Introduction

Dr. Ellen Csepe // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses this new class of medicines and how they impact your patients and their overall journeys to maximize their fitness and manage their weight.

Take a listen or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ELLEN CSEPEHey, good morning everybody. And welcome to the PT on ICE daily show brought to you by the coolest continuing education company in all of healthcare. My name is Ellen Csepe. I'm coming to you live from Littleton, Colorado. I normally teach with the older adult division, but today we're going to be talking about GLP one agonist medications and their impact on your patients. Um, You guys have probably heard about GLP-1 medications. They're all over social media right now. They're used to manage obesity and weight issues um and diabetes, so These medications are the medicines like ozempic that you've heard all about or the medication brand of that same Ozempic, but used for obesity, which is called Wegovy. So you've probably heard a lot about these medicines already. And if you didn't see them on your board questions, you might be feeling a little bit out of the loop as to how they could impact your patients. If you're like me, these medications have come out after I've already gotten my licensure as a PT, and these medicines are impacting our patients in ways that I'm not really familiar with. So, this podcast episode today is for you to know a little bit more about how these medicines could be impacting your patients as a rehab professional. This podcast is going to be a lot about introductory level information to talk about these medicines in context of our Patients with obesity this podcast is not going to be a conversation to talk about How these medicines are used by celebrities they're not going to be we're not going to talk about how these compound medications or Illegal versions of these medicines are flooding our healthcare scene and causing a lot of illnesses today, we're gonna be really talking about what they are and how they work, who they're for, what they do other than help people lose weight, and some considerations and practical tips for your patients. GLP-1 MEDICATION So let's talk a little bit more about how these medicines work. So in context of treating obesity, these GLP-1 medications are super helpful to kind of overcome the biology behind our body's resistance to losing weight. Let me break that down a little bit. I know it's really easy to look at somebody with weight issues and think, gosh, wouldn't they just feel better if they lost weight? And it's an interesting paradox because our bodies actually fight to regain lost weight. Our bodies might feel better. We might have less pain, less inflammation, less joint problems, but Unfortunately, when we lose a substantial amount of weight, our body's biology fights to regain that. Why? Because usually in the context of our human existence, losing weight has always been a bad thing and it usually means being in starvation. Unfortunately, our biology doesn't know that obesity can be just as much of a threat to our health as starvation. So, when our weight changes, unfortunately our ghrelin or the hormone circulating in our blood blood that's Tells us we're hungry unfortunately that increases when we've lost weight and unfortunately leptin or that satiety hormone is decreases when we lose weight. What does that mean for our patients? It means that losing weight is very difficult to maintain because our body is constantly fighting to get that weight back. So let's talk about these GLP-1 medications. I'd like to first start out by saying GLP-1 medications are the newest medications that are used to treat obesity, but they're not the only ones. They just have a lot fewer side effects than some of the other medications that we've used in the past. For example, oralistat is a medication that works at our gut to decrease the absorption of fat. It comes with a ton of really gnarly side effects. Google what steatorrhea is, and you'll see what I mean. Unfortunately, there are tons of GI side effects for people that use this medication that cause significant fat in their stools and a lot of loose stools with it. Another medication is fentramine or topiramate. Those medications used in combination Basically act as a sympathomimetic to increase our metabolism But those medications are really only effective for a short period of time and they can have a lot of cardiac side effects There are some medications that are used in combination to treat obesity specifically naltrexone was a medication to use to treat opioid addiction and bupropion is which is another antidepressant, in combination that kind of changes our satisfaction behind eating. Those are medications used to treat obesity too. And usually what we can guess is that those medications aren't going to be quite as effective as GLP-1 medicines. Just to kind of review if you're tuning in now, those GLP-1 medications are medications like Wegovy, Sexenda, Ozempic, although of note, Ozempic is only used to treat obesity as an off-label benefit. Ozempic is actually