (MVMR) analyses were conducted as supplementary analyses.

RESULTS

Twelve independent single nucleotide polymorphisms were identified as genetic instruments for GLP-1RAs. MR analysis indicated that genetically proxied GLP-1RAs were associated with a reduced risk of AF (odds ratio [OR] = 0.78, 95% confidence interval [CI] = 0.71-0.85, p = 4.45E-08, posterior probability of hypothesis 4 [PP.H4] = 0.007) and a lower risk of cardiac arrest and ventricular fibrillation (OR = 0.60, 95% CI = 0.42-0.85, p = 0.0039, PP.H4 = 0.018). Bayesian colocalization analysis revealed that genetically proxied GLP-1RAs did not share genetic variation with arrhythmias. MVMR analysis revealed that, after adjusting for body mass index and type 2 diabetes mellitus, genetically proxied GLP-1RAs did not have a significant effect on the risk of arrhythmias.

CONCLUSIONS

Our findings suggest that genetically proxied GLP-1RAs are causally associated with a reduced risk of AF, cardiac arrest, and ventricular fibrillation. Further randomized controlled trials are needed to confirm these results.

Contributions of Noncardiac Organ-Heart Immune Crosstalk and Somatic Mosaicism to Heart Failure: Current Knowledge and Perspectives

Heart failure is the final outcome of most cardiovascular diseases and shares risk factors with other cardiovascular pathologies. Among these, inflammation plays a central role in disease progression and myocardial remodeling. Over the past 2 decades, numerous studies have explored immune-related mechanisms in cardiovascular disease, highlighting the importance of immune cross-talk between the heart and extra-cardiac organs, including bone marrow, spleen, liver, gut, and adipose tissue. This review examines how immune interactions among these organs contribute to heart failure pathogenesis, with a focus on clonal hematopoiesis, an age-related alteration of hematopoietic stem cells that fosters pathological bone marrow-heart communication. Additionally, we explore recent advances in the understanding of clonal hematopoiesis and its role in heart failure, emphasizing its implications for prognosis and potential therapeutic interventions. By integrating insights from immunology, metabolism, and aging, we provide a comprehensive perspective on the immunologic determinants of heart failure, paving the way for precision medicine approaches aimed at mitigating cardiovascular risk.

Animal models for development of anti-obesity drugs in the age of GLP-1 agents

INTRODUCTION

Obesity is a major health crisis globally, with prevalence escalating significantly in recent decades. Obesity is not merely excessive weight but is associated with myriad health complications. Ensuring the translational effectiveness of pre-clinical obesity models is paramount, and the success of GLP-1 therapies has highlighted important benchmarks for guiding drug development.

AREAS COVERED

The authors discuss the status of various animal models used for the development of anti-obesity drugs, with particular emphasis on rodent models and their validity of preclinical-to-clinical translation. They also highlight innovative animal model integration opportunities between obesity and other associated pathology. The article is based on literature searches using PubMed for content (up until February 2025).

EXPERT OPINION

The effectiveness of GLP-1 therapies in treating type 2 diabetes and obesity presents an opportunity to evaluate the translational relevance of animal models of obesity. Due to their compelling safety profiles, GLP-1(s) are being tested in a wide range of obesity-associated diseases. Optimization of the mechanistic qualities in this drug class requires the incorporation of new endpoints beyond body weight, including lean mass preservation, cardiovascular health, and anti-inflammatory activities. Finally, we are compelled by the intersection of non-obesity disease models into an obesogenic framework to understand the combinatorial effects of obesity on these other disease indications, including heart failure, neurodegenerative diseases, and cancer.

Semaglutide effects on energy balance are mediated by Adcyap1+ neurons in the dorsal vagal complex

The use of the GLP-1R agonist semaglutide is revolutionizing the treatment of obesity, yet its mechanistic effects on energy balance remain elusive. Here, we demonstrate that reactivation of semaglutide-responsive dorsal vagal complex neurons mimics the drug's effects of reducing food intake and body weight and promoting fat utilization and conditioned taste aversion. We observe that many of the semaglutide-activated area postrema (AP) and nucleus of the solitary tract (NTS) neurons express Adcyap1 mRNA, and ablation of AP/NTS Adcyap1+ neurons largely reverses semaglutide's effects on energy balance acutely in lean mice and in subchronically treated obese mice. Semaglutide-activated AP/NTS Adcyap1+ neurons promote the loss of fat rather than lean mass, with only a modest effect on conditioned taste aversion. Furthermore, NTS Adcyap1+ neurons are engaged by GLP-1R-expressing AP neurons and are necessary for semaglutide-induced activation of several downstream satiety-related structures. Selective targeting of semaglutide-responsive Adcyap1+ neurons holds potential for improved future anti-obesity treatments.

Discovery and Evaluation of DA-302168S as an Efficacious Oral Small-Molecule Glucagon-Like Peptide-1 Receptor Agonist

Glucagon-like peptide-1 receptor (GLP-1R) holds pivotal importance as a therapeutic target for type 2 diabetes (T2D) and obesity. Several oral small-molecule agonists targeting GLP-1R have been developed to date. Nevertheless, these agonists suffer from several limitations, including low potency, poor pharmacokinetics, and unfavorable safety profiles. Here, we report the discovery of compound 29 (DA-302168S), which exhibits higher potency both in vitro/in vivo while mitigating the risk of drug-drug interaction compared to other reported candidate compounds. Preclinical studies show full efficacy in cAMP activation, glucose reduction, and appetite suppression. Safety assessments reveal minimal risks with hERG IC50 > 30 μM and no significant off-target toxicity. Its favorable pharmacokinetics support once-daily oral dosing, improving patient compliance. These findings suggest that compound 29 offers a promising therapeutic option for the management of T2D and obesity. Notably, it has successfully completed phase I clinical trials and is currently undergoing phase II clinical trials.

