Do you recommend switching from a GLP-1 agonist to insulin in female patients with type 2 diabetes who are planning to become pregnant?

Animal studies have indicated a potential for reproductive toxicity at maternally toxic doses of Semaglutide, Dulaglutide and Exenatide.

Due to the paucity of data with Semaglutide and Human pregnancy, the manufacturer advises stopping the drug 2 months before conception.

However, in a multicentric study of more than 5,000 patients, there was no increase of congenital malformations (Cesta et al., PMID 38079178).

In a recent observational study including 168 pregnancies of women exposed to GLP1-RA during the first trimester, alongside a reference group of 156 pregnancies of women with diabetes and 163 pregnancies of overweight/obese women, there was no increased incidence of birth defects. The cumulative incidence of live births, pregnancy loss...

The GLP-1 receptor agonist drugs are contraindicated in pregnancy (pregnancy category C). In women planning to get pregnant, who are on one of these drugs, I would consider switching to metformin if they are not already on it. Of course, insulin can be prescribed if necessary.