GLP-1 receptor agonists are reshaping diabetes and obesity care, raising important questions about patient selection, side effect management, long-term outcomes, access, and the evolving role of diabetes care and education specialists (DCESs). In this episode of Diabetes Care Conversations, host Paola Acevedo, PharmD, CDCES, speaks with Diana Isaacs, PharmD, BC-ADM, CDCES, about what DCESs need to know about GLP-1 therapies, including their impact on treatment approaches, the importance of patient education, and emerging opportunities and challenges in care.
Paola Acevedo
GLP-1s, what does the certified diabetes care and education specialists need to know? People are talking about them everywhere, from clinical hallways to dinner tables to headlines across the country. Some call them game changers. Others have questions about access, side effects, long-term outcomes, and what they really mean for the future of diabetes care. One thing is certain, GLP-1s are reshaping the conversation. I'm Paola Acevedo, clinical pharmacist and certified diabetes care and education specialist.
Welcome to Diabetes Care Conversations. Today, we're diving into one of the most talked about topics in diabetes care, GLP-1 receptor agonist. From improving glycemic outcomes to supporting weight management and reducing cardiovascular risk, these medications are transforming care and also raising important questions for diabetes care and education specialists. Joining us is Diana Isaacs, fellow clinical pharmacist and certified diabetes care and education specialist who is also board certified in advanced diabetes management. Together we'll explore what DCES professionals need to know about these increasingly relevant and for many people life-changing therapies. Diana, thank you so much for being here.
Diana Isaacs
Yeah, thank you so much for having me.
Paola
Wonderful. Let's start at the beginning. When should a diabetes care and education specialist be thinking, hmm, this patient is a good candidate for a GLP-1.
Diana
Yeah, well, there's a lot of people now that could be really good candidates. So I think when it comes to type two diabetes, GLP-1 drugs have become in many ways, first line agents. So certainly in the case if somebody has established cardiovascular disease or kidney disease, but also depending on how much glucose lowering that we're aiming for, they are listed kind of top tier as something that really can get a lot of glucose lowering. And then
For about 90 % of people with type 2 diabetes, they also live with overweight or obesity. And then we're looking for that dual lowering glucose and decreasing weight. And we know these drugs are really powerful at doing both. Now, beyond that, these drugs are also approved for overweight and obesity. And specifically the indication is body mass index or BMI over 30 or over 27 with comorbidities.
That could be things like, dyslipidemia, that could be hypertension, for example. And then beyond that, we have several agents that have even other indications, often together with obesity or together with type 2 diabetes. And some of those indications include things like sleep apnea, MASH, metabolic dysfunction associated steatohepatitis, as well as chronic kidney disease.
Paola
Wonderful, I think our educators will be happy to know that a broad patient population can actually qualify for these therapies. Now, once a patient gets started on one of these therapies, the education and support piece becomes incredibly important. Where do DCESs have the biggest impact in helping patients succeed on GLP-1s?
Diana
Yeah, I think we know that GLP-1 drugs can have a lot of GI side effects. And especially when starting, people may feel nauseous, which can lead to vomiting, but also there can be diarrhea and some people experience constipation. So ways that we can really help with that are education on eating and really trying to manage how much is eaten at one time.
Like a good rule of thumb is to really try to listen and stop eating when full. And maybe if it's a larger meal or going out to a restaurant, automatically taking half of it to go. We also find that higher fat or spicy foods tend to make the GI symptoms worse. So some education on trying to eat foods that aren't as high fat, not as spicy. The other thing is that I think with the dose titration, it's really important in most cases, we really do want to start at the lowest dose and then we want to slowly titrate up and we don't need to rush to the higher doses. In fact, it is perfectly fine to stay at the lower doses for longer to really allow someone to get used to it because when these side effects occur, they're often at initiation or when there is a dose increase.
And these side effects could be big reasons that people don't stick with this very beneficial therapy.
Paola
I think that's going to be very good information for our audience as we're just seeing an increasing number of patients getting on these therapies and more to come, I feel. Now, as use of these medication grows, we're also hearing more nuanced questions, not just about weight loss or A1C reduction, but also about nutrition, about strength and long-term health. How do you approach preserving lean muscle mass and appropriate nutrition while patients lose weight on these medications?
Diana
Yeah, it's a very good question because when people lose weight, they generally are going to lose a little bit of muscle with it. And we, of course, want to preserve that muscle mass. The other concern becomes when people lose weight, if they regain the weight that they've lost, they often regain a higher percentage as fat and less as muscle. So I think number one is we want to maintain the weight loss.
So I think not losing weight too quickly, definitely being in a dose that is working, but not causing weight loss to be too rapid. We don't want someone's appetite completely suppressed. That is not the goal. We still want people to get good nutrition, get enough protein. The other thing is that physical activity is really so important and weight bearing exercises, which can even be walking, but that is gonna maintain muscle. And even better if people can do specific strength training, which is actually recommended two to three days per week for people anyway, but really encouraging some type of strength training, which doesn't have to be this big, like you're going to the gym and you're lifting weights. There are a lot of body weight exercises that can be done at home, but doing that to really preserve the muscle. And the other thing is having a plan.