Renoprotective mechanisms of glucagon-like peptide-1 receptor agonists

Glucagon-like peptide-1 (GLP-1) is an incretin hormone, secreted from gut endocrine cells, which acts to potentiate nutrient-induced insulin secretion. Activation of its receptor, GLP-1R, decreases glucagon secretion and gastric emptying, thereby decreasing blood glucose and body weight. It is largely through these mechanisms that Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have transformed the treatment of type 2 diabetes. More recently, preclinical and clinical studies have reported that these agents have potent extra-pancreatic effects, exhibiting cardioprotective and renoprotective actions. The recent FLOW trial was the first multicentre clinical trial investigating the effect of GLP-1RAs on a primary renal outcome and reported robust evidence that GLP-1RAs are renoprotective. Studies in rodent models of renal injury have shown that gain and loss of GLP-1R signalling improves or deteriorates kidney function. However, the precise mechanisms responsible for renal benefits of GLP-1RAs are not yet fully understood. While prolonged activation of GLP-1 receptors (GLP-1R) has been shown to reverse diabetes-related disruptions in gene expression across various renal cell populations, GLP-1R expression in both rodent and human kidneys is thought to be primarily confined to certain vascular smooth muscle cells. This review discusses recent advances in our understanding of the effects of GLP-1 medicines on the kidney with a focus on indirect and direct mechanisms of action.

Multifunctional incretin peptides in therapies for type 2 diabetes, obesity and associated co-morbidities

Recent studies with peptide-based incretin therapies have focussed mainly on the glucagon-like peptide-1 (GLP-1) receptor agonist semaglutide and the dual agonist tirzepatide that engages receptors for GLP-1 and glucose-dependent insulinotropic polypeptide (GIP). Randomised clinical trials and 'real-world' studies have confirmed the marked glucose-lowering and weight-lowering efficacy of these agents across diverse populations. These include different ethnic groups, young and elderly individuals with and without diabetes and/or overweight or obesity. Recent studies have also confirmed protections against the development and progression of cardiovascular and renal diseases that are additive to the benefits conferred by improved control of blood glucose and body weight. Emerging evidence suggests that incretin therapies could additionally ameliorate fatty liver disease, chronic inflammation, sleep apnea and possibly degenerative bone disorders and cognitive decline. New incretin-based peptide therapies in development include a long-acting glucagon receptor agonist (LY3324954), dual GLP-1/glucagon receptor agonists (survodutide, pemvidutide, mazdutide, G49), triple GLP-1/GIP/glucagon receptor agonists (retatrutide, efocipegtrutide), a combination of semaglutide with the amylin analogue cagrilintide (CagriSema), a unimolecular GLP-1/amylin receptor dual agonist (amycretin), and a GIP receptor antibody with GLP-1 receptor agonism (MariTide). The creation of multi-targeting incretin-based synthetic peptides provides opportunities for improved management of type 2 diabetes and obesity as well as new therapeutic approaches to an expanding list of associated co-morbidities. The aim of the review is to acquaint the reader with developments in the field from 2023 to the present (February 2025).

Considering the use of GLP-1 receptor agonists in women with obesity prior to pregnancy: a narrative review

PURPOSE

Metabolic disease, including obesity and type 2 diabetes, are amongst the most significant health issues facing women of reproductive age. To date, no antenatal weight management tools have reduced the risk of adverse health outcomes for women with obesity and their offspring, resulting in a shift in focus to the pre-conception period. Although not yet recognised in most international weight management guidelines, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are being increasingly used for weight management prior to conception.

METHODS

A literature search of PubMed, Medline, and Embase databases identified relevant articles describing the use of GLP-1 RAs prior to and during pregnancy. Papers were selected based on relevance and originality, with clinical trials, large observational studies and meta-analyses being preferentially included.

RESULTS

This narrative review summarises the mechanism of action of GLP-1 RAs and the clinical effects observed in non-pregnant adults. It synthesises the available data from human and animal studies regarding the safety and efficacy of GLP-1 RAs prior to pregnancy, and the consequences of inadvertent drug exposure in early pregnancy. In considering the need to balance the risks of metabolic disease with the risks posed by inadvertent drug exposure, it highlights the areas where further research is needed to guide clinical decision-making.

CONCLUSION

GLP-1 RAs may have a role in facilitating weight loss and improving the metabolic health of women prior to pregnancy. However, there is currently insufficient evidence to demonstrate that the use of this class of drugs prior to pregnancy improves pregnancy outcomes.

GLP-1 receptor agonists for the treatment of alcohol use disorder

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), such as semaglutide, are widely used in the treatment of metabolic disorders, including type 2 diabetes (T2D) and obesity. These medications primarily function by enhancing insulin secretion; however, emerging evidence suggests that the effects extend beyond metabolic regulation. In this issue of the JCI, Farokhnia et al. evaluated the effects of GLP-1RAs alongside another T2D treatment, dipeptidyl peptidase-4 inhibitors (DPP-4Is), on alcohol consumption in humans and preclinical models. In humans, GLP1-RAs, but not DPP-4Is, were associated with reductions in alcohol consumption. Similarly, DPP-4 inhibition had no effect on alcohol intake in rodents. These findings invite further exploration of the mechanisms by which GLP-1RAs reduce alcohol consumption and redefine our pharmacotherapy approach to alcohol use disorder (AUD) by opening the possibility for application as an early harm-reduction tool.

