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Antiobesity drugs in the management of type 2 diabetes: A shift in thinking?

July 1, 2017|Cleveland Clinic Journal of Medicine
Bartolome Burguera, MD, PhD;Khawla F. Ali, MD;Juan P. Brito, MD
Author and Disclosure Information

Bartolome Burguera, MD, PhD
Director of Obesity Programs, Endocrinology & Metabolism Institute, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Medical Director, National Diabetes and Obesity Research Institute, Tradition, MS

Khawla F. Ali, MD
Endocrinology & Metabolism Institute, Cleveland Clinic

Juan P. Brito, MD
Division of Endocrinology, Assistant Professor of Medicine, Medical Director of the Shared Decision Making National Resource Center Investigator, Knowledge and Evaluation Research Unit, Mayo Clinc; Department of Medicine, Mayo Clinic, Rochester, MN

Correspondence: Bartolome Burguera, MD, PhD, Endocrinology and Metabolism Institute, F-20, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; burgueb@ccf.org

All authors reported no financial interests or relationships that pose a potential conflict of interest with this article.

ABSTRACT

Antiobesity medications can improve metabolic control for patients with type 2 diabetes mellitus (DM) and obesity, but are underutilized. In this review, we describe the role of antiobesity drugs in the context of medically supervised and comprehensive weight-loss interventions and propose a pragmatic therapeutic algorithm for patients with type 2 DM and obesity that incorporates the use of antiobesity drugs early in the course of management.

KEY POINTS

  • Obesity contributes to type 2 DM and worsens its control. Yet insulin therapy and most first-line diabetes drugs cause weight gain as a side effect.
  • We believe that physicians should include body weight along with blood glucose levels as targets of therapy in patients with type 2 DM.
  • Several drugs are approved for weight loss, and although their effect on weight tends to be moderate, some have been shown to reduce the incidence of type 2 DM and improve diabetic control.
  • A stepwise approach to managing type 2 DM and obesity starts with lifestyle interventions and advances to adding (1) metformin, (2) a glucagon-like peptide-1 receptor agonist or a sodium-glucose cotransporter-2 inhibitor, and (3) one of the approved weight-loss drugs.

THE NEED FOR PATIENT-CENTERED WEIGHT-LOSS CONVERSATIONS

Patient-centered care has become a core quality measure in our healthcare systems and a key to our patients’ success. The decision to start an antiobesity drug should therefore reflect careful consideration of medical and personal patient issues, all of which are valued differently by patients.34

Individualized therapy is even more relevant among patients suffering from a significant burden of disease. About 80% of patients with diabetes live with at least 1 other medical condition,35 and each of these patients spends over 2 hours a day, on average, following doctors’ recommendations.36 If antiobesity medications are prescribed without careful consideration of the patient’s preexisting workload, they will be destined to fail. Therefore, it becomes crucial to first account for the patient’s ability to cope with therapy intensification. This requires careful deliberation between healthcare providers and patients, in aims of targeting a weight-loss plan that fits patients’ goals and is aligned with providers’ expectations.

Healthcare systems also play a key role in supporting better conversations about obesity in type 2 DM patients. They could implement multifaceted initiatives to promote shared decision-making and the use of decision aids to advance patient-centered obesity practices.37 Policymakers could redesign quality measures aimed at capturing the quality of obesity conversations, and develop policies that support better education for clinicians regarding the importance of addressing obesity with adequate communication and patient-centered skills. Guidelines are often too disease-specific and do not consider comorbidities in their context when providing recommendations.38 Thus, diabetes societies should respond to the need to guide care for patients with diabetes and its comorbidities, particularly obesity.

CONCLUSIONS

Obesity is a serious global health issue and a leading risk factor for type 2 DM. Lifestyle measures are the cornerstone of preventing and treating obesity and type 2 DM. Emerging data support the effectiveness of intensive, interdisciplinary weight-loss programs in patients with diabetes. The use of antiobesity drugs should be considered in patients who have not achieved adequate responses to lifestyle interventions. Medications should be tailored to the individual’s health risks and metabolic and psychobehavioral characteristics. In many cases, the addition of weight-loss drugs will help accomplish and maintain the recommended 10% weight reduction, resulting in improvement in glycemic control and significant reduction in cardiovascular risk factors. New studies combining antiobesity and antidiabetes medications in the context of lifestyle interventions will help define the optimal therapeutic approach for patients with type 2 DM and obesity.

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