So these are meant to be chronic medications. And yes, people are investigating different strategies, like maybe, you know, can you start an injectable and switch to an oral? But in general, we have to have some plan or there's going to be weight regain. And so I think making sure we're ready for that and someone has continued access to their medication so that they don't have this unanticipated weight regain.
Paola
That brings us to another major area where educators often step in, helping patients manage side effects and stay engaged with therapy safely.
Are there any under-recognized or emerging safety concerns that educators should be aware of?
Diana
Yeah, so I think, you know, of course, the most common side effects are going to be the GI, but there are some other side effects that we want to be aware of. Most of the agents have this black box warning for medullary thyroid carcinoma. We actually haven't necessarily made a human connection to it. It's because high doses of these drugs given to rodents have demonstrated these types of rare human tumors.
But we certainly don't want to take any chances. And this is a highly genetic form of thyroid cancer. So there is the black box warning for medullary thyroid carcinoma or people with MEN2 multiple endocrine neoplasia. So we should ask if someone has had that and not use it if they have that or a personal history. The other thing is that these drugs have been associated with pancreatitis.
Since the beginning, like GLP-1, the first drug with exenitide back in 2005, and even the DPP-4 inhibitors, there's been case reports of pancreatitis. Now, case reports don't equal causation because people with diabetes using these drugs, they already have an increased risk of pancreatitis when you have diabetes. So we don't know that these drugs necessarily increase the risk.
But again, we also can't 100 % prove that they don't. So when someone has had a history of pancreatitis or if they develop pancreatitis while they're on the drug, usually we're gonna go ahead and we're gonna discontinue it and we're gonna try to determine their cause. And if we can't come up with a cause, we're gonna stop it. I think other things we've seen is that there's been some increased rates of retinopathy. And this is thought to be related to really fast glucose lowering, which can sometimes worsen some of the microvascular complications that occur like retinopathy. So it's definitely a good reminder, have people get their regular eye exams and make sure that they're up to date with all of that because this could potentially worsen that. And then there's also kind of a rare, a more rare complication. It is called non-arteriotic is ischemic optic neuropathy. And this is a condition where blood flow to the optic nerve is blocked. And this can cause sudden painless vision loss in one eye. So definitely you want people to, if they have any sudden vision changes to report that. This is overall very rare, but studies are showing that there's a slightly increased risk or increased rates using these drugs compared to people that aren't.
Paola
I love that the discussions of GLP one really ties the ADA guidelines together. We're educating on exercise and the importance of exercise to preserve that lean muscle mass. And we're also bringing up the importance of that annual eye exam. So it all ties in really nicely. Now one challenge many clinicians are facing right now is balancing evidence-based care with peer restrictions, national drug shortages, and the rise of compounded products. Tell me about how you navigate these challenges or these concerns.
Diana
Well, yeah, those are all really important concerns, but I think we are starting to see a shift. I know I'm really excited about the upcoming Medicare Bridge program that's hopefully gonna make it so it's easier for at least people with Medicare to access these drugs and make it a lower cost. Also, we are seeing that the FDA is cracking down on compounding. And so while many people have been obtaining these drugs through compounded pharmacies, I do think we are gonna start to see that shift. We are starting to see, for example, companies like Hims and Hers now partnering with like Novo Nordisk to make the brand product at a lower cost. And we're seeing now kind of direct programs that are bypassing insurance that are offering these for a lower cost. Now, admittedly, this is often still maybe too expensive for certain people to be able to afford.
But all that to say is I do think this is really going in the right direction. And then for type two diabetes, I do think because this is so prominent in the guidelines, in the algorithm, I think that the coverage has been very, very good and will hopefully continue to see that access continue to expand and people be able to take these, take the real product and kind of not have to try to take compounded and different peptides where they may not know where they're coming from.
Paola
Right, I know that brought up a lot of safety concerns amongst the CDCES educator community. I'm glad to hear that it's moving in the right direction. Another important layer to this conversation is the psychological and behavioral impact these medications can have. We're also seeing a broader cultural conversation around weight, body image, and eating behaviors, and not only in the exam rooms, but also across mainstream media, news outlets, and social media platforms.
What role does mental health or disordered eating play in deciding whether a GLP-1 is appropriate?