GLP-1-based therapies for diabetes, obesity and beyond

Glucagon-like peptide 1 (GLP-1)-based therapies, such as semaglutide and tirzepatide, represent highly effective treatment options for people with type 2 diabetes and obesity, enabling effective control of glucose and weight loss, while reducing cardiovascular and renal morbidity and mortality. The success of these medicines has spurred development of next-generation GLP-1-based drugs, promising greater weight loss, improved tolerability and additional options for the route and frequency of dosing. This Review profiles established and emerging GLP-1-based medicines, discussing optimization of pharmacokinetics and tolerability, engagement of new therapeutically useful pathways and safety aspects. Structurally unique GLP-1-based medicines that achieve substantially greater and rapid weight loss may impact musculoskeletal health, providing a rationale for therapeutics that more selectively target adipose tissue loss while preserving muscle mass and strength. Ongoing clinical trials in peripheral vascular disease, neuropsychiatric and substance use disorders, metabolic liver disease, arthritis, hypertension and neurodegenerative disorders may broaden indications for GLP-1-based therapeutics.

Antidiabetic combination therapy and cardiovascular outcomes: An evidence-based approach

Type 2 diabetes mellitus is associated with a 2-4 times increased risk of cardiovascular (CV) disease. Glucagon-like polypeptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) are two important classes of drugs with CV benefits independent of their antihyperglycemic efficacy. The CV outcome trials of both GLP1RA and SGLT2i have demonstrated CV superiority/neutrality concerning major adverse CV events (MACE). While GLP1RAs have exhibited a significant reduction in ischemic stroke and myocardial infarction (MI), SGLT2i have demonstrated a uniformly significant reduction in hospitalization for heart failure (HF) as a class effect. The unique clinical benefits and the distinct but complementary mechanisms of action make the combination of these drugs a mechanistically sound one. Recent meta-analyses suggest an independent and additive benefit of combination therapy of GLP1RA/SGLT2i vs monotherapy. Zhu et al, in a recent issue of the World Journal of Diabetes, demonstrates a numerically lower hazard ratio (HR) for CV outcomes with combination therapy vs monotherapy with either agent, with a reduction in MACE compared to GLP1RA alone [HR = 0.51, 95% confidence interval (CI): 0.16-1.65], or SGLT2i alone (HR = 0.48, 95%CI: 0.15-1.54). The CV death rate was also lower with combination therapy compared to GLP1RA alone (HR = 0.58, 95%CI: 0.08-3.39), or SGLT2i alone (HR = 0.55, 95%CI: 0.07-3.25). Fatal and non-fatal MI and fatal and non-fatal stroke were reduced with combination therapy compared to GLP1RA alone (HR = 0.45, 95%CI: 0.10-2.18 and HR = 0.86, 95%CI: 0.12-6.23, respectively), or SGLT2i alone (HR = 0.44, 95%CI: 0.09-2.10 and HR = 0.74, 95%CI: 0.10-5.47, respectively). Hospitalization for HF was prevented with combination therapy compared to GLP1RA alone (HR = 0.26, 95%CI: 0.03-1.88), or SGLT2i alone (HR = 0.33, 95%CI: 0.04-2.53). They also demonstrated that GLP1RA or SGLT2i monotherapy may not provide significant improvement in CV death and recurrent MI in patients with prior MI or HF, proposing a role for combination therapy in this subgroup. Appropriate patient selection is vital to optimize CV risk reduction as well as the cost-effectiveness of this combination therapy.

Metabolic improvement effects of jejunoileal side-to-side anastomosis in patients with type 2 diabetes and the glucagon-like peptide-1 mechanism

Wang et al explored the metabolic improvement effects of jejunoileal side-to-side anastomosis in patients with type 2 diabetes mellitus (T2DM), focusing on its multitarget metabolic regulatory potential through enhanced secretion of glucagon-like peptide-1. This surgical procedure alters the direction of nutrient flow, activates distal ileal L cells, and increases endogenous glucagon-like peptide-1 levels, supporting glucose homeostasis, enhancing insulin sensitivity, regulating body weight, and improving cardiovascular health. This structural adjustment transforms the gastrointestinal tract into an active endocrine regulatory organ, providing a pathway for metabolic improvement in patients with T2DM and other complex metabolic disorders. Although this procedure demonstrates significant metabolic improvements within 3-6 months after surgery, integrating hormone level measurements, metabolic marker analysis, and long-term follow-up has become crucial for exploring the complex mechanisms of T2DM in the field of metabolic surgery and T2DM management. Multidisciplinary collaboration involving support from endocrinology, nutrition, and rehabilitation teams before and after surgery is becoming increasingly vital in the long-term management of patients with T2DM. This collaboration optimizes surgical outcomes and enhances metabolic management. Side-to-side anastomosis shows potential in the multitarget metabolic management of T2DM, providing an additional intervention option for patients with T2DM and metabolic disorders.

