Can diabetes medicines lead to weight loss? Can they be given to the obese who are non-diabetic?

With obesity not restricted to the rich from metro cities anymore, several classes of diabetes medicines that are known to drive weight loss – and remission in diabetics and pre-diabetics – have great potential, says diabetolog Dr Anoop Misra. The morbidly obese may choose to use these drugs before thinking of bariatric surgeries.
Which diabetes medicines lead to weight loss and how?
There are two classes of diabetes medicines that help in moderate to substantial weight loss. The first is the SGLT-2 inhibitors, which we have been prescribing for diabetes for six to seven years now. They act eliminating glucose in the urine and preventing its re-absorption in the kidneys. This loss of glucose effectively means a loss of calories as well. So, in addition to decreasing blood sugar levels, it also leads to weight loss. This class of drug, on an average, leads to a weight loss of about 2 to 4 kg in a year. This is not too high, but that is good enough for several patients.
When it comes to weight loss, the second class of drugs are GLP-1 receptor analogues that are mostly injectable. (The drug that Elon Musk said he uses to stay fit belongs to this category).
We have been using these injectables for diabetes management for ten years now. Over the years, there have been many such injectables available – first we had a twice-daily injection, then once daily injection, then we had once-a-week injection, and now we have oral form of these drugs. These are powerful drugs that can lead to a loss of 5 per cent to 10 per cent of body weight over six months to one year.

The newer versions of these drugs, which are currently not available in India, can make a person lose up to 15 per cent of their body weight. This is remarkable. There is a great potential of these drugs as far as obesity is concerned.
Can these drugs be prescribed to obese persons who might not be diabetic?
As far as people who are only obese are concerned, right now the only approved drug in India is a very weak one called Orlat. It’s a very old drug that has been on the market for more than 20 years. This drug blocks the absorption of fat in the intestine. But, since it works on the intestine, it can also cause gastrointestinal symptoms such as diarrhoea. Besides, the weight loss is not much.
On the other hand, worldwide, injections of these GLP-1 receptor analogues at a high dose are available for weight loss in non-diabetics. Now, another drug of the same class is being approved on the fast track for the treatment of obesity.
For diabetics with obesity, there are SGLT-2 inhibitors – which are the frontline drugs for diabetes management – and injectable GLP-1 receptor analogues, along with the oral GLP-1 analogue, that is available the name Rybelsus for the last couple of months.

Just to repeat, in India however, there is only one approved weight loss drug. However, if you are using the GLP-1 receptor analogues in the doses currently available in India, then the patient has to be explained that it is being used out of the label (a drug used for the treatment of a condition for which it is not approved).
Does using diabetes medicines in non-diabetic obese persons lead to a drop in blood glucose levels?
No. These drugs are, in fact, known to not cause hypoglycaemia. These drugs are used us, infrequently, in those who have morbid obesity and don’t want to go for bariatric surgery.
Importantly, since these medicines lead to weight-loss, can they result in remission of the disease?
Of course, if they lose that much weight. There is a 60 to 70 per cent likelihood that the persons go into diabetes remission. This is the additional advantage of using these drugs in pre-diabetic and diabetic persons who are obese.

Now, can people go off these medications after remission? Usually, the patients and their doctors set a target weight. If they reach the target and their sugars are normal, they can go off the medicines. But, they need to have, say, a high degree of exercise and a good diet to prevent regaining weight. Weight regain is always a problem with whichever modality is used to lose weight, except bariatric surgery.
So, we wait and see what happens. If they are gaining weight at a slow pace then we would wait and watch, if they are gaining weight at a fast pace then we may have to restart the medicines.
Of course, some people stop because the injections are expensive – they cost about Rs 8,000 to 9,000 a month. Initially, they can cause nausea and vomiting for about four weeks. The alternative is, of course, bariatric surgery which may cost more initially but then there is less weight regain as compared to the medicines.
————–Why Dr Misra? Dr Anoop Misra is the Chairman of Fortis-CDOC Center of Excellence for Diabetes, Metabolic Diseases, and Endocrinology in New Delhi. He has been an advisor to the Minry of Health, the Indian Council of Medical Research (ICMR), and the Department of Biotechnology, offering his expertise on several issues related to diabetes and other non-communicable diseases. In the past two years, Dr Misra has published 40 papers on Diabetes and Covid-19 in top science journals.