The REWIND Trial Showed Weekly Dulaglutide Reduces Cardiovascular Events in Women with T2DM. Here Is the Female Subgroup Data.

The Opening Scene

The following is a composite of patients I have seen in clinic. Names and identifying details are changed.

Diane is 51 years old. She lives outside Champaign with her husband and two teenagers. She works as an elementary school principal, which means she is, in her own words, “the last person in the building to eat lunch and the last person to leave.” Her type 2 diabetes was diagnosed at 44, attributed to gestational diabetes she had twice in her 30s and to a weight gain of 22 pounds she never fully lost after her second child. She has been on metformin since diagnosis. At 49, her A1c hit 8.1 percent and her PCP added Trulicity.

She came to see me at 51, two years into Trulicity therapy, because her periods had become irregular, her sleep was fragmenting at 3 a.m., and her cardiologist had mentioned at a routine visit that her LDL was “a little high.” She had not been told her ApoB. She had not been offered a CAC score. She had not been told that Trulicity carried a cardiovascular risk-reduction indication added in 2020, she thought she was on it only for blood sugar.

What Diane did not know, and what no one had framed clearly for her, was this: she is exactly the patient the REWIND trial enrolled. She has type 2 diabetes. She has multiple cardiovascular risk factors, hypertension, dyslipidemia, a history of gestational diabetes (a known independent cardiac risk marker). She had not had a heart attack or stroke. She is 51. And the perimenopause she is entering right now is the period during which her lifetime cardiovascular risk profile shifts most sharply.

She asked me: “Is this medication doing anything important? Because no one has ever explained it to me.”

That sentence, “no one has ever explained it to me”, is the sentence that drives this article. The explanation she deserved at 44 when diabetes was diagnosed, at 49 when Trulicity was added, and at 51 when perimenopause begins, is in the sections that follow.

Methodology Note

This article draws from the FDA-approved prescribing information for dulaglutide (NDA 125469, most recent label revision 2023), the published RCT corpus listed in the References section, and real-world evidence from Optum Labs Data Warehouse, the TriNetX Global Collaborative Network, and peer-reviewed publications in NEJM, JAMA, Lancet, Circulation, JACC, Diabetes Care, and Nature Medicine. All citations use AMA Manual of Style format with DOIs inline. Every empirical claim carries a five-tier Honesty Scale tag (Solid / Promising / Early / Theoretical / Unsupported) placed immediately after the claim and before the DOI. Patient scenes are labeled Composite or anonymized per HIPAA standard. Dr. Mogire has no industry funding for this article. Compound pharmacies, off-label dosing regimens, and unapproved formulations are not endorsed.

What Trulicity Is, FDA Approval Status and Indication

Generic name: Dulaglutide Brand name: Trulicity Manufacturer: Eli Lilly and Company NDA number: 125469 Original FDA approval date: September 18, 2014 Drug class: Glucagon-like peptide-1 (GLP-1) receptor agonist; incretin mimetic

FDA-Approved Indication

From the USPI Section 1, Indications and Usage:

“Trulicity is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus and to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus who have established cardiovascular disease or multiple cardiovascular risk factors.”

The cardiovascular indication was added in May 2020 based on REWIND trial results. For women like Diane, who have T2DM plus hypertension, dyslipidemia, or a history of gestational diabetes, this indication is active. The FDA label is not written for women with established heart disease only. It is written for women with multiple risk factors. That population includes a substantial number of perimenopausal and postmenopausal women with type 2 diabetes.

Approved Dose Range

• 0.75 mg subcutaneous injection once weekly (starting dose)
• 1.5 mg once weekly (standard maintenance dose)
• 3.0 mg once weekly (uptitration option)
• 4.5 mg once weekly (maximum dose)

The dose escalation occurs at 4-week intervals. Most women remain at 1.5 mg, where glycemic efficacy and tolerability reach a practical balance.

Black-Box Warning (Verbatim)

“WARNING: RISK OF THYROID C-CELL TUMORS

In male and female rats, dulaglutide causes a dose-dependent and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether dulaglutide causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as the human relevance of dulaglutide-induced rodent thyroid C-cell tumors has not been determined.

Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk of MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (e.g., a mass in the neck, dysphagia, dyspnea, persistent hoarseness).”

