The Issue of Weight Gain in Diabetes Management
Hello Ardee
This is a great post, Ardee. Many diabetic patients complain of increased weight gain during therapy. Despite their adherence to medication guidelines and adopting healthier lifestyles, they cannot lose weight. The issue with weight during diabetes therapy is related to the medication regimen prescribed to a patient. The diabetes medication regimen determines how the body can control blood sugar and hunger cravings. Patients on insulin therapy have a higher risk of gaining weight than any other type of therapy. Insulin therapies such as Lantus, Levemir, NovoLog, Apidra, Fiasp, and Humulin control blood sugar levels and transfer glucose from the blood into the tissues. Naturally, the body automatically produces the required insulin to regulate blood sugar levels. However, with artificially injected insulin, there may be a mismatch between blood sugar and insulin levels in the blood. This may result in a regular state of hunger, causing the patients to overeat, resulting in energy imbalances and excessive weight gain (Ludwig et al., 2021). Therefore, I agree with you on prescribing GLP1-RA and SGLT2 classes of type 2 diabetes drugs to improve blood sugar control and help lose weight.
Hello Ernesto
Thank you for your post, Ernesto. The issue of weight gain is of great concern regarding the management of diabetes. This requires the adoption of new methods to better manage weight and diabetes in treating diabetes in obese patients. The efficacy of medications for diabetes treatment can be improved by focusing on the bodily hormone functions and how they influence weight gain and diabetes progression. Thyroid hormones help the body’s energy use and other metabolic processes. Thyroid dysfunction and type 2 DM are related. Low and low-normal thyroid function are risk factors for diabetes progression (Kalra et al., 2019). Thyroid function tests during diabetes treatment may help better prescribe medications to control insulin secretion and glucose homeostasis. However, before carrying out thyroid function tests, it is essential to understand that as obesity, directly and indirectly, affects the hypothalamic-pituitary-thyroid (HTP) axis, it may alter thyroid function tests, leading to inaccurate test results. This affects the class of drugs prescribed to the patient, compromising the medication’s safety and effectiveness in managing diabetes and hypothyroidism.
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References
Kalra, S., Aggarwal, S., & Khandelwal, D. (2019). Thyroid dysfunction and type 2 diabetes mellitus: screening strategies and implications for management. Diabetes Therapy, 10(6), 2035-2044.
Ludwig, D. S., Aronne, L. J., Astrup, A., de Cabo, R., Cantley, L. C., Friedman, M. I., & Ebbeling, C. B. (2021). The carbohydrate-insulin model: a physiological perspective on the obesity pandemic. The American journal of clinical nutrition, 114(6), 1873-1885.
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The Issue of Weight Gain in Diabetes Management
1. Ardee
Diabetic medications that don’t cause weight gain are dipeptidyl peptidase-4 inhibitors (DPP4i), alpha-glucosidase inhibitors (AGi), and bromocriptine-QR (BCR-QR) (Brock, 2020). Moreover, diabetic medications that induce weight loss are glucagon-like peptide-1 receptor antagonists (GLP1-RA), sodium-glucose cotransporter 2 (SGLT2) inhibitors, and biguanide (Brock, 2020). Metformin is the generic name of an oral drug that belongs to the biguanide class, and trade names for metformin are Glucophage, Fortamet, Glumetza, and Riomet (Epocrates, 2022).
Based on the American Diabetic Association (ADA) guidelines, the drug class SGLT2 inhibitors would be the appropriate medication to treat the patient’s type 2 diabetes and promote weight loss (Brock, 2020). The generic name is empagliflozin, and the trade name is Jardiance. The recommended starting dose is 10 mg daily and must be taken orally during the day (Epocrates, 2022). Contraindications for empagliflozin include individuals with a glomerular filtration rate (GFR) of less than 30, individuals on dialysis, patients with type 1 diabetes, and pregnancy (Epocrates, 2022). Additionally, lifestyle changes, such as incorporating daily physical activity, consuming healthy and nutritious meals, monitoring blood pressure and blood glucose levels, and adhering to medication regimens, must all be implemented into the patient’s treatment regimen. Furthermore, anti-lipid and antiplatelet medications should be added due to the patient’s high levels of lipids and her increased risk for cardiovascular disease. The ADA guidelines recommend atorvastatin 40 mg daily via oral route for lipid management and aspirin 81 mg orally daily for the antiplatelet medication (Brock, 2020).
