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Welcome to the Quick Consult podcast, brought to you by Metall. Before starting this podcast, please review the faculty information, disclosure statements, and learning objectives using the link in the episode description. To claim your CME credit, complete the evaluation using the link in the episode description. This podcast is a continuing education activity managed and accredited by Affinity CE in collaboration with Metal. This activity is supported by an independent medical education grant from Lily. Welcome back to the Global Obesity Academy Insights podcast series. In episode 2, we're going to be looking at how to adjust treatment based on guidelines. We move from initiation to ongoing management. Obesity is a chronic relapsing disease, and therapy adjustment is often necessary. I'm here again with Doctor Patrice Forner. A common challenge is when a patient is receiving treatment but has reached a plateau or isn't meeting their goal. For instance, let's consider a 62-year-old patient with severe obstructive sleep apnea and knee osteoarthritis. After 9 months on maximum dose semaglutide, which is 2.4 mg weekly, they have a 5% weight loss, and it has plateaued, which is less than their personal goal of 15%. And their obstructive sleep apnea has only mildly improved. What is the recommended time frame for reassessing a patient's response to pharmacotherapy, and what specific factors, clinical, weight-related, and patient reported outcomes measures should trigger a conversation about intensifying or substituting medication? So when we start someone on weight loss medication, it's really important to have a plan for follow-up and reassessment because not everyone responds the same way. Usually we check in around 3 months after starting treatment. Uh, by then, if a person hasn't lost a meaningful amount of weight, which we define as less than 5% of their starting weight on the maximum tolerated dose, we consider them a non-responder. And that's the point where we think about stopping that medication and exploring other options. But it's not just about the numbers on the scale, even if someone is technically losing weight, we need to look more broadly, and that means checking things like BP or glycemic control and seeing if any obesity related issues like sleep apnea or joint pain are improving. We also look at weight related measures beyond just total weight, so things like waist circumference or body composition, because sometimes that shifts before the scales really change, particularly in patients who are engaging in strength-based training. Then you've got the patient's own experience and that's where the patient reported outcome measures or prompts come in. Basically we ask, how do you feel, are you moving more easily, is your quality of life improving, is pain or fatigue lessening? If a patient isn't hitting their goals, whether that's weight, clinical measures, or how they feel day to day, that's the cue to have a conversation about stepping up therapy or trying a different approach. So really, it's about looking at the full picture, weight, weight-related complications, and most importantly, how does the patient experience those changes in their everyday life. Before switching or adding medication, what non-pharmacological factors must clinicians rule out and address as barriers to treatment response? Before we think about switching or adding a medication, it's crucial to again take a step back and, and have a look at that big picture. Firstly, we need to revisit the foundation of treatment, so there's 3 pillars, nutrition, physical activity, and psychological support. Are they consistently engaging with these strategies, are they realistic, are they sustainable? Next we look at the medication itself, are they taking it as prescribed? Are they taking the correct dose, have they reached the maximum tolerated dose? Are there adherence challenges, injection issues, or side effects that might be limiting effectiveness? Often this is the case, and that's very easy to modify. But we also need to consider the broader context, are there social or economic barriers like cost or access issues that could interfere with consistent use, or are there unaddressed psychosocial or medical factors like medications that might be blunting the response. If we address the non-pharmacological factors first, we can ensure that any medication changes we make are built on that solid foundation, and this is going to give the patient the best chance for a meaningful and sustainable result. In the case of our patient with suboptimal response who has severe OSA and OA, the clinician decides to switch from simaglatide to terzepetide. What is the evidence supporting this switch in this case? Yeah, so for patients not reaching goals on simmaglatide, especially those with severe obstructive sleep apnea and osteoarthritis, switching to tezepeide is a very logical escalation. We know that tezepeide delivers greater weight loss than simmaglatide, so that's up nearly 18% versus 12%, and weight reduction is a key driver of improvements in both obstructive sleep apnea and joint load. Tezepetide has been shown to significantly reduce the apnea hypopnea index, with many patients achieving disease resolution thresholds. For osteoarthritis, simaglatide remains the best studied agent while tezepeide is still under investigation, so switching is a very reasonable option. When a patient achieves significant weight loss and health optimization following a switch, what non-obesity medications may need proactive adjustment to prevent adverse events like hypotension or changes in hormone levels? This is a great point and certainly something worth discussing. When a patient achieves significant weight loss, it's not just their weight that changes, and we really need to think proactively about the other medications. For anti-hypertensives, even modest weight loss can cause a notable drop in BP, so anti-hypertensives may need to be reduced and sometimes stopped altogether, and this can actually happen quite early, sometimes even before dramatic weight loss occurs. Thyroid hormone is another example, so levothyroxine dosing is weight-based. As a patient loses weight, their requirements generally decrease, and carefully and, and careful monitoring of TSH is essential, so I usually do this every 4 to 6 weeks after commencing pharmacotherapy. Diabetes medications require particularly particular attention, so starting or escalating a GLP-1 or dual agonist can improve insulin sensitivity and lower blood glucose, which increases the risk of hypoglycemia for patients who are on insulin or sulfuras. Now, dose adjustment really depends on the baseline HbA1c, and if the A1C is quite reasonable, it's generally acceptable to either halve the dose or cease the sulfonylurea. For insulin, a common strategy is to reduce the the basal dose by about 20% initially and adjust the prandial doses according to glucose readings. A lot of patients will have a significant reduction in their prandial requirements as they consume less carbohydrate. So close monitoring during the 1st 1 to 2 weeks is critical, and we need to make sure that the patient's able to recognize and treat hypoglycemia. The key takeaway here is that effective weight management doesn't happen in isolation. As patients lose weight, clinicians need to review and adjust medications proactively. That's an important reminder to link escalation strategies directly to the evidence for both weight efficacy and comorbidity improvement. To our listeners, here is a reflective question. If a patient on pharmacotherapy plateaus, do you fully explore non-pharmacological barriers before switching, or do you prioritize medication adjustment? Thank you, Doctor Forner. Next, we'll move to episode 3 where we'll talk about building structured follow-up pathways. You can access the full series along with other comprehensive resources and CME credit by visiting metaleducation.com. Thank you for listening. To claim your CME credit, complete the evaluation using the link in the episode description.