Women initiating GLP-1 RAs should have a thyroid exam documented. Any new neck mass, change in voice, or difficulty swallowing during treatment warrants prompt evaluation. Thyroid nodules are common in perimenopausal women independent of GLP-1 therapy, and new-onset thyroid pathology during treatment requires clinical investigation to distinguish incidental thyroid disease from medication-related concern.

What Trulicity Is NOT Approved For

Trulicity is not approved for weight management. In the AWARD and REWIND trials, mean weight loss on dulaglutide was 1.5 to 3.0 kg at 52 weeks, not the 8 to 15 percent body weight reduction seen with high-dose semaglutide or tirzepatide. Women who are seeking meaningful weight loss as a primary treatment goal should have an explicit conversation with their physician about whether Trulicity is the right tool for that goal, or whether weight-management-specific GLP-1 RA therapy (Saxenda, Wegovy) or tirzepatide (Zepbound) better addresses their clinical picture.

The Mechanism, How It Works

GLP-1 Receptor Agonism and Its Specific Relevance for Women

Dulaglutide is a synthetic GLP-1 analog fused to an IgG4 Fc region for extended half-life. Like all GLP-1 receptor agonists, it activates GLP-1 receptors in the pancreas (insulin secretion, glucagon suppression), gastrointestinal tract (slowed gastric emptying), and central nervous system (appetite and satiety signaling). The glucose-dependent mechanism means hypoglycemia risk is minimal as monotherapy.

What is less commonly discussed with women: GLP-1 receptor expression extends to the ovary, uterus, and placenta. Animal studies show GLP-1 receptor activation affects gonadal function 2 / Theoretical . In clinical practice, this means there is a monitoring question to carry: in perimenopausal women with existing hormonal changes, does GLP-1 RA therapy interact with the estrogen-progesterone shift? The answer, as of the current literature, is that no confirmed interaction has been documented, but this is an area where the clinical trial data is thin, because menopausal women were not systematically characterized in AWARD or REWIND 2 / Theoretical ).

The Perimenopause-Cardiac Connection: Why This Matters for Mechanism

Estrogen has direct cardioprotective properties: it promotes endothelial nitric oxide production, reduces LDL cholesterol and increases HDL cholesterol, and exerts anti-inflammatory effects on the vascular wall 5 / Solid . When estrogen declines in perimenopause, each of these protective signals diminishes. The result: LDL rises (typically 10 to 15 percent in the first two years after menopause), HDL may fall, visceral fat increases even without weight gain, blood pressure tends to rise, and insulin resistance worsens, the same metabolic trajectory that defines type 2 diabetes progression.

This is why the period from perimenopause onset to 10 years post-menopause is the window of highest new-onset cardiovascular disease risk in women 5 / Solid . And it is why a woman with T2DM entering perimenopause at age 50 to 52 is not merely managing blood sugar, she is managing a cardiovascular risk profile that is shifting rapidly under her.

Dulaglutide’s mechanism in this context: it stabilizes glycemic control (preventing the A1c deterioration that accelerates with worsening insulin resistance during perimenopause), produces modest blood pressure reduction (2 to 3 mmHg systolic), and carries a documented cardiovascular risk-reduction indication that was established in a trial where 46.3 percent of participants were women. That is not a small number.

PCOS: A Mechanistic Note

Women with polycystic ovary syndrome (PCOS) carry increased lifetime cardiovascular risk through insulin resistance, dyslipidemia, and chronic low-grade inflammation, pathways that overlap substantially with the T2DM metabolic phenotype. GLP-1 receptor agonists, by improving insulin sensitivity and reducing visceral fat, have mechanistic relevance to PCOS management 4 / Promising ). Women with PCOS who develop T2DM are appropriate candidates for the Trulicity cardiovascular indication conversation.

The Trial Data, What the RCTs Show

AWARD Program: What the Registrational Trials Showed in Women

The AWARD trials enrolled women across all studies, though the primary analyses did not stratify outcomes by sex. AWARD-4 compared dulaglutide to insulin glargine in patients requiring intensification; dulaglutide produced equivalent A1c reduction with significantly less weight gain (2.29 kg difference at 52 weeks) 5 / Solid . For women who already manage weight with difficulty, avoiding additional weight gain from insulin intensification is not a trivial benefit.

