Advances in Therapy for Chronic Obesity: A Patient’s Journey

Obesity is a chronic progressive disease with new treatments available for our patients.

During my residency at Wake Forest, a legally blind, Spanish-speaking couple established care with me. After sewing in the factory for the blind with her husband, the wife would come to my office to explain her overwhelming joint pain, aching back, and fatigue through her Spanish translator. Her vitals showed high blood pressure, she breathed heavily during the physical exam, and she stopped frequently to gasp for air when walking to the checkout window. Her labs revealed elevated liver enzymes, indicating the development of metabolic-associated steatotic liver disease and that she was now pre-diabetic. Her husband also mentioned her heavy snoring suggesting that I needed to consider a new diagnosis of obstructive sleep apnea. I realized I needed to intervene to manage the progression of her obesity which led to these comorbidities.

We now have a new group of medications that mimic the enzymes in our body, acting on multiple organs including the brain, pancreas, and stomach. 

These enzymes help suppress appetite, reduce gastric emptying, and decrease insulin secretion as highlighted in the latest JAMA clinical review on medications for obesity¹. These medications include liraglutide: 

• Saxenda
• Semaglutide (Ozempic)
• Tirzepatide (Mounjaro and Zepbound). 

All these medications decrease cardiovascular risk for patients² and semaglutide specifically reduces stroke risk³. I explained to her that these medications are available as once weekly injections and that the oral form of liraglutide is less effective for weight loss than the injections. These medications are approved by the FDA in patients with obesity defined by a BMI of 30 or greater as well as a BMI of 27 with at least one comorbidity.

My patient was an excellent candidate for these medications; she was already signed up for weight management and established with the bariatric surgery clinic due to her BMI being greater than 30. 

I knew she was committed to behavioral changes before starting the injection and determined to lose weight in the long term. We discussed the potential side effects including nausea, diarrhea, vomiting, and abdominal pain, which can be mitigated by slowly escalating the dose every 4 weeks. She also needed to cut her meal portions in half, increase her fiber intake to prevent constipation, and meal plan. Some patients need to schedule their meals because they may lose their “hunger instinct” and forget to eat. This loss of protein can lead to muscle breakdown and unwanted weakness, with long-term complications.

Access, affordability, and patient eligibility can be significant barriers to filling prescriptions for these new medications. 

I signed the prescription for my patient but soon received a notification requiring prior authorization from her insurance. Celebrity endorsements and direct-to-consumer marketing have created a demand that does not reflect the population of patients who would benefit from the drug. This shortage has made it more difficult for patients needing the medication. It took several weeks and close collaboration with my pharmacist to get her on the medication. Despite these challenges and her status as being legally blind, she began taking the injections with several follow-ups where I gradually increased the dose and monitored the side effects of the medication.

After six months of this therapy in combination with lifting weights, walking, and cutting portions she saw her surgeon who cleared her for bariatric surgery. 

She lost even more weight after her sleeve gastrectomy. She was able to work in the sewing factory with her husband without any joint or back pain. Her liver enzymes normalized and her repeat hemoglobin A1C was below the pre-diabetic range. Since obesity is a chronic disease, like hypertension or diabetes, I continued to refill her Ozempic to maintain the weight loss. Patients who stop the medication can regain one-third to one-half of the weight they lost while on the medication. Current studies are exploring intermittent usage or reduced dosing after the patient achieves the desired BMI.

My patient’s journey to a healthy weight taught me how GLP-1 agonists in combination with exercise and dietary changes can prevent the serious complications of the chronic disease of obesity. 

Learn More about Dr. Kathleen Grant

Dr. Kathleen Grant is a board-certified internal medicine physician practicing with St. Mary’s Internal Medicine Associates. She earned her bachelor’s degree in neuroscience from Dartmouth College, completed a year of postbaccalaureate education at the University of Georgia, and then earned her medical degree from the Augusta University/University of Georgia Medical Partnership. She completed her internal medicine residency at Atrium Health Wake Forest Baptist Internal Medicine Residency Program.

Learn More About Dr. Grant

Resources, References, and Studies Cited

1. Gudzune KA, Kushner RF. Medications for Obesity: A Review. JAMA. 2024;332(7):571–584. doi:10.1001/jama.2024.10816
2. ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Das SR, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Kosiborod M, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care. 2023 Jan 1;46(Suppl 1):S158-S190. doi: 10.2337/dc23-S010. Erratum in: Diabetes Care. 2023 Apr 1;46(4):898. doi: 10.2337/dc23-er04. PMID: 36507632; PMCID: PMC9810475.
3. Strain WD, Frenkel O, James MA, Leiter LA, Rasmussen S, Rothwell PM, Sejersten Ripa M, Truelsen TC, Husain M. Effects of Semaglutide on Stroke Subtypes in Type 2 Diabetes: Post Hoc Analysis of the Randomized SUSTAIN 6 and PIONEER 6. Stroke. 2022 Sep;53(9):2749-2757. doi: 10.1161/STROKEAHA.121.037775. Epub 2022 May 18. PMID: 35582947; PMCID: PMC9389936.

 

St. Mary’s Blog is for general information only and is not a substitute for professional medical advice, diagnosis or treatment. Please consult your doctor or another qualified healthcare professional about health concerns you may have. If you or others are experiencing a medical emergency, call 911 or visit your nearest emergency department.