Newer Injectable Medications for Type II Diabetes or Chronic Weight Management
By Cathy Rosenbaum, PharmD MBA RPh CHC CDP CFNC
The American Medical Association (AMA) officially recognizes type II diabetes mellitus and obesity as complex chronic diseases that require a multifactorial range of treatment and prevention options.
Obesity can be caused by a combination of changes in the environment (family eating habits, lifestyle choices, behaviors), genes/metabolism, and stress and is oftentimes associated with depression in women (Pratt and Brody 2014).
As a certified health coach and certified fitness nutrition coach, I have been helping clients with their chronic weight management journey for many years. Regarding treatment interventions, use of the prescription phentermine is decreasing due to its side effect profile of increased heart rate, blood pressure, and nervousness. Dietary supplement and OTC medication usage has also decreased due to lack of efficacy. By comparison, newer injectable prescription medications have dramatically increased in popularity and I’m monitoring their place in weight management therapy.
The two types of injectable medications for weight management are called glucagon-like peptide-1 (GLP-1) receptor agonists or glucose-dependent insulinotropic polypeptide (GIP) receptor agonists. Consumer demand is causing intermittent supply disruptions and drug shortages for patients needing the FDA-approved indication of type II diabetic management.
Injectable GLP-1 and GIP Receptor Agonists
For perspective, GLP-1 is a hormone produced in the intestine that interacts with our hunger hormones. GLP-1 receptor agonists decrease appetite by slowing gastric emptying and increasing satiety after eating. They increase the pancreas’s production of insulin when glucose levels are high.
GIP is another hormone released from the small intestine. GIP receptor agonists reduce secretion of stomach acid and increase insulin sensitivity to control blood sugar after meal ingestion.
GLP-1 and GIP receptor agonists are combined in the injectable prescription medication, Mounjaro (tirzepatide) that is FDA approved for type II diabetes mellitus but not FDA approved for chronic weight management (e.g., off-label use).
Victoza (liraglutide) is FDA approved to treat type II diabetes mellitus, Saxenda (liraglutide) is FDA approved for chronic weight management in a different dosage regimen.
Ozempic (semaglutide) is FDA-approved for type II diabetes mellitus, and Wegovy (semaglutide) is approved for chronic weight management in a different dosage regimen.
Injectables are covered by insurance for type II diabetics but may not be covered for the weight management indication (cost ~$1000-$1200/month).
|Generic Drug Name||FDA Approved Type II Anti-Diabetic Drug/Brand Name||Chronic Weight Management in Adults with or without Type II Diabetes Drug/Brand Name||Comments|
|Wegovy* – inject SQ once weekly||GLP-1 receptor agonist
Is now FDA approved for chronic weight management in children > 12 years old who meet criteria.
|Liraglutide||Victoza||Saxenda* – inject SQ once daily||GLP-1 receptor agonist|
|Tirzepatide||Mounjaro||No different brand name yet, since it’s not yet FDA approved for this indication- inject SQ once weekly.||Combination GLP-1 receptor agonist and GIP receptor agonist|
GLP-1 receptor agonist side effects:
- Nausea & vomiting
- Constipation & abdominal pain
- “Ozempic face”
GIP receptor agonist side effect: Anti-emetic (good in combination with GLP-1 receptor agonists that can cause nausea)
Contraindications: Injectable GLP-1 receptor agonists and GIP receptor agonists are contraindicated in pregnancy and with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2.
GLP-1 receptor agonists carry a boxed warning about a risk of thyroid C-cell tumors (based on animal data, no corresponding human data).
Length of Therapy for Weight Management
Chronic diseases like obesity may require long-term treatment. The FDA has approved subcutaneous Saxenda and subcutaneous Wegovy for long-term weight management.
Please remember to only use chronic weight management medications after all other options have been exhausted and then only as an adjunct to healthy diet and regular exercise routine. It has been reported that once these medications are discontinued, weight comes back even more than before medication use.
Your health care provider will create a plan tailored to your weight-management goals. You’ll need to visit your health care provider 4 months after you begin taking Saxenda or Wegovy to review your progress and renew your prescription if appropriate.