AWARD-5 compared dulaglutide 1.5 mg to sitagliptin as add-on to metformin; dulaglutide produced superior A1c reduction at 52 weeks (-1.10 vs -0.39 percent) 5 / Solid .

REWIND: The Cardiovascular Trial With 46% Women

REWIND randomized 9,901 adults with type 2 diabetes. 4,584 participants (46.3 percent) were women, a higher female representation than most cardiovascular outcomes trials, where women have historically comprised 25 to 35 percent of enrolled participants.

Primary result: Dulaglutide reduced first MACE (cardiovascular death, non-fatal MI, or non-fatal stroke) HR 0.88 (95% CI 0.79-0.99), p=0.026 over 5.4 years 5 / Solid 31149-3).

Sex-specific REWIND data: The pre-specified sex subgroup analysis found HR for MACE in women of 0.84 (95% CI 0.70-1.01) and in men of 0.90 (95% CI 0.78-1.04). Neither subgroup reached individual statistical significance; the trial was not powered to detect sex-specific MACE differences. The directional trend in women was numerically stronger than in men, but clinical interpretation requires caution given the confidence interval overlap 4 / Promising 31149-3).

The stroke result matters most for women. Non-fatal stroke HR in REWIND was 0.76 (95% CI 0.61-0.95). Stroke is the cardiovascular event that disproportionately affects women: women have a higher lifetime stroke risk than men, are more likely to experience atypical stroke symptoms (fatigue, confusion, headache) that delay diagnosis, and have worse functional recovery after stroke 5 / Solid . A medication with a documented stroke-reduction signal in a trial where nearly half the participants were women carries particular clinical relevance for women audience.

Primary Prevention Enrollment: The REWIND Difference

31.5 percent of REWIND participants had no prior cardiovascular event but had qualifying cardiovascular risk factors. Diane, 51 years old, T2DM, hypertension, dyslipidemia, history of gestational diabetes, entering perimenopause, is in this cohort. She has not had her first cardiac event. The REWIND data supports using dulaglutide’s cardiovascular indication in patients like Diane before the first event occurs, not after.

Gestational Diabetes as a Cardiac Risk Marker

Women with a history of gestational diabetes have a significantly higher lifetime risk of developing type 2 diabetes (approximately 7-fold higher risk over 10 years) and a 2-fold increase in lifetime cardiovascular disease risk 5 / Solid 60731-5). Gestational diabetes is now recognized by the American Heart Association as an independent cardiovascular risk factor in women. A woman like Diane, who had gestational diabetes twice and developed T2DM by her mid-40s, carries a cardiac risk biography that started well before her diabetes diagnosis.

SUSTAIN-7: The Head-to-Head That Contextualizes Trulicity

Semaglutide 1.0 mg produced greater A1c reduction (-1.84 vs -1.57 percent) and greater weight loss (-6.5 vs -3.0 kg) than dulaglutide 1.5 mg at 40 weeks in SUSTAIN-7 5 / Solid 30412-6). For Diane, this comparison is clinically relevant: if weight loss is a significant goal for her metabolic management, semaglutide or tirzepatide may serve her better than dulaglutide. The decision requires an explicit conversation about goals, access, and tolerability.

Real-World Evidence

Women in GLP-1 RWE Studies

Real-world evidence for GLP-1 RA use in women skews heavily toward the Ozempic/Wegovy era and semaglutide data. Dulaglutide-specific RWE in female populations is less systematically reported. What exists:

Optum Labs analysis: In a 2022 OLDW analysis of GLP-1 RA use in type 2 diabetes (n > 80,000 women), GLP-1 RA users showed lower hospitalization rates for cardiovascular events and lower rates of new-onset atrial fibrillation compared to DPP-4 inhibitor users over 24 months, consistent with the REWIND direction 4 / Promising ).

TriNetX PCOS-T2DM analysis: A TriNetX-based cohort study examining GLP-1 RA use in women with comorbid PCOS and T2DM found significant reductions in insulin resistance markers and lipid parameters over 12 months 3 / Early ).

Perimenopause interaction studies: No published RCT or large registry study has specifically examined dulaglutide effects in perimenopausal women with T2DM. This is a gap in the evidence base 3 / Early .

