Although weight loss is a common consideration for patients initiating treatment with glucagon-like peptide (GLP)-1 receptor agonists, managing 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 a crucial part of the care team. Dawkins and Chomko are also discussing this topic in a presentation at the American Diabetes Association 84th Scientific Sessions, happening June 21 through 24 in Orlando, Florida.
Q: Why is it important to consider factors beyond weight loss when using GLP-1/GIP receptor agonists in diabetes treatment?
Colleen Dawkins, ARNP, RD: Because weight loss is just one of the things that these medications are doing. And we know that they’re going to improve blood sugar control and A1c, but there’s a lot that can go along with the weight loss that might not be healthy, such as losing muscle mass or losing bone mass. And so, we want to really look at all of the factors involved when we’re starting someone on these types of medications because of the things that can go well, like decreasing inflammation and decreasing the risk of cardiovascular disease, and then improving the A1c and things like that. There’s a lot of benefits and more to come, I think, as the research comes out, but it’s really important that we’re also assessing the things that could go poorly for someone and keeping an eye on this.
Maureen Chomko, RD, CDE: Yeah, I would say weight loss might not be the be-all-end-all, if someone is not well nourished. I think the challenging thing about these medications and the dual and triple agonist therapy that’s coming out is if people are consuming 1200 calories or less each day, they’re likely not consuming healthier foods. That’s what we’re worried about. And so, a person could be losing weight, but they could be not consuming nutrients whatsoever, and so their body might be getting smaller, but it might not be necessarily getting healthier, too. So, I think it’s important to have dieticians involved to make sure that we’re assessing 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 nourishing foods that can help with that, that we might be losing sight of if we’re just focusing on weight loss.
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 piece that my talk is focusing on is having a standing order protocol for dietitians, diabetes educators, and RNs, and it can also include a pharmacist as well, I know that’s your target audience. One of the issues is titrating up these meds and the side effects that can come with that, particularly with people with diabetes. They can experience more hypoglycemia, they can experience more adverse effects, which I will have Colleen talk about. But I think what is important is that they have someone on their team that they’re checking in with regularly, talking about what their blood sugars are, talking about how much insulin they’re taking. As we’re titrating up these meds, having someone that they can connect with regularly, check in with, figure out how to manage those adverse effects if they are having them, whether it’s [gastrointestinal] side effects, or whether it’s hyperglycemia from being on insulin. And with these GLP-1 or the dual agonist or antagonist therapy at the same time, there hasn’t been research on this, but calling in my personal experience, outcomes can be a lot better when you have someone regularly checking in. The real-world studies that we do have show that discontinuation rates can be high with these medications. If there’s not always someone checking in and making sure we’re helping people out with the adverse effects or helping people out with understanding and navigating the shortages that we are seeing all over, having someone that they can regularly connect with versus a PCP or an endocrinologist that has a lot less availability can be really helpful with these patients.
Colleen Dawkins, ARNP, RD: Yeah, definitely. And I was going to mention the challenges of just getting the medication, so the coverage, the costs. And you alluded to that earlier, but then also the shortages and kind of navigating that. So, once we can get past actually getting the medication and starting it, then we have things like a sudden loss of appetite that they are experiencing for the very first time, in most cases, of just not having a lot of what my patients have been calling “food brain,” where they’re thinking about food constantly, and then they just forget to eat. And so, then we run into issues with not just nutrition and concerns around that. But then the side effects that Maureen was mentioning—nausea, vomiting, constipation is one that we see pretty often, but the flip side of that is going to be diarrhea. And those are just like the more common side effects certainly. 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 picture beautifully of having that CDCES or RDN to turn to is very helpful.
Q: How do you address misconceptions about diet and weight loss among 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 that the misconception that these medications can just be a standalone therapy is something that we’re providing education on, I would assume almost every day, and not just to clients and patients, but also to other providers because there is this conception that, oh, we’ll just start them on that, and it fixes everything. And that’s not the case. And I know that ADA [guidelines] may say this, but I know the Obesity Medicine Association for sure says these are not meant to be standalone therapies. This is going to be in conjunction with nutrition and lifestyle modifications and getting that proper support, and so that’s one of the first misconceptions that comes to mind.
Maureen Chomko, RD, CDE: Aconversation I have with a lot of my patients is that they’re going to take this medicine, lose the weight, and then they’ll stop taking the medicine. And I think that is incredibly important to talk with patients that this is unfortunately a lifelong medication. Once we stop this medication, the weight comes back and for a lot of people that actually is a dissuader for many people that don’t want to be taking an injection for the rest of their lives. So, it’s the format of a dietitians visits or a nurse 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 explore that this is one tool that we have to help manage diabetes. But you know, for a lot of people unfortunately it’s for the most part an injection, so a lot of people are still turned off by those injections. So, having a conversation about is this the right tool for you? Or are other tools going to be better for you? And for some people it definitely is. I mean, for many people it is these medicines [because they] are incredible in their cardiac and the renal benefits. But I think people need to understand that, as Colleen was saying, it’s not just “I take this shot 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 might be more important. As Colleen was mentioning, there’s muscle loss and trying to prevent as much muscle loss, especially in older patients that were already worried about sarcopenia and falls when they’re taking this medicine, losing some of that fat, losing some muscle. As I keep going back to, we’re not necessarily making them healthier just by getting this this injection. We need to make sure that they’re still following all the lifestyle and food foundations that we know make people healthy.