Diagnostic procedures for hypothyroidism and hyperthyroidism include lab workup for thyroid-stimulating hormone (TSH) and serum thyroid levels- T3 and T4 (Dlugasch & Story, 2021). Hypothyroidism results in a high TSH level, with low serum T3 and T4; conversely, in hyperthyroidism, the TSH level is low, with high T3 and T4 levels (Dlugasch & Story, 2021). The treatment of choice for hypothyroidism is thyroid hormone replacement therapy, such as levothyroxine (Dlugasch & Story, 2021). The mechanism of action of levothyroxine is to replace the hormone thyroxine or T4, which is involved in metabolism and protein synthesis and helps T4 production by the thyroid (Eghtedari & Correa, 2021). Levothyroxine is the generic name, Synthroid is the trade name, and the recommended initial dose is 25 mcg daily via the oral route (Eghtedari & Correa, 2021). Adverse effects of this medication include palpitations, tachycardia, arrhythmia, diarrhea, alopecia, and decreased bone mineral density (Eghtedari & Correa, 2021). It is essential to educate the patient to take this medication at least 30 minutes before meals for better absorption of the drug and to avoid taking the medicine with other medicines or food containing iron, calcium, and antacids; additionally, it is recommended to take this medication during the day to prevent insomnia (Eghtedari & Correa, 2021).
2. Ernesto
Even though lifestyle interventions are part of the initial treatment for the management of diabetes mellitus, antidiabetic medication may be necessary. Lifestyle changes include eating a healthy, well-balanced diet and physical activity. If patients are still having difficulties keeping blood glucose values within normal limits, then pharmaceuticals are given to assist in glucose, lipids, and blood pressure management in diabetics. Weight management is essential in obese patients to prevent disease progression and improve overall health. Antidiabetic therapies that are considered weight neutral or weight loss potential include a-glycosidase inhibitors, Amylin memetics, Biguanides/metformin, GLP-1R agonists, DPP-4 inhibitors, and SGLT2 inhibitors (Gaal et al., 2015). Canagliflozin (Invoknana) is an SGLT2 inhibitor that improves glycemic control and decreases weight (Gaal et al., 2015). The patient will be started on biguanides (metformin) 500 mg twice daily. This drug is very safe, cardioprotective, and enables weight loss. Contraindications are indicated for patients with heart failure. Metformin therapy is also contraindicated when a patient’s eGFR is below 30 mL per minute per body surface area (Corcoran, 2021). The potential for metabolic acidosis is warranted due to the inhibition of mitochondrial inhibition of lactic acid, resulting in lactic acidosis (Rosenthal & Burchum, 2021). Caution must be taken with individuals with hepatic impairment due to the potential risk of lactic acidosis.
T4, Free T4, Total T3, Free T3, and TSH are thyroid function tests. The most sensitive test available to determine thyroid function is the measurement of serum TSH (Simon, 2020). Elevated thyroid-stimulating hormone (TSH) levels define hypothyroidism, and decreased TSH levels describe hyperthyroidism (Schneider et al.,2018). Hypothyroidism s/s include dry course skin, weight gain, cold intolerance, fatigue, hypersomnia, and constipation. On the other hand, hyperthyroidism s/s have weight loss, nervousness, heat intolerance, insomnia, diaphoresis, and frequent bowel movements. According to Rosenthal & Burchum (2021), the current standard and treatment of choice for hypothyroidism is levothyroxine (T4). Food reduces the absorption of oral levothyroxine. The tablet should be ingested on an empty stomach 30-60 minutes before breakfast. The administered dose is converted to T3 in the body. Levothyroxine can produce normal levels of T3 and T4. The medication is highly protein-bound and has a half-life of 7 days.
The patient will be started on levothyroxine (Synthroid) 50 mcg PO once in AM, 30 minutes before breakfast. The patient will be instructed on s/s to monitor, including tremors, nervousness, angina, tachycardia, insomnia, heat intolerance, and sweating. Drugs that can reduce the absorption of levothyroxine include H2 receptor blockers, PPIs, antacids, iron supplements, and cholestyramine, to name a few. Phenytoin, carbamazepine, rifampin, Zoloft, and phenobarbital accelerate levothyroxine metabolism. Caution must be taken when a patient is on warfarin and catecholamines. Warfarin is enhanced due to levothyroxine accelerating the degradation of Vitamin K-dependent clotting factors. Chronic usage of levothyroxine can accelerate bone loss and increase the risk of fractures in premenopausal and postmenopausal women. This chronic illness requires long-term, lifelong replacement therapy. The potential to overdose can result in thyrotoxicosis. I will recommend to the patient to set up a pillbox weekly, with an alarm, to remember to take the medications at the same time each day. A complete blood count, lipid profile, hemoglobin A1C, and complete metabolic profile will be ordered routinely to assess for safe management of diabetes and hypothyroidism.