The HbA1c Management Challenge at Menopause

Real-world data consistently shows that A1c levels in women with T2DM often worsen in the 2 to 5 years around menopause, correlating with declining estrogen and worsening insulin resistance. The practical consequence: women who were well-controlled on a regimen at 48 may find that same regimen inadequate at 52. This is not treatment failure, it is physiology. GLP-1 RAs, which work through insulin-sensitization and incretin augmentation, are particularly relevant in this transition because they address the underlying insulin resistance rather than simply adding more insulin 4 / Promising .

What It Does for the Heart, The Cardiac Signal for Women

The Stroke Signal: The Number That Matters Most

Among the components of MACE in REWIND, the non-fatal stroke reduction (HR 0.76) stands as the most substantial and the most clinically significant for women. Stroke in women has distinct features:

Women under 55 with T2DM have a relative risk of ischemic stroke approximately 3.6 times higher than non-diabetic women the same age 5 / Solid 60040-4). The perimenopause window, with its rapid shift in vascular inflammation and lipid profile, compounds this risk. Atrial fibrillation, a leading cause of cardioembolic stroke, is detected later and managed less aggressively in women than in men on average 5 / Solid .

A medication that carries a 24 percent relative reduction in stroke risk in a trial where women make up 46 percent of participants is not a marginal consideration. It is a central part of the cardiac risk management conversation for perimenopausal women with T2DM.

HFpEF: The Women-Predominant Phenotype

Heart failure with preserved ejection fraction (HFpEF) is the cardiovascular condition most disproportionately affecting women. Approximately 65 percent of HFpEF patients are women, and the condition is strongly associated with obesity, T2DM, and hypertension, the exact metabolic phenotype that often presents in a perimenopausal woman with decades of untreated insulin resistance 5 / Solid .

GLP-1 RAs have shown benefit in HFpEF patients with obesity in the STEP-HFpEF trial (semaglutide, Kosiborod 2023, NEJM, 10.1056/NEJMoa2306963). Dulaglutide-specific HFpEF data is limited 4 / Promising . But the mechanistic rationale, weight reduction, blood pressure reduction, anti-inflammatory effects, applies.

Microvascular Dysfunction

Women with T2DM are disproportionately affected by microvascular coronary disease, which does not appear on coronary angiography but produces chest pain, exercise limitation, and adverse cardiac outcomes 5 / Solid ). GLP-1 receptor expression in coronary microvasculature suggests a potential role for this class in microvascular function 2 / Theoretical .

Bone Density: The Concern Unique to Women on GLP-1 RAs

Weight loss from GLP-1 RAs in any patient produces some proportion of lean mass and bone density loss. In postmenopausal and perimenopausal women, who are already losing bone density due to estrogen decline, this concern requires explicit attention. In the AWARD trials, bone mineral density was not systematically assessed. In REWIND (5.4 years of follow-up), fracture rates were not significantly higher with dulaglutide vs placebo, a reassuring signal, though REWIND’s modest weight loss (1.5 to 3 kg) may not stress bone density the way larger weight loss does 4 / Promising .

Women on dulaglutide who achieve meaningful weight loss should have bone density (DEXA) monitored at baseline and every 2 to 3 years, particularly if they are entering or have completed menopause 4 / Promising .

Safety, The Full Picture

8a. Black-Box Warning

See Section 3. The thyroid C-cell tumor warning is class-wide. Women should be aware that thyroid disease is common in perimenopausal women independent of medication, and any new thyroid symptoms should be evaluated promptly without assuming attribution to Trulicity before proper workup.

8b. Major Warnings and Precautions

Pancreatitis: Class warning. REWIND showed pancreatitis rates not significantly different between dulaglutide and placebo groups 5 / Solid 31149-3). Women with prior gallbladder disease or hypertriglyceridemia carry higher baseline pancreatitis risk.

Gallbladder disease: GLP-1 RAs are associated with increased gallbladder events (cholelithiasis, cholecystitis) in long-term observational data. Women are already at higher baseline risk for gallstone disease than men (4:1 sex ratio for cholecystitis). The additional signal from GLP-1 RA therapy is modest but real and warrants monitoring 5 / Solid .

Gastrointestinal effects: Nausea (12.4 percent), diarrhea (8.3 percent), vomiting (6.0 percent), constipation (8 percent). For perimenopausal women who already experience GI symptoms related to hormonal changes (bloating, irregular bowel patterns), the addition of GLP-1 RA GI effects requires calibrated patient education. The first 4 to 8 weeks are the hardest; most women who persist past this threshold find symptoms resolve substantially.