Dietary Supplements Touted for Chronic Weight Management
In 2015 the NIH Health Office of Dietary Supplements reviewed 19 ingredients in dietary supplements touted for chronic weight management. None demonstrated significant beneficial effects on weight management or change in body composition.
|Product||Alleged Pharmacology (Animal/Lab Studies)||Side Effects||Comments|
|GTF Chromium||May promote glucose utilization and increased sensitivity of insulin receptors||Vertigo, N&V||Essential trace mineral.
Found in broccoli, whole wheat and rye breads, grape juice, potatoes, turkey breast, apples with peels, green beans, bananas, romaine lettuce)
|Green Tea Extract –
|Caffeine may stimulate body’s metabolism||Anxiety, irritability, insomnia||Caffeine, active
Catechins (flavonoids) are antioxidants (general health)
|Vanadium (vanadyl sulfate – oxidative form)||May improve insulin sensitivity and glucose uptake||Abdominal discomfort, diarrhea, gas, loss of energy||Trace mineral.
Found in pepper, dill, radishes
|Raspberry Ketones||May stimulate the hormone adiponectin, an enhancer of fatty acid oxidation, glucose regulation||Jitteriness, increased heart rate, increased blood pressure||Found in red raspberries, kiwifruit, peaches, and apples|
|Green Coffee Bean Extract||Possible inhibition of the enzyme glucose-6-phosphatase
In vitro, glucose-6-phosphatase induces glucose production in the liver
|Increased heart rate, increased blood pressure||Chlorogenic acid (antioxidant)
|Garcinia Cambogia||May reduce synthesis of fatty acids and glycogen storage via inhibition of ATP citrate lyase||Liver toxicity, long term in higher dose (case studies)||Hydrocitric acid, active|
Holistic Weight Loss Strategy
Any successful chronic weight management program is first and foremost dedicated comprehensive, healthy lifestyle choices (e.g., walking, exercise, stress management, socialization, sleep hygiene, spiritual health, other healthy food choices and portions).
The initial recommendation for safe weight loss is 5%-10% of body weight over six months to reduce risk of developing type II diabetes mellitus, high cholesterol, and high blood pressure. This translates into a decrease in daily calorie intake by ~500 below daily energy needs (e.g., 1-2 pounds/week). A greater rate of weight loss does not yield better long-term results.
Evidence-based dietary guidelines (U.S. Department of Agriculture 2015-2020) have given us www.choosemyplate.gov for proper portion control and recommend dividing one’s plate into 4 quarters (1/2 for fruits and veggies, ¼ for lean protein, and ¼ with whole grains, plus milk or calcium-rich foods for bone health). The Mediterranean Diet is the world’s gold standard for plant-based nutrition.
How to Eat Mindfully (National Society of Health Coaches)
- Set a mealtime S.M.A.R.T. satisfaction goal with a health coach
- Create your personal ‘I’m done eating’ signal
- Sit down to eat and minimize outside distractions with a focus on the present
- Be mindful of your hunger and fullness level before, during, and after eating
- Create several mindful pauses before, during and after eating
- Express mindful attitudes of self-compassion, non-judgment, kindness, patience, joy, and thanksgiving regarding food intake
Take Home Message
- Physicians and CNP’s with prescribing privileges should be aware of national injectable chronic weight management/type II diabetes mellitus treatment medication supply shortages
- All medications and dietary supplements can have side effects, and some interact so they are ideally be managed by talking with a pharmacist
- Work with a health coach to assess your readiness to change and your commitment to change and personal values about taking medications before embarking on a weight loss program
- Purchase and use a fitness wearable to track steps, calories burned, heart rate, REM sleep
- Weight yourself once a week; regularly exercise with a routine approved by your physician and guided by a trainer
- Measure your waistline at least once a month (high risk of developing chronic condition if > 35 inches for women and >40 inches for men)
- Reducing risk of obesity: defining the role of weight loss drugs. Pharmacotherapy 2013:
- The safety and effectiveness of natural supplements for weight loss in populations with obesity: a critical review of the literature from 2006 to 2016. Crit Rev Food Sci Nutri 2019:
- Obesity therapy: How and why? Curr Med Chem 2019:26:1-12.
- The Medical Letter on Drugs and Therapeutics Volume 64, Issue 1651, May 30, 2022.
- The Medical Letter on Drugs and Therapeutics Volume 65, Issue 1670, February 20, 2023.