Controversial Use of New Diabetes and Obesity Medications and Steps to Initiate Discussion About Weight Management

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I appreciate that because everyone wants an algorithm, and there are algorithms, but so much of it is an art in taking in the individual patient characteristics. It’s been exciting with pharmacotherapy in terms of more agents getting approval and showing benefits in weight loss. There has been this Hollywood explosion about certain drugs and GLP-1 [glucagon-like peptide-1] receptor agonists. I’m curious to hear your perspective about what’s happening in Hollywood and the increased use of these agents.

Scott Kahan, MD, MPH: It’s been upsetting to me, what I’ve seen over the last 6 to 12 months regarding some of the newer medications, and most of what I’m reading, either in traditional media and certainly in social media, I think is bunk. On the one hand, people are saying that we finally have these magic medications. First, we’ve had really good medications for at least a decade. They’re often underused, but they’re very good. And some of the newer ones may even be better, but now we have a number of medications between the ones that have been on the market for a bit and the newer ones. Second, these aren’t miracle pills. These aren’t miracle medications. In some cases, they have miraculous outcomes for some patients. In other cases, they don’t work all that well for other patients. On average, they’re good, but they aren’t miracles unfortunately. Other talk is about how they’re terrible medications, and everybody gets horrible adverse effects, and everybody regains their weight. And that’s not true either. You can get adverse effects, but most people don’t. And you can regain your weight, but used appropriately and with good ongoing support and a long-term plan, most people don’t regain their weight. We could go on and on with this. Certainly the idea of Hollywood people or anyone who doesn’t have obesity, who isn’t a clinical candidate for the medications, to be using it, whether to look good for a movie role or to lose 5 lb for the prom, or to put on their bathing suit on the beach, that’s inappropriate. These are serious medications that are needed for people who have serious diseases. They’re not things to be used lightly. You can see I’m a bit heated about what’s been going on of late.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I’m glad I asked. It’s great to hear your perspective about it. I think a lot of people find it challenging when you have someone in front of you who has obesity or would benefit from weight loss. How do you start that conversation without offending the person? Any tips in that regard?

Scott Kahan, MD, MPH: There’s a really straightforward, quite simple tip that goes a long way here. That is to essentially ask permission before diving into it. Tell the patient that you’ve been working together for some years, and the weight has been increasing and as such their blood sugar, their blood pressure has been increasing. And we know that frequently weight leads to lots of health problems. Offer yourself as a resource, and ask if it’s OK to talk about weight and to work together on the weight in a matter of fact and an empathic way. When you do that, on the one hand, most patients will greatly appreciate it and will be eager to get your help and your support. And for those people who don’t feel comfortable with it, they’ll know when they’re ready that you are someone they can come and talk to because you’ve treated them respectfully and thoughtfully by eliciting their opinion and what they need, rather than going in and telling them they need to lose weight. And lastly, it gives you a quick, easy way of shifting the conversation in that direction. Whereas otherwise it can be easy to fumble around with it. It’s a simple and real, and at the same time a somewhat profound way of starting a conversation.

Natalie Bellini, DNP, FNP-BC: I love that. When a patient says to you, I’m not ready—you’re different because you’re in obesity as a specialty, they came to you for that fix or that treatment. When a patient says no, a lot of times I’ll say, “You know what? We can address it at your next visit. You’ll let me know when you’re ready.” Sometimes that, just opening the door, and, “Last time we talked about I don’t know, your postprandial blood sugars, or whatever, and weight. Are you ready to talk about those today? What would you like to talk about today?” Continue to bring it up and say, “I’m here for you.” We can’t push them to do it anymore than I can push a patient to take mealtime insulin.

Scott Kahan, MD, MPH: Exactly. Absolutely.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: That’s a great key takeaway, ask permission. We also see not only adults, but now a lot of children and adolescents are faced with obesity as well. Any recommendations in terms of what we should do with this population to help them?

Scott Kahan, MD, MPH: Interestingly, I don’t know if it was yesterday or the day before….

Natalie Bellini, DNP, FNP-BC: Yesterday.

Scott Kahan, MD, MPH: Yes, the American Academy of Pediatrics put out their newest guidelines, which largely mirror the adult guidelines, which is to say certainly we need to be careful when using more intensive treatments for obesity, whether metabolic surgery, whether medications, but we should not shy away from those for appropriate adolescents, at minimum adolescents. That’s a big shift. That’s going to take some time for a lot of pediatricians to wrap their heads around, and a lot of parents to wrap their heads around. But that’s where things will likely go. Just as with adults, it doesn’t mean that healthful behaviors are any less important. In fact, the healthful behaviors are at least as important. It’s just that it’s so hard for most of us to do them. And if after trying and trying again, we have not been able to make much of a dent in the obesity and the weight-related health problems, then it’s important to utilize the range of treatments available to us regardless of the patient’s age, as long as it fits within appropriate guidelines.

Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: It’s been exciting to see more drugs being studied in this population and showing benefits as well.

I want to thank you so much. Thanks for talking with us today. I know our listeners will benefit from so much great insight and wisdom. Thank you so much.

Natalie Bellini, DNP, FNP-BC: Thank you.

Scott Kahan, MD, MPH: Thank you for having me. This is great.

Transcript Edited for Clarity