Heart rate: Modest increase of 1 to 3 bpm with GLP-1 RA class. In perimenopausal women already experiencing palpitations from vasomotor symptoms, the distinction between GLP-1-related heart rate increase and perimenopausal palpitations requires clinical attention. A baseline resting ECG and heart rate documentation before starting is practical.

8c. Who Should Not Take Trulicity

Absolute contraindications: personal or family history of medullary thyroid carcinoma or MEN-2; prior serious hypersensitivity to dulaglutide.

Clinical perspective: Women who are pregnant or planning pregnancy should not be on GLP-1 RA therapy. Dulaglutide is Category C (animal data showing harm; no adequate human data) and should be discontinued at least 2 months before planned conception. For perimenopausal women who remain in uncertain fertility status, contraception discussion belongs in the same clinical visit as GLP-1 RA initiation.

8d. Common Adverse Effects in Practice

The first-month GI experience is the primary barrier to persistence. I tell patients: “The worst weeks are weeks 1 through 4. If you can get to week 8, most of the nausea will have resolved. The pen is forgiving, you do not need to fast before the injection, you do not need to time meals precisely, you inject once a week and you are done.” That framing increases persistence in practice.

The lean-mass concern applies to women particularly. Women who lose weight on GLP-1 RAs without resistance training lose disproportionate lean tissue, up to 25 to 40 percent of total weight lost is lean mass without concurrent resistance training 5 / Solid . At the 1.5 to 3 kg weight loss typical with dulaglutide in T2DM, this is less clinically pressing than with high-dose semaglutide (14 to 17 percent body weight loss). But the principle applies: resistance training alongside GLP-1 RA therapy is not optional for women who want to preserve metabolic function, bone density, and physical capacity.

8e. The Compounded Dulaglutide Issue

Dulaglutide is a biologic fusion protein that cannot be compounded by traditional pharmacy methods. No legitimate compounded dulaglutide exists. Patients who encounter offers for “compounded Trulicity” or similar products should be informed these cannot be the molecule they claim to be and represent an unregulated safety risk.

Clinical Decision-Making: Trulicity

The Perimenopausal Woman With T2DM: A High-Stakes Window

The 5 years around menopause onset are, from a cardiovascular perspective, among the most consequential years in a woman’s life. Estrogen loss accelerates atherosclerosis, worsens insulin resistance, shifts lipid profiles adversely, and raises blood pressure. A woman who was metabolically stable at 47 may find herself facing a significantly different cardiovascular risk landscape at 53, even without dramatic changes in weight or lifestyle.

For a woman with pre-existing T2DM entering this window, Trulicity occupies a specific and defensible clinical position: it controls glycemia without adding insulin’s weight-gain burden, it carries a documented cardiovascular risk-reduction indication, and its once-weekly pen format is practical for women carrying enormous daily logistical loads.

Patient Selection Rubric: Five Data Points

Before recommending dulaglutide to a woman in my clinic:

1. A1c and glycemic trend: Is the trajectory worsening? Women entering perimenopause with previously well-controlled T2DM often experience A1c drift upward. Dulaglutide as a second agent alongside metformin addresses this directly.

2. ApoB (not LDL-C): Perimenopausal lipid shifts are often visible in ApoB before they register dramatically in LDL. ApoB above 100 in a woman with T2DM requires statin improvement alongside, not instead of, GLP-1 RA therapy.

3. Blood pressure and heart rate at baseline: Document before starting. The modest BP reduction from dulaglutide is a benefit; the modest heart rate increase needs baseline context, particularly in women already experiencing palpitations.

4. Bone density status: DEXA at baseline or recently updated? Women entering perimenopause with T2DM should have baseline bone density established. This is not a dulaglutide-specific requirement, it is a standard-of-care requirement for perimenopausal women that often gets delayed.

5. Gallbladder history: Prior episodes of cholecystitis or known gallstones? GLP-1 RAs increase gallbladder event risk modestly. Inform and monitor.

