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Managing Obesity: Patient With T2D
Patient Cases From Primary Care: A Patient With Obesity and Type 2 Diabetes

Released: December 12, 2023

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Key Takeaways
  • In patients with type 2 diabetes (T2D) and obesity, thorough medical, family, and social histories as well as considerations for comorbid conditions should inform treatment decisions.
  • Medications that are FDA-approved to treat both T2D and obesity include the glucagon-like peptide-1 receptor agonists injectable semaglutide and liraglutide and now the glucose-dependent insulinotropic polypeptide receptor and glucagon-like peptide-1 coagonist tirzepatide.
  • Choosing an agent that treats both T2D and obesity makes sense for many patients, but other anti-obesity agents may still be considered based on patient characteristics and insurance coverage.

In this commentary, Nicole Fox, MPAS, PA-C discusses the first of 2 interactive patient cases from the program “Overcoming the Challenges of Managing Obesity: Strategies for the Primary Care Setting”. She provides insights on how she would approach these patients if they were coming into her primary care clinic. The first case is about a patient with obesity and type 2 diabetes (T2D).

Medical, Social, and Family History
Lawrence is 69 years old and has gained significant weight since retirement. His body mass index (BMI) is currently 35 kg/m2. He is a former PE teacher but now has chronic knee pain due to osteoarthritis that limits his mobility and exercise. He is considering trying weight loss medications because he saw some advertised on TV.

His medical history indicates he has T2D and he checks his blood sugar once daily. His most recent A1C was 8.0%. He is currently taking metformin 1000 mg twice daily and dapagliflozin 10 mg once daily. He has a history of hypertension for which he currently takes lisinopril 40 mg once daily with a current blood pressure of 130/78 mm Hg. He also has a history of hyperlipidemia, and takes atorvastatin 10 mg daily. All of his labs for cholesterol are well controlled other than elevated triglycerides at 170 mg/dL.

Lawrence’s social history indicates that he is not currently exercising due to chronic knee pain—this is an important clue to keep in mind. He has never smoked but drinks socially. While I would likely not look for additional comorbidities that could be impacting his exercise as it seems clear that the knee pain is the primary barrier, I would want to explore his social drinking and what that means to him. I would ask Lawrence if he drinks 1 drink every couple of weeks or if he has 5 drinks on the weekend. Alcohol could be a significant source of extra calories and extra carbohydrates that could be contributing to some of his excess weight.

I also like to get a thorough nutrition history to understand the patient’s nutrition literacy, including their understanding of carbohydrates and proteins. Is this someone who needs more guidance and who would benefit from a referral to our colleagues in nutrition? Lawrence’s family history tells us that both parents had obesity, his father had T2D and hypertension and died of a myocardial infarction at age 85, and his mother died of CVA at age 90. Lawrence has 1 adult child with obesity. This family history informs our considerations for his comorbidities and for his care.

Comorbidity and Treatment Considerations
Lawrence has already had the labs done that I would be interested in, particularly with his history of T2D and knowing that his A1C is elevated. For this patient, my first thought is to try one medication that would target both obesity and T2D. Fortunately, we have 2 classes of medications available to try. One class is the glucagon-like peptide-1 receptor agonists (GLP-1 RAs) such as semaglutide, dulaglutide, and liraglutide. Since dulaglutide is indicated only for T2D, we can consider semaglutide or liraglutide, both of which have dual indications for T2D and as monotherapy for obesity management.

The second class of drug was recently approved for chronic weight management and is a combination of glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 RA, tirzepatide. We have already been using tirzepatide for T2D so if it is available through the patient's formulary it would be a great option for Lawrence as well. Clinical trial data suggest that tirzepatide may be more effective at weight lowering compared with other GLP-1 RAs, but you may encounter insurance coverage hurdles when trying to obtain it for your patients. I would start with one of these medications if I wanted an option to both lower his A1C and address obesity.

It is important to add obesity to his diagnosis list to support the medication choice and so that we are following up on his T2D and on his obesity at each office visit. I would also work with Lawrence to find ways for him to be more physically active without hurting his knees. I would suggest lower impact exercise like using a recumbent bicycle or swimming and try to encourage him to remain as physically active as he is able without increasing pain. Patients may think of exercise only in terms of activities that they used to do, which may not currently be available to them due to injury or chronic pain. It is important to re-frame what options are within their current capability to keep movement as part of their daily routine.

Once I have assessed Lawrence’s nutrition history and literacy, referring him to a dietitian could provide additional help with carbohydrate reduction and setting a goal of decreased alcohol if that is an issue for him. I would try to set a concrete goal every time we meet of making a small change within his nutrition.

I would also consider referring him for a sleep study. A lot of times our patients with obesity also struggle with sleep apnea and that both increases weight gain and makes it much more difficult to lose. Therefore, I screen every patient that has not had a prior sleep study for sleep apnea. Since Lawrence has T2D, having him engage with a diabetes educator could also open up more resources for nutrition and for diabetes control in particular, and may be beneficial.

Follow-up Visit
Six months later, Lawrence’s insurance changes which prompts a change in therapy. In my practice, I see this happening more frequently than I would like, especially if we are having success with a certain agent and I recommend trying to stay in the same medication class if the patient has responded well.

Since Lawrence was on a GLP-1 RA that he tolerated well and he had good responses regarding A1C reduction and weight reduction, I would see if there are any other agents in that class that might be covered by his insurance. Another option would be to switch him from the GLP-1 RA to a GIP-GLP-1 coagonist or vice versa if insurance coverage is available. If neither of these options are available, other FDA-approved medications for obesity are still appropriate for this patient and could be considered as alternatives. Therefore, if targeting both obesity and T2D with one agent is not possible due to lack of availability, Lawrence can still reduce his A1C with approved T2D medications, and an anti-obesity medication such as phentermine and topiramate or bupropion-naltrexone can help him achieve his weight loss goals.

Your Thoughts?
In your practice, are your patients with T2D and obesity interested in incretin-based therapies? Share your experience by leaving a comment and answering the polling question below.

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