Treatment with GLP-1 medications involves many factors beyond weight loss

Although weight loss is a common consideration for patients starting treatment with glucagon-like peptide (GLP)-1 receptor agonists, the management of these treatments involves many considerations, including glycemic control and nutrition, among others. In an interview with Pharmacy Times, experts Colleen Dawkins, ARNP, RD, a nurse practitioner at Big Sky Medical Wellness, and Maureen Chomko, RD, CDE, a dietitian and diabetes educator at Neighborcaare Health, discussed the many considerations for GLP-1 medications and how pharmacists are an important essential. part of the care team. Dawkins and Chomko are also discussing the topic in a presentation at the American Diabetes Association’s 84th Scientific Sessions, June 21-24 in Orlando, Florida.

Q: Why is it important to consider factors beyond weight loss when using GLP-1/GIP receptor agonists in the treatment of diabetes?

Colleen Dawkins, ARNP, RD: Because weight loss is just one of the things these drugs are doing. And we know they’ll improve blood sugar control and A1c, but there’s a lot that can go along with weight loss that might not be healthy, like muscle loss or bone loss. And so, we want to really look at all the factors involved when we start somebody on these kinds of drugs because of the things that can go well, like reducing inflammation and reducing the risk of cardiovascular disease, and then improving A1c . and things like that. There are a lot of benefits and more to come, I think, as the research comes out, but it’s really important that we appreciate the things that can go wrong for someone and keep an eye on that.

Maureen Chomko, RD, CDE: Yes, I would say that weight loss may not be all if one is not eating well. I think the challenging thing about these medications and the dual and triple agonist therapy that’s coming out is that if people are consuming 1,200 calories or less every day, they’re likely not consuming healthier foods. This is what we are concerned about. And so, a person may be losing weight, but they may not be consuming any nutrients, and so their body may be getting smaller, but it may not necessarily be healthier. So I think it’s important to get nutritionists involved to make sure we’re evaluating what people are eating, making sure they’re eating enough of the right foods and that they’re eating for their other conditions. You know, if they have diabetes, if they have hypertension, there are nutritional foods that can help with that, that we can lose sight of if we just focus on losing weight.

Q: What are some common challenges patients face when starting GLP-1/GIP receptor agonist therapy and how can these be addressed?

Maureen Chomko, RD, CDE: The part that my talk focuses on is having a regular protocol for dietitians, diabetes educators, and RNs, and it can also include a pharmacist, I know that’s your target audience. One of the issues is the titration of these drugs and the side effects that can come from that, especially with people with diabetes. They may experience more hypoglycemia, they may experience more adverse effects, which I’ll talk about Colleen. But I think what’s important is that they have someone on their team that they’re checking in with regularly, talking about their blood sugar, talking about how much insulin they’re taking. As we’re titrating these medications, having someone they can connect with regularly, check in with, understand how to manage those side effects if they have them, whether they’re [gastrointestinal] side effects, or if it’s hyperglycemia from being on insulin. And with these GLP-1 or dual agonist or antagonist therapy at the same time, there hasn’t been research on that, but given my personal experience, the results can be much better when you have someone checking regularly. The Truth – The worldwide studies we have show that the discontinuation rate can be high with these medications. Unless there’s always someone checking in and making sure we’re helping people with the side effects or helping people understand and navigate the deficiencies that we’re seeing everywhere, having someone they can connect with regularly versus a PCP or an endocrinologist that has much less availability can be really helpful with these patients.

Colleen Dawkins, ARNP, RD: Yes, of course. And I would mention the challenges of getting medication, ie coverage, costs. And you alluded to that earlier, but then also the shortages and the kind of navigation in it. So once we get through actually getting the medication and starting it, then we have things like a sudden loss of appetite that they’re experiencing for the first time, in most cases, just not having a lot of that that my patients have. calling it “food brain”, where they are constantly thinking about food and then just forget to eat. And so, then we run into issues not only with food and worries about it. But then the side effects that Maureen was mentioning – nausea, vomiting, constipation are ones that we see quite often, but the other side of that will be diarrhea. And those are certainly the most common side effects. And so those challenges are things that we can meet and address one on one and individualize that care, but it’s knowing who to turn to if they’re experiencing any of these issues. And I think Maureen was painting a nice picture of the richness of that CDCES or RDN to go back to is very helpful.

Q: How do you address misconceptions about diet and weight loss in patients using GLP-1 agonists?

Colleen Dawkins, ARNP, RD: So what I hear from patients who are new to me is that they just want something that’s going to work, so they don’t have to think about what else they’re doing. And I think the misconception that these medications can just be a stand-alone therapy is something that we’re providing education on, I would guess almost every day, and not just to clients and patients, but to other providers because there is this concept that, oh, we’ll just start with that, and that fixes everything. And it’s not like that. And I know that the ADA [guidelines] may say that, but I know that the Society of Obesity Medicine certainly says that these are not meant to be stand-alone therapies. It’s going to be about nutrition and lifestyle modifications and getting that support right, and so that’s one of the first misconceptions that comes to mind.

Maureen Chomko, RD, CDE: The conversation I have with many of my patients is that they will take this drug, lose weight, and then stop taking the drug. And I think it’s incredibly important to talk to patients that this is unfortunately a lifelong medication. Once we stop this medication, the weight comes back and for many people this is actually a deterrent for many people who don’t want to take an injection for the rest of their lives. So it’s the format of a nutritionist’s visit or a nurse’s visit. In my clinic, we often have a lot more time to talk to our patients, we might have 60 minutes to talk to a patient, and so we can find that this is a tool we have to help manage diabetes. But you know, for a lot of people unfortunately it’s mostly an injection, so a lot of people are still turned off by those injections. So have a conversation about whether this is the right tool for you? Or will other tools be better for you? And for some people it definitely is. I mean, for a lot of people it’s these drugs [because they] are incredible in their cardiac and renal benefits. But I think people need to understand that, as Colleen was saying, it’s not just, “I do this shoot and I don’t have to think about my diabetes,” “I don’t have to think about what I’m eating or how I’m moving my body .” If anything, it may be more important. As Colleen was mentioning, there is muscle wasting and trying to prevent as much muscle wasting as possible, especially in older patients who were already concerned about sarcopenia and falls when they were taking this drug, losing some of that fat, losing some of that muscle. As I keep coming back, we’re not necessarily making them healthier just by getting this injection. We have to make sure they’re still following all the basics of lifestyle and food that we know make people healthy.