Diana
Well, this is an area I have a lot of concerns about because I do see on social media advertising about use of these drugs in people that don't have indications. So advertising like, hey, you want to lose 10 pounds, you know, try this drug. And so it is very concerning the marketing, also the way people are able to obtain these medications. So it's not having to go to your primary care provider. It's people can do these various telehealth platforms online and it's someone they don't have a relationship with already. Some of them are not even, you're not even talking to a real person. It's asynchronous interaction. And so people can easily lie. They can say they're maybe, they're overweight when they're not and obtain these medications. And so I think the concern, there's a great concern about disordered eating and mental health. We know that conditions like anorexia can be life-threatening and really concerning about nutrient deficiencies. I think when we have someone in front of us, we should do a thorough review. We definitely should ask about different mental health conditions and previous disordered eating behaviors. And I think we just want to make sure we're not contributing to that. We want someone to continue to eat, to still have an appetite, to be able to take in good nutrition. Those things are really, really important to have optimal health. And so this is likely an area that diabetes care and education specialists will have to really pay attention to and be very involved with because we often have more time to spend with the person. And so we may be able to navigate these issues and uncover this more than, you know, their 20 minutes maybe with their primary care provider.
Paola
20 minutes is very kind.
Diana
Right, it's usually not that much.
Paola
I'll also say, I think this is an opportunity for us to tap into some of our colleagues in the behavioral health space. I know in my practice in a federally qualified health center, each of our clinics has a behavioral health consultant. And so I think that's a great way to merge those two things together. And if we identify it, we can refer to the right person immediately. So thank you for that.
Diana
That's a great point. Like having team-based care is really important. We're very fortunate. I do have clinical psychologists on my team. We also have social workers. So yes, like taking advantage of behavioral health support is key. There's often not enough of them, but definitely when we can utilize them, it is amazing.
Paola
Now before we wrap up, I'd love to look ahead because this field is evolving incredibly quickly. What developments are you most closely watching for and what do you think could meaningfully change diabetes or obesity care in the next few years?
Diana
Oh there is so much that I am looking forward to. So one is that we are just on the cusp of now we have a dual agonist, right? We've got tirzepatide. It's our first GLP, GIP agonist. But this is really just the beginning. So retatrutide is going to be a triple agonist, glucagon, GLP, and GIP.
And so far, the data looks really encouraging. There's going to be more data at the ADA scientific sessions. But the data in terms of the weight loss, especially in people with type 2 diabetes that often struggle to lose weight as compared to people without diabetes, that I think is very exciting. There's also other drugs like cagrilinitide with semaglutide. So this is combining a GLP-1 with amylin mimetic.
And we previously had Pramlintide, but that was removed from the market last year. And that drug, I mean, required three times a day injections. So that really wasn't an easy medication to take anyway. So the idea that now there's a weekly that will be combined with semaglutide in one injection, I think is really, really, really exciting. And then there's others as well.
There's Maritide, which is a monthly GLP-1 that is in development as well and to reduce the injection burden I think is really exciting. Very recently we had Orforaglipron approved and that is available now and that's been our first non-peptide GLP-1. So that's exciting because it's an oral drug and it doesn't have any special way, unlike the oral semaglutide, it can be taken with food, it can be taken with other pills. It's just kind of an easy, pretty easy drug to take. Now the unknowns is that because it's a non-peptide, I don't think we can assume that the cardiovascular benefits that we maybe have seen with GLP-1 drugs like semaglutide, dulaglutide, even now tirzepatide, I don't know that we can assume that that applies to Orforaglipron.
So I think it'll become really important with these new agents that now have slightly different mechanisms that we do the cardiovascular outcome trials and make sure that they are indeed safe. The other thing is that we are looking at expanded indications. So these drugs are being studied for things like osteoarthritis, peripheral vascular disease, even looking at it for dementia. There was a study with oral semaglutide that unfortunately didn't necessarily show benefit, but I don't think the story's over there. I think there's still more that we can learn. Recently, there was a study with some semaglutide with alcohol use disorder showing benefit. So I think it's like we're learning there's these receptors all throughout the body. And while this was like originally made as a diabetes drug, now it works for so many different things. And so really, it's exciting times to see expanded molecules, expanded indications, and hopefully, also expanded access. One more thing is that loraglutide, which is an older daily GLP-1, but does have the cardiovascular indication that now is a generic drug. Now granted, do people want to take a daily injection when they can take a weekly? Maybe not, but it's certainly a more affordable way to access this great type of class of medication. So all that to say is I'm very excited of where this whole field is going.
Paola
I'm very excited too, Diana, and especially those expanded indications. I think that's also going to expand our role a bit more as diabetes educators outside of the realm of diabetes, because we are technically the experts in these therapies. So we might be called to educate some of the additional patients who don't have diabetes but can qualify through these expanded indications. I'm very, very excited.
Diana
Definitely.
Paola
Well, this has been such a thoughtful and practical discussion. I think our listeners will walk away with a much deeper understanding not only of the medications themselves, but of the critical role that we play as educators in helping patients use them safely and successfully. Diana, thank you so much for sharing your expertise and helping us navigate the evolving landscape of GLP-1 therapies.
From dosing and nutrition challenges to mental and physical health considerations and the exciting therapy still on the horizon, you've highlighted the critical role diabetes care and education specialists play in supporting people with diabetes through informed and individualized care. To learn more and access additional resources, visit adces.org. Thank you for listening to Diabetes Care Conversations. We'll see you next time.