When considering medication regimens for patients with overweight or obesity, ADA guidelines recommend that clinicians consider each medication's effect on weight. Antihyperglycemic agents associated with variable degrees of weight loss include metformin, alpha-glucosidase inhibitors, sodium-glucose cotransporter 2 (SGLT2) inhibitors, GLP-1 RAs, and amylin mimetics; dipeptidyl peptidase 4 (DPP-4) inhibitors are weight neutral. Conversely, insulin secretagogues, thiazolidinediones, and insulin are frequently associated with weight gain.
Given her BMI, risk factors, and treatment goals, adding a GLP-1 RA would be an appropriate choice for this patient.
Liraglutide is a GLP-1 RA that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes and to reduce the risk for major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) in adults with type 2 diabetes and established cardiovascular disease. Treatment with subcutaneous liraglutide is initiated at 0.6 mg once daily and gradually titrated to a maximum of 1.8 mg daily.
A higher dosage of liraglutide is indicated as an adjunctive therapy to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI ≥ 30 (obese) or a BMI ≥ 27 (overweight) who have at least one weight-related condition (eg, hypertension, type 2 diabetes, dyslipidemia). For this indication, liraglutide is titrated up to a maximum dose of 3 mg daily.
Semaglutide is a GLP-1 RA–incretin mimetic that is available in subcutaneous and oral formulations. The subcutaneous formulation is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes and to reduce risk for major adverse cardiovascular events (eg, cardiovascular death, nonfatal myocardial infarction, nonfatal stroke) in adults with type 2 diabetes and established cardiovascular disease. Dosing begins at 0.25 mg subcutaneously once per week and is titrated up to 0.5 mg subcutaneously once per week. If glycemic control is not achieved after at least 4 weeks on the 0.5-mg dose, the dosage can be increased to 1 mg subcutaneously once per week.
A higher dosage of subcutaneous semaglutide has been approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial BMI ≥ 30 or higher (obesity) or ≥ 27 (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes, dyslipidemia). An initial dose of 0.25 mg once weekly is gradually escalated to the maintenance dose of 2.4 mg subcutaneously weekly to minimize gastrointestinal adverse reactions. When using subcutaneous semaglutide in patients with type 2 diabetes, blood glucose should be monitored before initiation and during treatment.
When prescribing medications such as subcutaneous liraglutide or semaglutide for a weight loss indication, cost/lack of reimbursement may be an issue. Oral semaglutide is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes. Dosing begins at 3 mg once daily and is gradually titrated up to a maximum dose of 14 mg daily if additional glycemic control is needed.
The ADA emphasizes the importance of nutrition in the overall management of diabetes; however, it does not endorse a "one size fits all" eating plan (eg, ketogenic diet, low-fat diet, etc.) given the wide spectrum of individuals affected by diabetes and prediabetes with varying cultural backgrounds, personal preferences, comorbidities, and socioeconomic backgrounds. Instead, individualized, diabetes-focused medical nutrition therapy in addition to pharmacologic therapy is recommended at diagnosis, as needed throughout the lifespan, and during periods of shifting health status to attain treatment goals. A variety of eating patterns are acceptable for the management of diabetes; emphasis should be placed on:
Increasing consumption of nonstarchy vegetables
Minimizing added sugars and refined grains
Selecting whole foods over highly processed foods to the degree possible
Although data suggest that there is no ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes, reducing overall carbohydrate intake has the most evidence for improving glycemia and may be used through a variety of eating patterns that meet the individual needs and preferences of people with glycemia. In select cases, when individuals with type 2 diabetes are not meeting glycemic targets or when reducing antihyperglycemic medications is a priority, reducing overall carbohydrate intake with low- or very low–carbohydrate eating plans may be pragmatic. For more information on various eating plans for people with diabetes, including the Mediterranean diet, low- or very low–carbohydrate diets, intermittent fasting, and the Dietary Approaches to Stop Hypertension (DASH) diet, see ADA's Consensus Report on nutrition therapy for adults with diabetes/prediabetes.
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Cite this: Anne L. Peters. Skill Checkup: A 53-Year-Old Woman Recently Diagnosed With Type 2 Diabetes - Medscape - Dec 21, 2022.