Glucagon-like peptide-1 receptor agonists for major neurocognitive disorders

Disease-modifying treatments for major neurocognitive disorders, including Alzheimer's disease, Parkinson's disease and other cognitive deficits, are among the main unmet needs in modern medicine. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), currently licensed for the treatment of type 2 diabetes mellitus and obesity, offer a novel, multilayered mechanism for intervention in neurodegeneration through intermediate, aetiology-agnostic pathways, likely involving metabolic, inflammatory and several other relevant neurobiological processes. In vitro and animal studies have revealed promising signals of neuroprotection, with preliminary supportive evidence emerging from recent pharmacoepidemiological investigations and clinical trials. In this article, we comprehensively review studies that investigate the impact of GLP-1RAs on the various aetiologies of cognitive impairment and dementia syndromes. Focusing on evidence from human studies, we highlight how brain energy homeostasis, neurogenesis, synaptic functioning, neuroinflammation and other cellular stress responses, pathological protein aggregates, proteostasis, cerebrovascular system and blood-brain barrier dynamics may underlie GLP-1RA putative neuroprotective effects. We then report and appraise evidence from clinical studies, including observational investigations, clinical trials and pooled analyses. Finally, we discuss current challenges and perspectives ahead for research and clinical implementation of GLP-1RAs for the care of people with major neurocognitive disorders, including their individual brain penetrance potential, the need for response biomarkers and disease stage-based indications, their possible non-specific effects on brain health, their profile in terms of adverse events and other unwanted effects, the lack of long-term data for efficacy and safety, and issues surrounding cost and availability of treatment.

Beyond wear and tear at the joint

Bile acid metabolism meets glucagon-like peptide 1 signaling in osteoarthritis.

Once-Weekly Semaglutide in Adults With Alcohol Use Disorder: A Randomized Clinical Trial

Importance

Preclinical, observational, and pharmacoepidemiology evidence indicates that glucagon-like peptide 1 receptor agonists (GLP-1RAs) may reduce alcohol intake. Randomized trials are needed to determine the clinical significance of these findings.

Objective

To evaluate the effects of once-weekly subcutaneous semaglutide on alcohol consumption and craving in adults with alcohol use disorder (AUD).

Design, Setting, and Participants

This was a phase 2, double-blind, randomized, parallel-arm trial involving 9 weeks of outpatient treatment. Enrollment occurred at an academic medical center in the US from September 2022 to February 2024. Of 504 potential participants assessed, 48 non-treatment-seeking participants with AUD were randomized.

Intervention

Participants received semaglutide (0.25 mg/week for 4 weeks, 0.5 mg/week for 4 weeks, and 1.0 mg for 1 week) or placebo at weekly clinic visits.

Main Outcomes and Measures

The primary outcome was laboratory alcohol self-administration, measured at pretreatment and posttreatment (0.5 mg/week). Secondary and exploratory outcomes, including prospective changes in alcohol consumption and craving, were assessed at outpatient visits.

Results

Forty-eight participants (34 [71%] female; mean [SD] age, 39.9 [10.6] years) were randomized. Low-dose semaglutide reduced the amount of alcohol consumed during a posttreatment laboratory self-administration task, with evidence of medium to large effect sizes for grams of alcohol consumed (β, -0.48; 95% CI, -0.85 to -0.11; P = .01) and peak breath alcohol concentration (β, -0.46; 95% CI, -0.87 to -0.06; P = .03). Semaglutide treatment did not affect average drinks per calendar day or number of drinking days, but significantly reduced drinks per drinking day (β, -0.41; 95% CI, -0.73 to -0.09; P = .04) and weekly alcohol craving (β, -0.39; 95% CI, -0.73 to -0.06; P = .01), also predicting greater reductions in heavy drinking over time relative to placebo (β, 0.84; 95% CI, 0.71 to 0.99; P = .04). A significant treatment-by-time interaction indicated that semaglutide treatment predicted greater relative reductions in cigarettes per day in a subsample of individuals with current cigarette use (β, -0.10; 95% CI, -0.16 to -0.03; P = .005).

Conclusions and Relevance

These findings provide initial prospective evidence that low-dose semaglutide can reduce craving and some drinking outcomes, justifying larger clinical trials to evaluate GLP-1RAs for alcohol use disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT05520775.

Estimating direct tissue effects versus weight loss effects of incretin-based drugs for obesity on various chronic conditions

The extent to which newer, incretin-based drugs for obesity improve disease outcomes via weight loss versus the direct effects of these drugs is the subject of intense interest. Although reductions in major adverse cardiovascular events appear to be predominantly driven by the direct tissue effects of such drugs, the associated weight loss effects must be relevant to the benefits observed in other major outcomes, albeit to differing extents. In this Personal View, we draw on evidence to support that weight loss is at least partly responsible (albeit to differing extents) for the reported benefits of incretin-based drugs for obesity in people living with heart failure with preserved ejection fraction, hypertension, chronic kidney disease, and type 2 diabetes. Concurrently, we propose that drug-induced weight loss is largely responsible for the reported improvements in osteoarthritis, obstructive sleep apnoea, and metabolic dysfunction-associated steatohepatitis outcomes. However, more evidence is needed to solidify these observations, including, when possible, trials comparing the effects of incretin-based drugs for obesity with calorie-reduced diets on both outcomes and mechanistic pathways. Such evidence has implications for public health and the design of future trials of novel drugs for obesity.

Incretin-based therapeutics for the treatment of neurodegenerative diseases

Neurodegenerative diseases (NDDs) represent a heterogeneous group of disorders characterized by progressive neuronal loss, which results in significant deficits in memory, cognition, motor skills, and sensory functions. As the prevalence of NDDs rises, there is an urgent unmet need for effective therapies. Current drug development approaches primarily target single pathological features of the disease, which could explain the limited efficacy observed in late-stage clinical trials. Originally developed for the treatment of obesity and diabetes, incretin-based therapies, particularly long-acting GLP-1 receptor (GLP-1R) agonists and GLP-1R-gastric inhibitory polypeptide receptor (GIPR) dual agonists, are emerging as promising treatments for NDDs. Despite limited conclusive preclinical evidence, their pleiotropic ability to reduce neuroinflammation, enhance neuronal energy metabolism and promote synaptic plasticity positions them as potential disease-modifying NDD interventions. In anticipation of results from larger clinical trials, continued advances in next-generation incretin mimetics offer the potential for improved brain access and enhanced neuroprotection, paving the way for incretin-based therapies as a future cornerstone in the management of NDDs.

