Tirzepatide captured 41% of new GLP-1 starts in 12 months, while semaglutide's SELECT cardiovascular label reshapes a $22B US formulary landscape.

The US Type 2 Diabetes market spans GLP-1 receptor agonists, SGLT2 inhibitors, DPP-4 inhibitors and insulin, covering an estimated 38.4 million US adults with total drug spend exceeding $22 billion in 2023. Tirzepatide (Mounjaro/Zepbound, Eli Lilly) achieved 41% of new GLP-1 prescriptions within 12 months of launch, driven by superior A1c reduction of 2.0 to 2.3% at maximum dose and 15 to 22% weight loss from the SURPASS trials.

Semaglutide's SELECT cardiovascular outcome trial, showing a 20% MACE reduction in overweight and obese adults without Type 2 Diabetes, is reshaping payer access policies beyond glycemic control. Major commercial payers are building new step-edit pathways requiring an SGLT2 trial before GLP-1 access in some populations. IRA Medicare negotiation targets SGLT2 inhibitors, empagliflozin and dapagliflozin, for price reduction starting in 2026, adding downstream pricing pressure across the class.

A cardiovascular label, not glycemic data, is now setting the payer access bar.

Five questions this report answers:

Q1 - How is tirzepatide's dual GIP/GLP-1 mechanism translating into formulary preference over semaglutide at major payers?

Q2 - What is the IRA Medicare negotiation exposure for empagliflozin and dapagliflozin through 2028?

Q3 - Which next-generation agents, orforglipron, retatrutide and CagriSema, threaten to displace current class leaders by 2027?

Q4 - How did semaglutide's SELECT trial 20% MACE reduction change payer step-edit design beyond glycemic control?

Q5 - What SGLT2 patent expiry and generic timeline pressures are reshaping step-edit requirements ahead of GLP-1 access?

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Mike || Global Pharma Commercial Marketing Head

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