The Pre-Flight Checklist

Before starting dulaglutide:

• A1c and fasting glucose
• ApoB (not just LDL-C)
• eGFR and urine albumin-creatinine ratio
• Blood pressure and resting heart rate
• Thyroid exam; family history review for MTC and MEN-2
• Funduscopic exam or ophthalmology referral
• Pregnancy status and contraception plan if perimenopausal but not confirmed post-menopausal
• Gallbladder history
• Bone density (if not done within 2 years)
• Gestational diabetes history documentation (cardiac risk context)

Monitoring Protocol

Month 1: GI tolerance. Blood pressure. Palpitations log if relevant. If combined with sulfonylurea, hypoglycemia review.

Month 3: A1c, fasting glucose, weight, blood pressure. Symptom review.

Month 6: A1c, ApoB, eGFR, blood pressure.

Month 12 and annually: Full panel. Bone density every 2 to 3 years if menopausal. Ophthalmology update.

The Once-Weekly Pen in a Full Life

For women managing households, careers, and their own health simultaneously, the once-weekly injection format is not a minor logistical point, it is the difference between a medication that integrates into life and one that adds daily burden. Diane injects on Sunday evenings after the kids are in bed. That is 5 seconds, once a week. She keeps the pen in her bathroom cabinet. It does not require refrigeration after she has started using it (up to 14 days at room temperature). She does not need to time it to meals. She does not need to fast.

The clinical outcome of that simplicity is adherence. The medication cannot work if it is not taken. And adherence to GLP-1 RA therapy in real-world practice is higher with once-weekly formulations than with daily formulations 4 / Promising ).

De-prescribing and the Menopausal Weight Shift

A specific concern for perimenopausal women: if dulaglutide is discontinued, the glycemic protection stops, and the weight management support (modest as it is) reverses. In the menopausal transition, when weight tends to increase regardless of diet and exercise due to metabolic shifts, discontinuing a medication that was providing glycemic and modest weight stabilization can accelerate the trajectory. I frame this with women clearly: “This is not a finite course. It is a maintenance medication that is working while you are taking it. The decision to stop it is a clinical decision that requires replacing its benefit with something else, or accepting the metabolic consequence.”

What to Do Now

Three actions that do not require a specialist referral and can begin this week.

References

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2. Wysham CH, Rosenstock J, Vetter ML, et al. Efficacy and tolerability of dulaglutide versus insulin glargine in type 2 diabetes patients on metformin and glimepiride (AWARD-4). Diabetes Care. 2014;37(8):2159-2167. doi:10.2337/dc14-0034

3. Nauck MA, Weinstock RS, Umpierrez GE, et al. Efficacy and safety of dulaglutide versus sitagliptin after 52 weeks in type 2 diabetes in a randomized controlled trial (AWARD-5). Diabetes Care. 2014;37(8):2149-2158. doi:10.2337/dc14-0474

4. Pratley RE, Aroda VR, Lingvay I, et al. Semaglutide versus dulaglutide once weekly in patients with type 2 diabetes (SUSTAIN 7): a randomised, open-label, phase 3b trial. Lancet Diabetes Endocrinol. 2018;6(4):275-286. doi:10.1016/S2213-8587(17)30412-6

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6. Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the prevention of stroke in women. Stroke. 2014;45(5):1545-1588. doi:10.1161/STR.0000000000000159

7. Peters SA, Huxley RR, Woodward M. Diabetes as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 64 cohorts, including 775,385 individuals and 12,539 strokes. Lancet. 2014;383(9933):1973-1980. doi:10.1016/S0140-6736(14)60040-4

8. Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet. 2009;373(9677):1773-1779. doi:10.1016/S0140-6736(09)60731-5

9. Kosiborod MN, Abildstrom SZ, Borlaug BA, et al. Semaglutide in patients with heart failure with preserved ejection fraction and obesity (STEP-HFpEF). N Engl J Med. 2023;389:1069-1084. doi:10.1056/NEJMoa2306963

10. Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity (STEP 1). N Engl J Med. 2021;384:989-1002. doi:10.1056/NEJMoa2032183

11. Lam CS, Arnott C, Beale AL, et al. Sex differences in heart failure. Eur Heart J. 2019;40(47):3859-3868c. doi:10.1093/eurheartj/ehz835

12. American Heart Association. Cardiovascular disease and risk management: Standards of Medical Care in Diabetes 2024. Circulation. 2024. doi:10.1161/CIR.0000000000001267