Diabetes treatment has moved beyond blood glucose control and entered the era of “personalized strategies,”

With the Korean Diabetes Association’s 2025 clinical guidelines removing the long-standing recommendation of metformin as the first-line therapy and instead advising initial treatment based on patient characteristics and comorbidities, attention is now turning to the need for reimbursement of GLP-1RA therapy Ozempic (semaglutide).

During an interview with Dailypharm, Professor Choi Sung-Hee, Director of Public Relations for the Korean Diabetes Association and professor at Seoul National University Bundang Hospital, stressed the importance of insurance policies in enabling treatment strategies tailored to individual patient needs.

KDA revises guidelines and opens the era of personalized care

The 2025 revised guidelines of the Korean Diabetes Association boldly removed the recommendation of metformin as the first-line therapy, which had long been considered the standard, shifting instead toward patient-centered, personalized treatment.

The revision goes beyond simple glucose control to include consideration of comorbidities (cardiovascular and renal) through a personalized treatment approach. In other words, it is no longer necessary to always start with metformin; the doctor may consider combination therapy from the outset according to the patient’s condition and clinical profile.

Professor Choi explained, “Diabetes patients present in highly diverse situations, and some cannot tolerate metformin well. Depending on individual conditions such as impaired kidney function or obesity, it may not be necessary to use metformin first, and in severe cases, combination therapy could be considered from the beginning,” highlighting the flexibility of the new guidelines.

Professor Choi added that in actual clinical practice, some patients cannot take metformin, and depending on comorbidities such as impaired kidney function, heart failure, or severe obesity, GLP-1 receptor agonists or SGLT2 inhibitors have already been emerging as first-line options.

The KDA has sought to move away from a purely glucose-lowering focus, pushing for a paradigm shift toward comprehensive management of comorbidities such as hypertension and dyslipidemia.

Professor  Choi stated, “For patients with impaired renal function, heart failure, or obesity/severe obesity, the role and clinical value of GLP-1RAs and SGLT2 inhibitors are becoming increasingly significant. This guideline revision carries significant implications for diabetic patients with such complications.”

The treatment paradigm is being reshaped to meet the increasing incidence of obesity-related diabetes. Professor Choi cited the publication of the Diabetes & Obesity Fact Sheet as an example, underscoring the seriousness of obesity in younger generations.

In particular, the number of obese diabetes patients in their 20s to 40s is rapidly increasing, with the obesity rate among young men being especially pronounced.

Professor Choi explained, “The key to realizing personalized treatment is early detection and proactive management of high-risk patients. Since semaglutide-based anti-obesity drugs, which can simultaneously manage diabetes and obesity, were derived from diabetes treatments, early intervention to control obesity is the key to preventing chronic complications.”

Ozempic's value verified through clinical evidence...“Expect it to benefit obese diabetics”

Against this backdrop of rising obesity-related diabetes, the role of Ozempic (semaglutide) is gaining attention.

Professor Choi said, “Ozempic is a viable option for obese diabetic patients. While existing therapies have shown limited weight loss effects in this group, Ozempic excels not only in lowering blood glucose but also in promoting significant weight reduction.”

Indeed, across the SUSTAIN trial series (phases 1–9), Ozempic significantly improved HbA1c and body weight compared to DPP-4 inhibitors, sulfonylureas, other GLP-1 analogs, and even insulin.

“Ozempic-based regimens have consistently outperformed traditional combinations in obese diabetic patients, and this has been demonstrated in multiple studies. Furthermore, the recently published FLOW trial was particularly impressive, as it confirmed with large-scale clinical data the kidney-protective effects of GLP-1RAs that had previously only been hypothesized.”

The FLOW study directly focused on kidney function and found that Ozempic reduced the rate of decline in estimated glomerular filtration rate (eGFR) and the progression to end-stage renal disease (ESRD) by approximately 24%.

She further highlighted the strengths of Ozempic in diabetic patients at high risk of atherosclerotic cardiovascular disease.

“Diabetic patients with obesity or severe obesity face very high risks of atherosclerotic cardiovascular events. Ozempic has robust clinical data across this area,” she said. “For diabetic patients with still unmet medical needs, such as obesity and cardiovascular disease, Ozempic represents a powerful new weapon.”

Accessibility remains a hurdle due to non-covered status… Emphasis on the need for reimbursement without restrictions

Ozempic is currently approved in Korea as a diabetes treatment but remains non-reimbursed. Consequently, regardless of the drug's efficacy, a significant cost burden persists.

Professor Choi said, “Reimbursement for Ozempic in type 2 diabetes is essential. Most patients cannot afford to use it without reimbursement. While obesity is important, in diabetic patients, Ozempic must enter the reimbursement framework, and reimbursement criteria must allow combination therapy with diverse agents.”

Novo Nordisk Korea reapplied for reimbursement of Ozempic in the first half of 2025. Its insurance price has been agreed with the Health Insurance Review and Assessment Service in earlier negotiations; the final talks collapsed due to supply instability last time, raising hopes for a more favorable outcome this time.

Regarding the reimbursement discussion for Ozempic, Professor Choi emphasized that reimbursement criteria should not impose restrictions to ensure personalized treatment for diabetes patients.

Currently, even with dulaglutide, the only GLO-1RA class drug granted reimbursement, there are limitations, as it can only be combined with metformin or sulfonylureas under reimbursement.

The opinion is that, after Ozempic becomes reimbursed, to achieve sufficient efficacy, an environment must be established where it can be freely combined with existing diabetes medications to see additional benefits, and then treatment can proceed by gradually reducing the number of combination drugs based on the patient's situation.

“In hypertension, up to four drugs are commonly combined, but in diabetes, combination is usually limited to two, which is highly restrictive. At minimum, Ozempic must be allowed use in combination with standard oral agents such as DPP-4 inhibitors and SGLT2 inhibitors.”

Professor Choi further noted, “While it is important to begin reimbursement under criteria similar to those of existing drugs in the same class, the real goal should be enabling broader combination therapy aligned with Ozempic’s evidence base. This approach will maximize therapeutic benefit.”

Concluding the interview, Prof. Choi reiterated, “Diabetes is not merely a condition of elevated blood sugar, but a complex disease entangled with multiple metabolic complications.”

“Based on diverse research findings, healthcare providers should be able to combine treatments with sufficient evidence, and if it aligns with guidelines, insurance should support various treatment options. Going forward, if there is sufficient scientific evidence, the government and pharmaceutical companies should engage in more bold negotiations to ensure domestic patients can benefit from advanced treatments.”