Several classes of diabetes medicines are known to drive weight loss — and remission in diabetics and pre-diabetics — and have great potential. The morbidly obese may choose to use these drugs before thinking of bariatric surgeries.
Which diabetes medicines lead to weight loss and how?
There are two classes of diabetes medicines that help in moderate to substantial weight loss. The first is the SGLT-2 inhibitors, which we have been prescribing for diabetes for six to seven years now. They act by eliminating glucose in the urine and preventing its re-absorption in the kidneys. This loss of glucose effectively means a loss of calories as well. So, in addition to decreasing blood sugar levels, it also leads to weight loss.
This class of drugs leads to a weight loss of about 2-4 kg in a year on average. This is not a lot, but it is good enough for several patients.
The second class of drugs are GLP-1 receptor analogues that are mostly injectable. (Wegovy, the drug Twitter’s owner Elon Musk recently said he uses to stay fit, belongs to this category.)
We have been using these injectables for diabetes management for 10 years now. First we had a twice-daily injection, then once daily, then a once-a-week injection, and now we have these drugs in oral form. These are powerful drugs that can lead to a loss of 5 per cent to 10 per cent of body weight over 6 months to a year.
Newer versions of these drugs, which are currently not available in India, can lead to a loss of 15 per cent of body weight. This is remarkable, and these drugs have great potential as far as obesity is concerned.
Can these drugs be prescribed to obese persons who might not be diabetic?
For such people, the only approved drug in India currently is a very weak one called Orlistat, which has been on the market for more than 20 years. This drug blocks the absorption of fat in the intestine, and can cause gastrointestinal symptoms such as diarrhoea. Besides, the weight loss is not much.
Worldwide, injections of GLP-1 receptor analogues at a high dose are available for weight loss in non-diabetics. Another drug of the same class is now being fast-tracked for approval for the treatment of obesity.
But in India, there is only one approved weight-loss drug. If GLP-1 receptor analogues are used in the doses currently available in India, it has to be explained to the patient that it is being used ‘out of the label’ (drug used for the treatment of a condition for which it is not approved).
Does using diabetes medicines in non-diabetic obese persons lead to a fall in blood glucose?
No. These drugs are known to not cause hypoglycaemia. These drugs are used by us, infrequently, in those who have morbid obesity, and don’t want to go for bariatric surgery.
Since these medicines lead to weight-loss, can they result in remission of the disease?
Of course — if the patient loses that much weight. There is a 60-70 per cent likelihood that the person’s diabetes will go into remission. This is the additional advantage of using these drugs in pre-diabetic and diabetic persons who are obese.
Can people go off these medications after remission? Usually, patients and their doctors set a target weight. If they reach the target and their sugars are normal, they can go off the medicines. But they need to have a high degree of exercise and a good diet to prevent regaining weight. Weight regain is always a problem with whichever modality is used to lose weight, except bariatric surgery.
So, doctors wait and watch. If the patient is gaining weight at a fast pace, they may have to restart the medicines.
Some people stop because the injections are expensive — they cost about Rs 8,000-9,000 a month. Initially, they can cause nausea and vomiting for about four weeks. The alternative is bariatric surgery, which may cost more initially but there is less weight regain as compared to the medicines.
Dr Anoop Misra is Chairman of Fortis-CDOC Center of Excellence for Diabetes, Metabolic Diseases, and Endocrinology in New Delhi. He has been an advisor to the Ministry of Health, the Indian Council of Medical Research (ICMR), and the Department of Biotechnology, offering his expertise on several issues related to diabetes and other non-communicable diseases. Over the past two years, he has published 40 papers on diabetes and Covid-19 in top science journals.
Dr Misra spoke to Anonna Dutt.
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