Expanding the Reach of Sustainable Solid-Phase Peptide Synthesis: One-Pot, Metal-Free Alloc Removal-Peptide Coupling

While the allyloxycarbonyl (Alloc) protecting group has played a key role in solid-phase peptide synthesis (SPPS), providing access to a wide range of peptides, its removal has suffered from relying on air-sensitive Pd(0) complexes in hazardous solvents. We report metal-free, on-resin Alloc removal using readily available iodine/water in environmentally sensible PolarClean (PC)/ethyl acetate (EtOAc) carried out in a one-pot manner with racemization-free peptide couplings employing both 9-fluorenylmethoxycarbonyl (Fmoc) and Alloc amino acids (AAs). Alloc SPPS has been demonstrated by performing consecutive one-pot Alloc removals-peptide couplings, whereas compatibility with long peptides has been proven by carrying out an Alloc removal-coupling on a 39 AA peptide resin. Upscaling to 10 g was combined with TFA-free peptide resin cleavage, opening up opportunities for employing Alloc-AAs as synthons for sustainable peptide manufacturing.

On the causes of obesity and its treatment: The end of the beginning

Over the last 30 years, our understanding of the causes of obesity has been transformed, and new, highly effective medicines for reducing weight have been developed. This remarkable progress marks an end and a beginning. By establishing that obesity is a biologic disorder amenable to scientific inquiry and rational drug development, simplistic notions about its causes and treatment should be laid to rest. The future holds the promise that additional therapeutic approaches for inducing or maintaining weight loss will be developed, and that these treatments will be tailored to different subgroups to potentially address the pathogenic mechanisms.

Mapping the effectiveness and risks of GLP-1 receptor agonists

Glucagon-like peptide 1 receptor agonists (GLP-1RAs) are increasingly being used to treat diabetes and obesity. However, their effectiveness and risks have not yet been systematically evaluated in a comprehensive set of possible health outcomes. Here, we used the US Department of Veterans Affairs databases to build a cohort of people with diabetes who initiated GLP-1RA (n = 215,970) and compared them to those who initiated sulfonylureas (n = 159,465), dipeptidyl peptidase 4 (DPP4) inhibitors (n = 117,989) or sodium-glucose cotransporter-2 (SGLT2) inhibitors (n = 258,614), a control group composed of an equal proportion of individuals initiating sulfonylureas, DPP4 inhibitors and SGLT2 inhibitors (n = 536,068), and a control group of 1,203,097 individuals who continued use of non-GLP-1RA antihyperglycemics (usual care). We used a discovery approach to systematically map an atlas of the associations of GLP-1RA use versus each comparator with 175 health outcomes. Compared to usual care, GLP-1RA use was associated with a reduced risk of substance use and psychotic disorders, seizures, neurocognitive disorders (including Alzheimer's disease and dementia), coagulation disorders, cardiometabolic disorders, infectious illnesses and several respiratory conditions. There was an increased risk of gastrointestinal disorders, hypotension, syncope, arthritic disorders, nephrolithiasis, interstitial nephritis and drug-induced pancreatitis associated with GLP-1RA use compared to usual care. The results provide insights into the benefits and risks of GLP-1RAs and may be useful for informing clinical care and guiding research agendas.

The effect of glucagon-like Peptide-1 receptor agonists on measures of suicidality: A systematic review

Reports submitted to the FDA and EMA suggest that Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) may be associated with an elevated risk of suicidality. To ascertain this association across available pharmacovigilance and cohort studies, Pubmed, Medline, Cochrane Library, PsychInfo, Embase, Scopus, and Web of Science were searched from database inception to November 20, 2024 in accordance with PRISMA guidelines. A manual search using Google Scholar was also conducted to identify additional studies. Cohort studies were assessed for quality using the Newcastle-Ottawa Scale. We endeavored to define and operationalize suicidality as suicide ideation (SI), suicide attempts (SA), and suicide completion (SC), in cases where study authors failed to separate these three dimensions, the term "suicidality" was applied. 22 studies meeting inclusion criteria comprised of pharmacovigilance (n = 10) and cohort studies (n = 12) were identified. Pharmacovigilance studies indicate that semaglutide and liraglutide are associated with disproportionate reporting of SI. Results from cohort studies indicate that GLP-1 RAs are not consistently associated with an increase in any aspect of suicidality; instead, some agents are associated with decreased SI and SA. There is inadequate information to ascertain whether causality exists linking GLP-1 RAs to suicidality. Ongoing vigilance and further information is required to inform if the possibility of causality exists. Practitioners prescribing GLP-1 RAs should be vigilant for the possibility of the emergence of SI and be aware of the higher risk of mental illness in persons who would be candidates for GLP-1 RAs (e.g. Type 2 Diabetes, obesity).

