Extra Caution Needed for GLP-1s in Those With Chronic Issues

People with disabilities and chronic illnesses may find it more difficult to eat healthy, control their weight, and remain active, as a result of physical limitations, food desserts, a lack of transportation and access to the outdoors, and as a result, they’re more than twice as likely to develop obesity than the general public.

These patients may benefit from glucagon-like peptide 1 (GLP-1) medications just as much or more as those with no comorbidities. But there are some additional considerations that primary care physicians need to consider when prescribing GLP-1s to patients with disabilities as well as to those with prior chronic conditions.

Staving Off Muscle Loss

In patients whose activity is low due to physical limitations, extra guidance may be necessary because of the risk that these medications will further reduce muscle mass while they help with weight loss, said Sonal Haerter, MD, an internal medicine and obesity medicine physician at St. Joseph’s Hospital and Medical Center in Phoenix.

“These medications can cause dramatic weight loss and with that weight loss comes fat and muscle loss,” Haerter said. “We can’t afford to cause muscle loss that might lead to frailty in some of these patients.”

Primary care physicians should encourage patients to lift weights, drink plenty of water, and eat ample protein to reduce muscle loss. In those with physical limitations who might have someone helping them make nutritional decisions, transportation and other lifestyle choices, caretakers need to be in the loop so that patients are able to make the right choices in their weight loss journey.

In patients with intellectual disabilities, there needs to be awareness from a caretaker on how to properly care for patients on GLP-1 medications. Some patients with disabilities may have trouble swallowing and may need help taking these medications, which are generally given by injection once a week but also come in a pill form, called Rybelsus.

Preparing Patients With Disabilities for Potential Side Effects

Regardless of whether a patient has a disability, their primary care physician should counsel them on potential side effects. But for patients with physical limitations, this can be even more important. For example, in those who use a wheelchair, diarrhea, vomiting, and nausea that can accompany these medications may cause additional difficulties.

All patients, no matter the limitations, need to have a plan in place if they do experience some of these symptoms. But it’s also important to recognize that most people don’t experience severe side effects. Research has shown that 10%-20% of people taking GLP-1s experience severe gastrointestinal symptoms.

“It would be unfortunate to withhold these medications from someone just because they are in a wheelchair or have another physical disability because they have even fewer options for physical fitness than the general public,” said Carolynn Francavilla, MD, a nationally recognized obesity physician who owns and operates Green Mountain Partners for Health and Colorado Weight Care, both in Denver.

Some patients with disabilities may already have trouble getting the nutrients they need to stay healthy and in this case, additional nutritional counseling is essential. Eating small, balanced meals with ample protein and ensuring that patients remain hydrated throughout the day is important to stave off symptoms and keep patients on track to lose weight in a healthy manner, especially in patients with intellectual disabilities.

“If patients don’t have enough support to get quality nutrition, they could experience significant health consequences,” Francavilla said.

Contraindications in Patients With Chronic Mental and Physical Conditions 

GLP-1 medications have been shown in recent research to help patients with some severe mental health conditions like suicidal ideation and schizophrenia. This may come from reduced inflammation and neuro-inflammation, which can impact many psychological disorders.

However, patients with alcohol use disorders need to particularly be careful especially if they’re at risk of drinking alcohol in place of most of their calories. Research has shown that these medications can be helpful for addictive behaviors, but they can also make it difficult to eat, which causes electrolyte imbalances and nutrient deficiencies that can be very serious.

“This is a population that really needs to be watched carefully and I don’t think there’s enough understanding of their risk,” Francavilla said.

In individuals who may be more at risk for contraindications, it’s important to schedule more frequent follow-up visits with a healthcare provider. Patients aren’t in contact with their physicians, so healthcare providers should be proactive.

“A nurse can call the patient once a week, for example, to ensure they’re doing fine on the medication and check to see if they’re experiencing certain symptoms,” said Silvana Pannain, MD, an endocrinologist and director of Chicago Weight, a multidisciplinary weight loss program at the University of Chicago Medicine, Chicago. She added that additional check-ups should be scheduled monthly before patients increase on dosage.

In some chronic conditions like unresolved pancreatitis and some gastrointestinal issues like gastroparesis — a condition that happens when the stomach muscles are slow to move food through the gastrointestinal system — GLP-1s may not be a good fit.

“In this case, the medications can cause severe nutritional deficiencies and other health issues,” Haerter said.

But it’s also worth noting that these medications improve a wide breadth of chronic conditions like diabetes, cardiovascular diseases, Alzheimer’s disease, dementia, clotting disorders, chronic obstructive pulmonary disease, and liver diseases. Most patients with chronic conditions will improve on GLP-1s and the number of those who benefit is only increasing.

Pannain said that we initially thought that these medications could have a negative impact on gastrointestinal issues like Crohn’s disease and inflammatory bowel disease, but evolving research is showing that the opposite might be true. GLP-1s seem to put the brakes on the inflammation that causes a host of gut health issues.

“I would not be surprised if these medications show a benefit for conditions that we initially thought might be a contraindication,” Pannain said.