only, excuse me, only approved to treat diabetes by the FDA right now. MECHANISMS OF GLP-1 MEDICATION So let's talk a little bit more about what this GLP medication is. GLP-1 is a hormone that we naturally secrete in our bodies. and the GLP-1 medicines are receptor agonists that look pretty similar to that hormone in our bodies and that when used mimic that hormones actions throughout our tissues. For example at the pancreas that GLP-1 receptor increases our body's secretion of insulin and helps to make that insulin last better. So that's why it's also used for people with diabetes. Interestingly enough, we also have GLP-1 receptors in our stomach. So another way this medicine works is to slow gastric emptying and basically make our food last longer throughout our stomachs so that we feel fuller for longer. What I think is the most interesting is that we have these GLP-1 receptors in our brain, in our hypothalamus, and the way these GLP-1 medicines work is to suppress both hunger and cravings. A lot of people with obesity experience something called food noise. And basically because of the obesity, they have these constant and intrusive thoughts about food. They could be eating something and have no hunger, but already be thinking about their next meal. So this GLP-1 agonists, Turn down that food noise to make it less likely for them to experience these constant intrusive thoughts about hunger So we talked a little bit about how they work. Let's talk a little bit more about who they're for so GLP-1 agonists are used for people with obesity. So that means generally their BMI is 30 or more or they could have overweight and a BMI of 27 with comorbidities. Comorbidities specific to their weight significantly causing risks to their health. So these medications aren't just for people who are looking to shed a few pounds. Obesity is a disease and these medicines really help us treat that disease process, which is a long-term, lifelong problem that relapses and recurs, unfortunately, in a lot of patients. It's contraindicated in a few patients. Good news, patients' physicians have to figure that out, not us. But just for context, people that are pregnant, people that have gastroparesis, irritable bowel disease, those patients might not be appropriate for these medicines, as well as those with certain thyroid cancers or familial risks of those cancers. So these medicines are also used to treat diabetes and in patients with obesity and diabetes, this is a great new medication to manage both conditions at once. Interestingly, or Wigovy, which is the ozempic for obesity, is also used to treat those who are 12 and older. So it's not just adults that are using these medicines, it's also those with obesity who are children who are 12 or older and weigh 132 pounds or more and have obesity. So let's talk a little bit about what they do. So pragmatically, they really reduce cravings. We talked about that. They can result in about an 8 to 15 percent weight loss in the first year of use. That's a lot compared to some of the older classes of medication. Liraglutide decreases the risk of diabetes compared to a placebo. So in those with obesity, liraglutide decreases the risk of obesity development and that rate of onset much sooner. So these aren't just to lose a few pounds before summer and celebrities. This medication can be very helpful for people who are struggling with their weight long term. Notably, Long term is how long these medications have to be used. So unfortunately, in most users, if they discontinue this medication, weight is almost always regained, and about 66% of the weight that they've lost over the past year is regained when people stop using this medication. but again, this isn't just a cosmetic thing to lose weight and a lot of us as Providers think about weight in the context of how we look societally and how we feel but this medication in those with obesity and diabetes Decreases the risk of cardiovascular events decreases the risk of stroke atherosclerosis Heart attack. So these medications aren't just here to help you get shed a few pounds These can be really life-saving medications for those with obesity CLINICAL CONSIDERATIONS Let's kind of talk through some of the considerations for you as a clinician. So keep in mind these medications are injected by the patient at home one time a week. And the dose is gradually increased to a therapeutic dose over several months. Here's why that matters. Because there are quite a few side effects with these medications. It's not a medicine that comes without side effects. This is not the easy way out to lose medicine. It does not feel good to be on these medicines. And a lot of the most common side effects are going to be nausea, vomiting, GI issues, cramping, bloating, dizziness, headaches and fatigue, hypoglycemia, which is important for us to consider for our patients if we're going to be having them exercising, acute pancreatitis, and gallbladder disease. So how does that impact our patients? Friends, team, we are in the business of helping our patients maintain their muscle mass. That's our job. Our job is to be fitness