Recent advances in incretin-based therapy for MASLD: from single to dual or triple incretin receptor agonists

Clinically effective pharmacological treatment(s) for metabolic dysfunction-associated steatotic liver disease (MASLD) and its progressive form metabolic dysfunction-associated steatohepatitis (MASH) represent a largely unmet need in medicine. Since glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been licensed for the treatment of type 2 diabetes mellitus and obesity, they were one of the first drug classes to be examined in individuals with MASLD/MASH. Successful phase 2 randomised clinical trials with these agents have resulted in progression to phase 3 clinical trials (principally testing the long-term efficacy of subcutaneous semaglutide). Over the last few years, in addition to GLP-1RAs, newer agents with glucose-dependent insulinotropic peptide and/or glucagon receptor agonist functions have been tested, with increasing evidence from phase 2 randomised clinical trials of histological improvements in MASLD/MASH, as well as benefits on MASLD-related extrahepatic complications. Based on this background of evidence, single, dual or triple incretin receptor agonists are becoming an attractive and promising treatment option for MASLD or MASH, particularly in individuals with coexisting obesity or type 2 diabetes mellitus. In this narrative review, we examine the rapidly expanding body of clinical evidence supporting a role of incretin-based pharmacotherapies in delaying or reversing MASH progression. We also discuss the biology of incretins and the putative hepatoprotective mechanisms of incretin-based pharmacotherapies for managing MASLD or MASH.

An update on drug repurposing in Parkinson's disease: Preclinical and clinical considerations

The strategy of drug repositioning has historically played a significant role in the identification of new treatments for Parkinson's disease. Still today, numerous clinical and preclinical studies are investigating drug classes, already marketed for the treatment of metabolic disorders, for their potential use in Parkinson's disease patients. While drug repurposing offers a promising, fast, and cost-effective path to new treatments, these drugs still require thorough preclinical evaluation to assess their efficacy, addressing the specific neurodegenerative mechanisms of the disease. This review explores the state-of-the-art approaches to drug repurposing for Parkinson's disease, highlighting particularly relevant aspects. Preclinical studies still predominantly rely on traditional neurotoxin-based animal models, which fail to effectively replicate disease progression and are characterized by significant variability in model severity and timing of drug treatment. Importantly, for almost all the drugs analyzed here, there is insufficient data regarding the mechanism of action responsible for the therapeutic effect. Regarding drug efficacy, these factors may obviously render results less reliable or comparable. Accordingly, future preclinical drug repurposing studies in the Parkinson's disease field should be carried out using next-generation animal models like α-synuclein-based models that, unfortunately, have to date been used mostly for studies of disease pathogenesis and only rarely in pharmacological studies.

Neural pathways of nausea and roles in energy balance

Our internal sensory systems encode various gut-related sensations, such as hunger, feelings of fullness, and nausea. These internal feelings influence our eating behaviors and play a vital role in regulating energy balance. Among them, the neurological basis for nausea has been the least well characterized, which has hindered comprehension of the connection between these sensations. Single-cell sequencing, along with functional mapping, has brought clarity to the neural pathways of nausea involving the brainstem area postrema. In addition, the newly discovered nausea sensory signals have deepened our understanding of the area postrema in regulating feeding behaviors. Nausea has significant clinical implications, especially in developing drugs for weight loss and metabolism. This review summarizes recent research on the neural pathways of nausea, particularly highlighting their contribution to energy balance.

Advances of deep Neural Networks (DNNs) in the development of peptide drugs

Peptides are able to bind to difficult disease targets with high potency and specificity, providing great opportunities to meet unmet medical requirements. Nevertheless, the unique features of peptides, such as their small size, high structural flexibility, and scarce data availability, bring extra challenges to the design process. Firstly, this review sums up the application of peptide drugs in treating diseases. Then, the review probes into the advantages of Deep Neural Networks (DNNs) in predicting and designing peptide structures. DNNs have demonstrated remarkable capabilities in structural prediction, enabling accurate three-dimensional modeling of peptide drugs through models like AlphaFold and its successors. Finally, the review deliberates on the challenges and coping strategies of DNNs in the development of peptide drugs, along with future research directions. Future research directions focus on further improving the accuracy and efficiency of DNN-based peptide drug design, exploring novel applications of peptide drugs, and accelerating their clinical translation. With continuous advancements in technology and data accumulation, DNNs are poised to play an increasingly crucial role in the field of peptide drug development.

Variability in the management of GLP-1 agonists and endoscopic procedures: an opportunity for standardization

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), also known as incretin mimetics, have significantly revolutionized the treatment of type 2 diabetes mellitus (T2DM) and obesity worldwide, far exceeding initial expectations regarding their global prescription. This class of medications has demonstrated weight losses of up to 20 % of baseline body weight. Beyond their proven benefits in T2DM and obesity, GLP-1RAs, as well as dual and triple agonists (GLP-1/GIP/glucagon), are being investigated for their effects on conditions such as metabolic-associated steatotic liver disease, various cardiovascular disorders, neurocognitive impairments, and certain addictions. These emerging effects appear to be linked not only to their metabolic action but also to their ability to modulate the chronic inflammatory state underlying these pathologies.

Metabolic dysfunction-associated steatotic liver disease: heterogeneous pathomechanisms and effectiveness of metabolism-based treatment

The global epidemic of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing worldwide. People with MASLD can progress to cirrhosis and hepatocellular carcinoma and are at increased risk of developing type 2 diabetes, cardiovascular disease, chronic kidney disease, and extrahepatic cancers. Most people with MASLD die from cardiac-related causes. This outcome is attributed to the shared pathogenesis of MASLD and cardiometabolic diseases, involving unhealthy dietary habits, dysfunctional adipose tissue, insulin resistance, and subclinical inflammation. In addition, the steatotic and inflamed liver affects the vasculature and heart via increased glucose production and release of procoagulant factors, dyslipidaemia, and dysregulated release of hepatokines and microRNAs. However, there is substantial heterogeneity in the contributors to the pathophysiology of MASLD, which might influence its rate of progression, its relationship with cardiometabolic diseases, and the response to therapy. The most effective non-pharmacological treatment approaches for people with MASLD include weight loss. Paradoxically, some effective pharmacological approaches to improve liver health in people with MASLD are associated with no change in bodyweight or even with weight gain, and similar response heterogeneity has been observed for changes in cardiometabolic risk factors. In this Review, we address the heterogeneity of MASLD with respect to its pathogenesis, outcomes, and metabolism-based treatment responses. Although there is currently insufficient evidence for the implementation of precision medicine for risk prediction, prevention, and treatment of MASLD, we discuss whether knowledge about this heterogeneity might help achieving this goal in the future.

