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Weight and T2D: Case 2

CE / CME

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

ABIM MOC: maximum of 1.00 Medical Knowledge MOC point

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™

Released: November 08, 2023

Expiration: November 07, 2024

CME/CE Information

Activity

Progress
1 2
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 large vessel complications such as stroke and cardiovascular disease and small-vessel complications such as diabetic retinopathy and diabetic nephropathy. 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 
Unfortunately, overall glycemic control is not improving. Approximately one half of the patient population does not achieve a glycemic target of <7.0%,5 the ADA-recommended goal for most 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 need for improved glycemic control.

Historically, health care providers 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 unsuccessful at losing weight, despite lifestyle changes including exercise and nutrition. Although the patient’s blood glucose was well controlled to her goals, a GLP-1 receptor agonist with evidence for cardiovascular benefit is indicated because of her increased BMI and history of MI. After maximal titration of her GLP-1 receptor agonist, the patient’s weight improved. An SGLT2 inhibitor would not be recommended at this point because of the risk of lowering her blood glucose further and causing hypoglycemia but could be considered in the future if her A1C increases.

Obesity is a chronic disease with numerous complications. The ADA recommends at least a 5% weight loss for most people with T2D and overweight or 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

If the patient in the case had not achieved at least a 5% weight loss with semaglutide, it would have been reasonable to change to or add an alternative agent for weight loss. Semaglutide could also be changed to the weight loss formulation, which has a maximum dose of 2.4 mg weekly vs the 2.0 mg weekly approved for T2D treatment, but insurance coverage for the weight loss formulation is not as prevalent. Tirzepatide might also be an option, as it has very high efficacy for blood glucose lowering and weight loss.9 Tirzepatide does not yet have data for cardiovascular benefit, but trials are ongoing. For patients in need of cardiovascular risk reduction, combination therapy with tirzepatide and another agent that provides cardiovascular benefit, such as an SGLT2 inhibitor, may be considered.