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Weight and T2D: Case 1

CE / CME

Shifting the Treatment Paradigm of Weight Management and Type 2 Diabetes in Primary Care: Interactive Case Challenge 1

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurses: 1.00 Nursing contact hour

Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™

ABIM MOC: maximum of 1.00 Medical Knowledge MOC point

Released: October 31, 2023

Expiration: October 30, 2024

Martin J Abrahamson
Martin J Abrahamson, MD, FACP
Debbie Hinnen
Debbie Hinnen, APN, BC-ADM, CDCES, FAAN
CME/CE Information

Activity

Progress
1
Course Completed

Discussion
In the United States, more than 37 million people (or 11.3% of the population) have been diagnosed with diabetes.1 Worldwide, it is projected that 783 million people will have diabetes by 2045, with certain populations at higher risk than others.2 Primary care physicians are estimated to deliver 90% of care to individuals with T2D and have an increasing role in providing diabetes care.3

Diabetes is a progressive disease and is of clinical importance because of long-term complications associated with the condition, including small-vessel complications such as diabetic retinopathy and diabetic nephropathy and large vessel complications such as stroke and cardiovascular disease. Research has shown that both microvascular and macrovascular complications are associated with higher glycemic levels, underscoring the importance of glycemic control in improving outcomes for patients with T2D.4 

Over the past 2 decades, overall glycemic control has not improved. Approximately one half of the patient population does not achieve a glycemic target of <7.0%,5 the ADA-recommended goal for most nonpregnant adults,6 and approximately 25% of patients do not achieve an A1C of <8.0%.7 Therefore, despite the emergence of new treatments for diabetes, there is an unmet need for glycemic control. 

Historically, physicians have followed a treat-to-failure approach for managing diabetes, initially starting metformin and, as glycemic levels reach a certain threshold, adding other agents or insulin therapy.8 The ADA no longer recommends metformin as first-line therapy for all patients. Instead, treatment should be individualized based on patient risk factors. For those with atherosclerotic cardiovascular disease or indicators of high risk of cardiovascular disease, a GLP-1 receptor agonist or SGLT2 inhibitor with proven cardiovascular benefit should be used. For those patients with heart failure or chronic kidney disease, SGLT2 inhibitors with evidence for benefit in those disease states should be used. For patients not meeting glycemic goals, the ADA recommends agents with very high or high efficacy for glucose lowering, including dulaglutide, semaglutide, tirzepatide, and insulin (very high), followed by other GLP-1 receptor agonists, metformin, SGLT2 inhibitors, sulfonylureas, and thiazolidinediones (high). For patients not meeting weight management goals, the ADA recommends agents with very high or high efficacy for weight loss, including semaglutide and tirzepatide (very high), followed by dulaglutide and liraglutide (high).9

The ADA also recommends that GLP 1 receptor agonists be considered as the first injectable in most patients who are not achieving A1C targets with oral agents.9 The patient illustrated in this case was started on metformin and insulin at an urgent care clinic following diagnosis of T2D. Although it is reasonable to continue the patient’s metformin and even increase it because of continued poor glucose control, a GLP-1 receptor agonist or GIP/GLP-1 coagonist is indicated because of his increased BMI and additional goal of weight loss. Insulin is therefore unnecessary at this stage of treatment. After maximal titration of his GLP-1 receptor agonist, the patient’s blood glucose and weight improve but remain above goal. At this point, an SGLT2 inhibitor is a reasonable choice, as it is not only highly efficacious for glucose lowering, but also has intermediate efficacy for weight management.

Obesity is a chronic disease with numerous complications. The ADA recommends at least a 5% weight loss for most people with T2D and overweight and obesity. A sustained weight loss of greater than 10% confers additional benefits, including possible remission of T2D and improved cardiovascular outcomes and mortality. Obesity pharmacotherapy can be an effective adjunct to lifestyle therapy for patients with a BMI greater than or equal to 27 kg/m2. When starting obesity pharmacotherapy, a failure to achieve at least a 5% weight loss in the first 3 months typically indicates a lack of efficacy and need for change in therapy. For those who are successful in their weight loss, therapy should be continued long term to prevent weight regain.10

Dulaglutide is not currently one of the GLP-1 receptor agonists approved for obesity treatment and is considered to have high efficacy for weight loss. If the patient in the case had not achieved at least a 5% weight loss with dulaglutide, it would have been reasonable to try an alternative agent such as semaglutide or tirzepatide, which have shown greater weight loss in clinical trials. Other agents approved for long-term treatment of obesity also would be options. However, as the patient has concurrent T2D, an agent that treats both T2D and obesity is a good choice unless contraindicated.