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The coming of GLP-1 receptor agonists has revolutionized remedy choices for other people with weight problems and clinical apply.

Medscape Clinical Information lately hosted a panel of professionalsthroughout specialties — together with endocrinology, gastroenterology, and weight problems medication — to speak about those probably life-changing medicines and to reply to questions from the target market.

As a result of the flood of queries from our target market, Medscape Clinical Information requested our panelists to deal with one of the most questions that did not make the recording. Their solutions are under.

photo of Beverly Tchang
Beverly Tchang, MD

Beverly Tchang, MD, endocrinologist, Weill Cornell Drugs, New York Town

Target audience member: Are you able to start up glucagon-like peptide-1 agonists (GLP-1 RAs) as a number one drug in a affected person with weight problems and newly recognized kind 2 diabetes?

BT: We frequently prescribe GLP-1 RAs to people with kind 2 diabetes as a first-line medicine. Tips from the American Diabetes Affiliation are truly emphasizing a patient-centered way, and metformin is probably not the most efficient first-line medicine anymore.

Target audience member: What will have to clinicians learn about dose titration of GLP-1 RAs in diabetic sufferers with renal illness, particularly the ones in levels IV and V continual kidney illness?

BT: GLP-1 RAs don’t wish to be renally dosed, however I nonetheless suggest conferring with the affected person’s nephrologist since the glomerular filtration fee would possibly lower within the environment of dehydration. As a result of GLP1s suppress the thirst, no longer simply urge for food, sufferers can move all day with out ingesting water and no longer really feel thirsty.

photo of Michael Camilleri
Michael Camilleri, MD

Michael Camilleri, MD, gastroenterologist, Mayo Medical institution, Rochester, Minnesota

Target audience member: Will have to GLP-1 RAs be held for 1 week or 4 weeks previous to surgical treatment to cut back the affected person’s threat for aspiration? And is tapering required?

MC: For a affected person taking liraglutide, I might cling the drug for 1 week previous to surgical treatment. For sufferers taking different GLP-1 RAs, together with prolonged exenatide, I counsel retaining for between 2 and three weeks sooner than the process. It is usually essential to ensure the affected person’s diabetes is well-controlled with different medicines — no longer GLP-1 RAs — right through this era.

After surgical treatment, you’ll restart GLP-1 RA treatment as soon as there may be restoration of oral meals consumption and standard bowel serve as.

Target audience member: Is remedy with GLP-1 RAs suitable for a affected person with a circle of relatives historical past of colon most cancers however an another way unremarkable clinical and circle of relatives historical past?

MC: I’ve no longer noticed a contraindication to receiving GLP-1 RAs according to a circle of relatives historical past of colorectal most cancers or different malignancies. An evaluation of the French nationwide healthcare insurance coverage device database has advised 1-3 years use of GLP-1 RAs (exenatide, liraglutide, and dulaglutide) could also be connected with larger incidence of thyroid most cancers. Knowledge from 37 randomized managed trials and 19 real-world research having 16,839 sufferers in placebo keep an eye on staff, 16,550 sufferers in energetic keep an eye on staff, and 13,330 sufferers in real-world research had been analyzed in a 2023 systematic evaluate and meta-analysis. In comparison to placebo or energetic keep an eye on remedies, incidence of pancreatic most cancers, thyroid most cancers, and all neoplasms — benign, malignant, and another way unspecified — had been an identical within the semaglutide staff.

photo of Tochi Iroku Malize
Toshi Iroku-Malize, MD, MPH, MBA, FAAFP

Toshi Iroku-Malize, MD, MPH, MBA, FAAFP, circle of relatives doctor, Zucker Faculty of Drugs, Hempstead, New York

Target audience member: What do you do about increased liver purposes after beginning remedy with GLP-1 RAs, and what do you do when a affected person has reached their weight reduction objective?

TI-M: I like to recommend tracking the liver serve as checks, comparing for underlying reasons, similar to viral hepatitis, alcohol-related harm, or issues of different medicines, and consulting a gastroenterologist or liver specialist if vital. It is usually essential to speak about the risk-benefit of constant at the GP-1 RA for that exact affected person.

Target audience member: What results will GLP-1 RAs have on sleep-disordered respiring/obstructive sleep apnea (OSA)? Have you learnt of any ongoing trials addressing this topic?

TI-M: GLP-1 RAs can have really helpful results on sleep-disordered respiring and OSA via weight reduction, which may end up in a discount in extra adipose tissue, and enhancements in metabolic parameters. Relating to research, a 2023 paper addressed this query, however extra analysis is wanted.

Target audience member: Is it inside a psychiatric supplier’s scope of apply to prescribe GLP-1 brokers for the relief of weight achieve related to psychiatric medicines?

TI-M: Weight problems medication is an interdisciplinary procedure. A lot of medicines prescribed for psychological well being can give a contribution to weight problems, and psychiatrists can play a task in participating with a affected person’s number one care supplier and/or weight problems medication specialist to decide which medicines may also be adjusted or changed. You will need to take into account that weight problems control isn’t just about medicines. It calls for managing diet and process along with behavioral well being problems and social determinants of well being. If the clinician has had the learning to control those pillars and is at ease managing this continual sickness — very similar to diabetes, high blood pressure, and different stipulations — then this can be a risk. In a different way, team-based care is suitable.

photo of Holly Lofton
Holly Lofton, MD

Holly Lofton, MD, weight problems medication, NYU Langone Well being, New York Town

Target audience member: Are we able to safely use them on sufferers who’ve had bariatric surgical treatment and ceaselessly expand dumping syndrome?

HL: Those medicines can be utilized after bariatric surgical treatment in sufferers who meet the standards for pharmacologic remedy. If a affected person is having postoperative signs of dumping syndrome or over the top gastrointestinal losses from vomiting or diarrhea, nutritional changes and different strategies of managing the dumping syndrome in gastric bypass sufferers will have to be initiated sooner than making an allowance for GLP-1 RAs as a result of those sufferers would not have a functioning pylorus of their alimentary tract and those medication don’t seem to be indicated to regard dumping syndrome. The primary-line way usually comes to lowering the affected person’s consumption of straightforward carbohydrates however too can come with medicines or surgical intervention when suitable.

Target audience member: Would instructing a affected person to speedy intermittently whilst they are on GLP-1 RAs lend a hand them maintain weight reduction in the event that they select to wean off the medicine?

HL: In my opinion, I think it’s best to make use of the titration length and the time through which the affected person is actively dropping pounds when on GLP-1 RAs. Those are the most efficient sessions to lend a hand expand an individualized remedy plan, one that incorporates diet, process, habits amendment, and resistance coaching. The affected person’s way of life plan will most probably alternate according to their atmosphere and different elements. Intermittent fasting may also be part of one of these plan. There’s no consensus as to precisely which consuming trend will lend a hand sufferers care for weight when they lose the physiologic advantage of the burden loss medicines. Alternatively, research were printed that exhibit a median weight regain of 66% or larger when sufferers move from taking the utmost dose of a GLP-1 RA to taking none in any respect. Thus, sufferers will have to nonetheless be adopted intently for weight regain after they discontinue a GLP-1 RA.


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