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Department of Endocrinology
Lisa Coco, MSN, CRNP, CDCES: consultant/advisor/speaker: AstraZeneca, Novo Nordisk, Xeris.
As an endocrinology nurse practitioner in a very large, university-based hospital in a large city, much of my practice is the management of type 2 diabetes (T2D), which includes obesity as well. I see patients from all walks of life, including those with heart transplants, renal transplants, and kidney failure.
During the past several years, I have incorporated incretin therapy—specifically, the glucagon-like peptide-1 (GLP-1) receptor agonists dulaglutide, exenatide, liraglutide, lixisenatide, and semaglutide—into my practice for many patients with T2D. These agents are approved for patients with T2D and some are also approved for weight loss and reducing cardiovascular disease risk. In addition, they have limited renal and hepatic adverse events. Therefore, there are few contraindications for those patients whom I help manage their T2D.
Using Incretins to Decrease Comorbidity in Diabetes
Using these medications, I have seen robust reductions in hemoglobin A1C as well as improved overall glycemic control and weight loss. This is in sharp contrast to my patients on insulin therapy. Once patients are on large doses of insulin, they tend to gain a tremendous amount of weight. As we know, excess weight increases the risk for diabetes and uncontrolled blood sugars, which may also lead to associated cardiovascular and renal sequelae.
If a patient already has established cardiovascular disease and renal disease and then gains weight, the vascular and renal disease will actually accelerate even with good glycemic control. However, if I combine incretin therapy with insulin therapy and help patients lose weight, they are very often able to reduce their insulin dose. The incretin therapy also helps reduce their appetite. Therefore, a whole cascade falls in place, leading to improvement in other comorbidities as well.
When using incretin therapies, my goal is to have a fully informed patient. The first hurdle with many patients is adding an “extra” medication. It is important to take the time to describe the benefit they will see with this drug. In the end, most of my patients are very happy with the results they achieve with these medications.
Insurance Coverage: Documentation Is Key
With many patients, we also have to work with insurance companies to acquire authorization to use these therapies. Our office has staff who work hard to get coverage for our patients.
For instance, we are able to get semaglutide covered by most insurance companies—even Medicaid—if the patient has a prediabetes diagnosis and a hemoglobin A1C >5.7%.
However, if patients come to us for weight loss only and they do not have T2D or prediabetes, there is a semaglutide formulation that is indicated for weight loss, but it is a little harder to get approved. In my experience, the liraglutide weight loss formulation has been easier to get approved for my patients because it is an older medication. However, liraglutide is administered as a daily injection whereas semaglutide is a weekly injection, and many patients prefer to administer fewer injections. In addition, we tend to see higher levels of weight loss with semaglutide, compared with liraglutide, although both are quite beneficial.
It is very important to be thorough in your medical charting so that the benefit to the patient will be evident to the insurance company. Weight gain is an issue with many comorbidities. So if I am seeing a particular patient for an endocrine disorder in which excess weight will be a risk, I thoroughly document that. If a patient has cardiovascular disease, weight loss is very important, and I document that thoroughly also. If I have a patient with obesity and other comorbidities such as metabolic syndrome or hyperlipidemia, but who does not have T2D or prediabetes, I thoroughly document how weight reduction will help improve that patient’s health. If one takes the time, the medications are usually approved.
Incretins for Cardiovascular Risk
The other exciting aspect of incretin therapy is that it does have a benefit for those patients with T2D that have in increased risk for both cardiovascular and renal complications. Whether these medications will be prescribed in the future for patients with primarily cardiovascular disease remains to be seen. There are ongoing studies of some GLP-1 receptor agonists in persons without T2D who have obesity, and we are awaiting those results.
How to Get Started Prescribing Incretin Therapy
It goes without saying that those providers who are interested in using these drugs for the benefit of their patients should also provide thorough education to patients to ensure patients have a better understanding of the positive outcomes associated with these medications. We are fortunate to now have these medications as part of our armamentarium.
Are you—or have you considered—using incretins for your diabetic patients? Share your experience by leaving a comment.