forward, to advocate for our patients, and to be here for them through every season of life. And on the days that they're taking these medicines and throughout the week, there's a lot of stigma attached to these medicines that we have to be aware of as providers. Where I'm going with that is that they need a hype squad. Patients need somebody to cheer them on and say hey, I know you feel like crap. I know that this medication is hard What I want you to know is that I'm here in your corner You are making a big decision for your health and even if you only lose five to ten percent of your weight Overall, that is a huge huge way to reduce your risk of overall cardiovascular disease. HYPE UP YOUR PATIENTS So friends We need to hype up our patients who are on these medicines when it's appropriate and it usually is if it's prescribed by a doctor. This needs to be our goal to hype up our patients and encourage them to maintain their consistency with this medicine. A lot of patients stop because they plateau losing weight after about a year. And they still have the side effects. So they feel like crap. They don't want to take this medicine. They're not seeing the pounds shed off anymore. And they need a health care provider to say, hey, this isn't just a quick fix to lose a few pounds. This is a lifelong endeavor to manage obesity, which has serious risks to your health. So another consideration, our business is to make sure that our patients are sticking through these medicines and Also maintaining their exercise participation and their muscle mass So patients who are taking these medicines feel like crap. They need somebody to still say hey I know you don't feel great. We still need to have a plan to have you doing strength training. We still need to have a plan for you to get enough protein in your, in your, in your mouth throughout the day, because unfortunately these medicines work by saying, Hey, you're not so hungry anymore, which is how those medicines are effective. But unfortunately, if you're not intentional, you will lose not only fat mass, but muscle mass with this endeavor with using these medicines. So, Encouraging your patient. Hey, I know you're losing weight. This is awesome Let's really keep this ball rolling and be super Intentional to make sure that you're still able to get to the gym that you're still able to get enough protein in your diet I'm on your team. I am in your corner to help you and These patients are prime time for behavioral change to say i'm making a change on myself already with this medicine. How can I really? Maximize this and get as much as I can and we are on their team team I recommend patients to talk with their doctor about these medicines. I talk with my patients about their weight all the time in a way that's constructive and empathetic. I listen to my patients and recognize that losing weight is a struggle. These medicines can be super helpful for our patients who have struggled for a long time to manage their weight. And that's not because they're unmotivated or lazy, it's because their biology is fighting to get that weight back. This is not cheating and these medications can be super helpful. I often talk with patients and recommend them to go back to their doctors and ask if it could be helpful in their journey to manage their weight. A quick caveat on that, not all insurances in all states cover these medicines the same, which is very unfair. These medications can be really life-saving for our patients with obesity, and unfortunately, insurance is making it hard for people that need it most to get access to it, specifically those in poverty. Obesity disproportionately affects those from a lower socioeconomic status, and it's really important to recognize that in the treatment of obesity, those people are unfortunately going to be the last to get access to this stuff, and that stinks. So knowing that as a provider is another important thing that I've learned. You can't just shoot from the hip and say, oh, you've got to go talk to your doctor about this. It might not be covered by their insurance, and that's super demoralizing. So make sure that you kind of know that before you make this recommendation that, oh, you can be on this new drug, it'll be super helpful for you, and it's not covered. So friends, to wrap up this summary, so these GLP-1 medications are new but not the only way that obesity can be treated medically. They're very helpful and effective in helping those individuals lose weight but they often come with side effects. Our job as providers is to know what those side effects look like and feel like and how to still emphasize exercise participation to our patients no matter how they feel and come up with a plan to say, hey, we still need to do strength training. We still have protein goals to make sure that you maintain your muscle mass. Thank you guys so much for taking time out of your morning to join me to talk about these medicines. And I hope that it was helpful in the long run for you to know how they can be helpful for your patients. Have a great day.

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