Glucagon like peptide-1 (GLP-1) agonists and cardiometabolic protection: historical development and future challenges

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have revolutionized the treatment of cardiometabolic diseases, extending their therapeutic applications far beyond glycemic control in type 2 diabetes (T2D) and obesity. This editorial synthesizes key milestones, from the discovery of GLP-1 to recent clinical trials highlighting the pleiotropic effects of GLP-1RAs in addressing the interconnected spectrum of cardiometabolic conditions, with a focus on cardiovascular, renal, and hepatic benefits. In addition, as GLP-1RAs continue to reshape the management of cardiometabolic disease and global public health, we discuss future challenges to better elucidate their mechanisms of cardiometabolic protection and maximize their therapeutic potential.

Behavioral medicine in the GLP-1 era

Glucagon-like peptide-1 (GLP-1) agonist medications are receiving high levels of attention because of their dramatic efficacy in causing weight loss. This commentary discusses several ways that those in behavioral medicine and health psychology might think about these medications-whether they should be fully in support of them or whether they pose a risk. The positive aspects of GLP-1s include their great promise in improving health independent of weight loss and the perspective that their efficacy frees individuals from the difficulties of behavioral weight maintenance and the associated stigma of "failing" to lose weight. However, GLP-1 agonist medications also risk medicalizing weight and increasing weight stigma (in addition to those on GLP-1 medications being stigmatized for taking the "easy way out"). From a social identity perspective, GLP-1 medications could even be perceived as a tool to eradicate an entire social group-those that identify as higher weight. In terms of clinical care, a patient-centered, weight-inclusive approach will allow for individuals to receive the treatment that fits with their own social and health context. In terms of research, behavioral medicine should shift away from weight loss interventions simply to lower body mass index, and instead intervene on actual health markers, disease endpoints, or healthy behaviors. Doing so will improve health regardless of a person's weight or whether they are on GLP-1 agonist medications.

Prevention of cardiovascular disease in women with type 2 diabetes: the role of incretin mimetics and sodium-glucose cotransporter-2 inhibitors

Cardiovascular disease (CVD) is the leading cause of death among individuals with type 2 diabetes (T2D), with women experiencing a disproportionate risk of events compared with men. Women have an amplified burden of cardiovascular risk factors once T2D is diagnosed. Incretin mimetics now plays a central role in managing cardiovascular risk by improving glycemic control, promoting weight loss, and potentially exerting direct cardioprotective effects. Similarly, sodium-glucose cotransporter-2 inhibitors contribute to CVD prevention through various nonglucose-lowering mechanisms. Both classes of medications are integral to personalized treatment strategies aimed at addressing the heightened cardiovascular risk faced by women with diabetes. This mini-review addresses possible mechanisms underlying the increased cardiovascular risk and explores the role of incretin mimetics and SGLT2 inhibitors in mitigating CVD in women with T2D. Emphasizing personalized and sex-specific approaches in diabetes care is crucial for optimizing treatment outcomes and improving cardiovascular health.

Cardiovascular, Kidney, and Safety Outcomes With GLP-1 Receptor Agonists Alone and in Combination With SGLT2 Inhibitors in Type 2 Diabetes: A Systematic Review and Meta-Analysis

BACKGROUND

GLP-1 (glucagon-like peptide-1) receptor agonists and SGLT2 (sodium-glucose cotransporter 2) inhibitors both improve cardiovascular and kidney outcomes in people with type 2 diabetes. We conducted a systematic review and meta-analysis to assess the effects of GLP-1 receptor agonists on clinical outcomes with and without SGLT2 inhibitors.

METHODS

We searched MEDLINE and Embase databases from inception until July 12, 2024, for randomized, double-blind, placebo-controlled outcome trials of GLP-1 receptor agonists in type 2 diabetes that reported treatment effects by baseline use of SGLT2 inhibitors, with findings supplemented by unpublished data. We estimated treatment effects by baseline SGLT2 inhibitor use using inverse variance-weighted meta-analysis. The main cardiovascular outcomes were major adverse cardiovascular events (nonfatal myocardial infarction, stroke, or cardiovascular death) and hospitalization for heart failure. Kidney outcomes included a composite of ≥50% reduction in estimated glomerular filtration rate, kidney failure or death caused by kidney failure, and annualized rate of decline in estimated glomerular filtration rate (estimated glomerular filtration rate slope). Serious adverse events and severe hypoglycemia were also evaluated. This meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42024565765).

