Using GLP-1 Medications for the Treatment of Patients With Type 2 Diabetes, Obesity
In this video, Kathryn Kreider, DNP, APRN, FAANP, FNP-BC, speaks about the use of glucagon-like peptide-1 (GLP-1s) agonists in patients with type 2 diabetes (T2D) and obesity, including how the medication has evolved over the years since being introduced in 2005, the benefits of using GLP-1s in patients with T2D and obesity, and how clinicians can properly inform their patients on the use of GLP-1s.
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Kathryn Kreider, DNP, APRN, FAANP, FNP-BC, is a clinical professor of nursing and the director of the Endocrinology Specialty Training Program for nurse practitioners at Duke University School of Nursing (Durham, NC)
TRANSCRIPTION:
Kathryn Kreider, DNP, APRN, FAANP, FNP-BC: Hi everyone, thanks so much for joining me today. My name is Kathryn Kreider. I am a faculty member, a clinical professor at Duke University School of Nursing where I am also the director of the endocrinology specialty training program for nurse practitioners there.
And I also practice clinically in Duke's division of endocrinology, diabetes, metabolism, and nutrition. And I practice one day a week there as well. So I'm here today to talk a bit about diabetes and some of the current challenges and topics that we have.
Consultant360: How have GLP-1 agonists evolved over the years since being introduced to the market in 2005?
Dr Kreider: It's really exciting to see what has happened with GLP-1s. I think everyone, when they first came on the market, everyone was a little bit intimidated not really knowing how this was going to play out, and this happens with every new drug class. And they started, of course, with a focus on diabetes. They started by only being available in a twice-a-day formulation, which then evolved to a once a day and then it evolved to a once-a-week formulation, which is what we have now and it really is kind of the best practice for many patients. But really with a focus on diabetes. And then all of the data started showing how effective these medicines were for weight loss.
So then of course the clinical trials started investigating these medicines specifically for weight loss, even without diabetes as a comorbidity. And now there's more and more research looking at other things that these drugs can possibly do. For example, there are marked improvements in non-alcoholic fatty liver disease. There are improvements in things like memory and potentially Alzheimer's and addictive disorders like substance use disorders. All of that is still very preliminary, but there's some really interesting articles out there about different things that these drugs could possibly do that beneficial even besides their known effects on diabetes and weight.
C360: Which type of patient benefits the most from GLP-1s?
Dr Kreider: Yeah, so we have all seen that GLP-1s have exploded, especially for weight loss purposes, but also in patients for the treatment of diabetes. And I know that you will see the most benefit in your patients that have diabetes and that are obese. And the additional benefits they get from both a glucose-lowering perspective and a weight loss perspective will also help their other comorbidities, like blood pressure, for example, like sleep apnea. So that is really the group of people that we look at as being the most benefited by this drug class because you get the double-edged sword of having lower glucose and improved weight reduction.
We do see these medicines having some improvement in patients in type 1 diabetes, for example, and that is a different conversation for another day, but the best bang for your buck will be the patients with type 2 diabetes with obesity. Yes.
C360: There have been some “myths” regarding GLP-1 agonists for the use of weight loss, such as they are a new class of medications. How can clinicians properly inform their patients about the use of these medications for type 2 diabetes and weight loss?
Dr Kreider: I think what a lot of us have seen in the press is a lot of bad press about these medications and people are reading articles about dangerous side effects and problems with these medicines. And to a degree, there will always be risks of taking medications, right? Most medicines have some side effects. So for example, slowed gastric emptying, which is called gastroparesis, is a byproduct of taking GLP-1 receptor agonists. And I just saw an article about how dangerous it was that people taking these medications could have slow gastric emptying.
So, I think the problem becomes when a lot of these things in the press are not framed correctly and it doesn't come from your clinician talking about you and your body and how this medicine will affect you. And it's our job to look at the patient in front of us and say, "This is why this might benefit you, but these are some of the possible things that you might encounter with this medicine, and here's how we're going to try to mitigate the risks or the possible downstream effects." So, yes, there has been some concerns about it, and I think some of that is appropriate, rightfully so. We always want to have a critical eye about new medications. These medicines are not new, like you said, they've been around since 2005. We have a lot of data on safety outcomes. We have a lot of data on how they affect patients long term. And so far, it all looks very promising. Many of these drugs have cardiovascular risk indication, risk reduction indications, meaning that the clinical trials have shown that they will protect your heart and you from cardiovascular events.
There's definitely enough beneficial things that we are still very strongly recommending these medicines for most people. But with that being said, we always have a discussion about what is known and what is not known and what works best for the patient in front of us.
C360: What would you say is next in research on GLP-1 medications?
Dr Kreider: Yeah, so I think one of the big things when we think about this from a diabetes perspective is going to be the possibility of diabetes prevention, right? Or how long can we suppress pre-diabetes so that patients don't develop overt diabetes? And this is very strongly hypothesized because of the tremendous amount of weight loss that people get.
So, if we're able to significantly reduce weight and prevent the progression or prevent the onset of pre-diabetes, that can be very substantial in the future for these patients. And then like I mentioned earlier, there's a lot of research going on in different fields about how these medications can be beneficial, not only for diabetes and weight, but also for other things, like I mentioned, substance use disorder. That's really neat, isn't it? Because we have limited options in that space.
And so, it will be fascinating in the next five to seven years to see some of the other studies that come out potentially supporting the use in other areas. I saw one recently about reduction in orthopedic pain from GLP-1s, which makes sense because of the weight loss. So there's all kinds of things that I think are possibilities and it's really exciting to see what the future might hold.
C360: For clinicians, what are some of the take-home messages from our conversation today?
Yes, so GLP-1s are an incredible option for patients. They are very, very highly effective, second only to insulin therapy. And in some cases, can be more effective than insulin therapy, depending on how you prescribe it and how you use it.
The American Diabetes Association recommends that we consider GLP-1s before insulin for the right patient. So, we really have a repositioned opportunity to select a medication class that can help from a cardiometabolic perspective, and that is not something that we had prior to GLP-1s and SGLT-2s for diabetes. So, think about whether this could be a great option, but always counsel your patient on potential risks, potential benefits, and then you weigh that out together and decide whether this is the right approach .I think we definitely have gotten to a place where, you know, everyone seems to be on some semaglutide, right? And that may or may not be the right answer. We want to make sure that it's right for everyone. For that particular patient, I mean, not for everyone. And how we make sure that we're doing sort of individualized medication prescribing for optimizing the health of that person right in front of us.