RESULTS

We identified 3 trials with 1743 of 17 072 (10.2%) participants with type 2 diabetes receiving an SGLT2 inhibitor at baseline. GLP-1 receptor agonists reduced the risk of major adverse cardiovascular events by 21% (hazard ratio [HR], 0.79 [95% CI, 0.71-0.87]), with consistent effects in those receiving and not receiving SGLT2 inhibitors at baseline (HR, 0.77 [95% CI, 0.54-1.09] and HR, 0.79 [95% CI, 0.71-0.87], respectively; P-heterogeneity=0.78). The effect on hospitalization for heart failure was similarly consistent regardless of SGLT2 inhibitor use (HR, 0.58 [95% CI, 0.36-0.93] and HR, 0.73 [95% CI, 0.63-0.85]; P-heterogeneity=0.26). Effects on the composite kidney outcome (risk ratio, 0.79 [95% CI, 0.66-0.95]) and estimated glomerular filtration rate slope (0.78 mL/min/1.73 m2/y [95% CI, 0.57-0.98]) also did not vary according to SGLT2 inhibitor use (P-heterogeneity=0.53 and 0.94, respectively). Serious adverse effects and severe hypoglycemia were also similar regardless of SGLT2 inhibitor use (P-heterogeneity=0.29 and 0.50, respectively).

CONCLUSIONS

In people with type 2 diabetes, the cardiovascular and kidney benefits of GLP-1 receptor agonists are consistent regardless of SGLT2 inhibitor use.

Dietary Restriction Enhances CD8+ T Cell Ketolysis to Limit Exhaustion and Boost Anti-Tumor Immunity

Reducing calorie intake without malnutrition limits tumor progression but the underlying mechanisms are poorly understood. Here we show that dietary restriction (DR) suppresses tumor growth by enhancing CD8+ T cell-mediated anti-tumor immunity. DR reshapes CD8+ T cell differentiation within the tumor microenvironment (TME), promoting the development of effector T cell subsets while limiting the accumulation of exhausted T (Tex) cells, and synergizes with anti-PD1 immunotherapy to restrict tumor growth. Mechanistically, DR enhances CD8+ T cell metabolic fitness through increased ketone body oxidation (ketolysis), which boosts mitochondrial membrane potential and fuels tricarboxylic acid (TCA) cycle-dependent pathways essential for T cell function. T cells deficient for ketolysis exhibit reduced mitochondrial function, increased exhaustion, and fail to control tumor growth under DR conditions. Our findings reveal a critical role for the immune system in mediating the anti-tumor effects of DR, highlighting nutritional modulation of CD8+ T cell fate in the TME as a critical determinant of anti-tumor immunity.

The emerging role of gut hormones

The gut is traditionally recognized as the central organ for the digestion and absorption of nutrients, however, it also functions as a significant endocrine organ, secreting a variety of hormones such as glucagon-like peptide 1, serotonin, somatostatin, and glucocorticoids. These gut hormones, produced by specialized intestinal epithelial cells, are crucial not only for digestive processes but also for the regulation of a wide range of physiological functions, including appetite, metabolism, and immune responses. While gut hormones can exert systemic effects, they also play a pivotal role in maintaining local homeostasis within the gut. This review discusses the role of the gut as an endocrine organ, emphasizing the stimuli, the newly discovered functions, and the clinical significance of gut-secreted hormones. Deciphering the emerging role of gut hormones will lead to a better understanding of gut homeostasis, innovative treatments for disorders in the gut, as well as systemic diseases.

The Effect of Semaglutide on Mortality and COVID-19-Related Deaths: An Analysis From the SELECT Trial

BACKGROUND

Patients with overweight and obesity are at increased risk of death from multiple causes, including cardiovascular (CV) death, with few therapies proven to reduce the risk.

OBJECTIVES

This study sought to assess the effect of semaglutide 2.4 mg on all-cause death, CV death, and non-CV death, including subcategories of death and death from coronavirus disease-2019 (COVID-19).

METHODS

The SELECT (Semaglutide Effects on Cardiovascular Outcomes in Patients With Overweight or Obesity) trial randomized 17,604 participants ≥45 years of age with a body mass index ≥27 kg/m2 with established CV disease but without diabetes to once-weekly subcutaneous semaglutide 2.4 mg or placebo; the mean trial duration was 3.3 years. Adjudicated causes of all deaths, COVID-19 cases, and associated deaths were captured prospectively.

RESULTS

Of 833 deaths, 485 (58%) were CV deaths, and 348 (42%) were non-CV deaths. Participants assigned to semaglutide vs placebo had lower rates of all-cause death (HR: 0.81; 95% CI: 0.71-0.93), CV death (HR: 0.85; 95% CI: 0.71-1.01), and non-CV death (HR: 0.77; 95% CI: 0.62-0.95). The most common causes of CV death with semaglutide vs placebo were sudden cardiac death (98 vs 109; HR: 0.89; 95% CI: 0.68-1.17) and undetermined death (77 vs 90; HR: 0.85; 95% CI: 0.63-1.15). Infection was the most common cause of non-CV death and occurred at a lower rate in the semaglutide vs the placebo group (62 vs 87; HR: 0.71; 95% CI: 0.51-0.98). Semaglutide did not reduce incident COVID-19; however, among participants who developed COVID-19, fewer participants treated with semaglutide had COVID-19-related serious adverse events (232 vs 277; P = 0.04) or died of COVID-19 (43 vs 65; HR: 0.66; 95% CI: 0.44-0.96). High rates of infectious deaths occurred during the COVID-19 pandemic, with less infectious death in the semaglutide arm, and resulted in fewer participants in the placebo group being at risk for CV death.

CONCLUSIONS

Compared to placebo, patients treated with semaglutide 2.4 mg had lower rates of all-cause death, driven similarly by CV and non-CV death. The lower rate of non-CV death with semaglutide was predominantly because of fewer infectious deaths. These findings highlight the effect of semaglutide on mortality across a broad population of patients with CV disease and obesity. (Semaglutide Effects on Cardiovascular Outcomes in Patients With Overweight or Obesity [SELECT]; NCT03574597).