Reduce insulin if SAXENDA is used for weight loss

Overview

As a nutrition support pharmacist, you will hear more about using Saxenda for weight loss in adolescents 12 and up, not just in adults. Saxenda will be the first GLP-1 agonist for obesity, that in addition to stimulating insulin release and inhibiting glucagon secretion, slows gastric emptying and increases satiety after eating, (see our Note about Saxenda for weight loss, writen for community pharmacists, here).

NPS-adv

Saxenda and weight loss

Mechanism of action & eligibility

• Saxenda is liraglutide same as Victoza for type 2 diabetes, but Saxenda is used at a higher dose to help reduce hunger.
• Saxenda is for patients with or without diabetes if BMI ≥ 30 or ≥ 27 with a weight-related condition (hypertension, etc).

Perspective on weight loss benefits with Saxenda

Keep the benefits of Saxenda in perspective. Weight loss starts with a healthy lifestyle and weight loss medications are ONLY an adjunct.

• Weight loss at one year is about 10 lbs (4.5 kg) more than placebo with Saxenda 3 mg/day "see table 2", compared to 6 lbs with Victoza 1.8 mg/day, 7 lbs with Belviq (lorcaserin), 9 lbs with Contrave (bupropion/naltrexone ER), and 20 lbs with Qsymia (phentermine/topiramate ER).

Managing side effects and dosing

GI symptoms such as nausea, vomiting, and diarrhea likely contribute to weight loss, but cause about 5% of patients to stop Saxenda. Titrate to 3 mg over 5 weeks to reduce GI effects "see table 1". Symptomatic hypoglycemia is rare in patients without diabetes, but is more common in patients with diabetes taking hypoglycemic medications. Labeling says not to combine Saxenda with insulin because it hasn't been studied. But this IS okay.

• Combining other GLP-1 agonists with basal insulin often leads to decreased weight and insulin requirements.
• For most patients, reduce the insulin dose by at least 20% if Saxenda is added and reduce sulfonylurea doses by at least 50%.
• When it becomes available in pharmacy, consider it if you need a weight loss medication for a patient with diabetes or prediabetes, to help both obesity AND hyperglycemia.

Table 1. Dosage Escalation Schedule for the Treatment of Obesity
Week	Daily Dose	Note
1	0.6 mg	Obesity, Sub-Q Initially, 0.6 mg daily. Increase daily dosage by 0.6 mg at weekly intervals to maintenance dosage of 3 mg daily. If dosage increase not tolerated (e.g., adverse GI effects), may delay dosage escalation for approximately 1 week. If 3-mg daily dosage not tolerated, discontinue therapy; efficacy not established at dosages 3 days have elapsed since the last dose, reinitiate at 0.6 mg to minimize adverse GI effects; retitrate to maintenance dosage of 3 mg once daily.
2	1.2 mg
3	1.8 mg
4	2.4 mg
5 and onward	3 mg
This information from, AHFS Drug Information Essentials...

NPS-adv

Weight loss normally starts within 2 weeks of starting Saxenda (liraglutide). Stop weight loss medications if patients don't lose at least 5% of their body weight after 12 weeks on maximal doses. Others recommend to discontinue Saxenda if weight loss of at least 4% is not achieved after 16 weeks of therapy. Document the BMI and treatment plan for obese and overweight patients at least every 6 months to meet this quality measure.

Table (2). Saxenda for Weight Loss
Product	Usual Dose	Mean Weight Loss	Considerations for Use
Products that work as a glucagon-like peptide-1 (GLP-1) receptor agonist to reduce appetite and food/calorie intake. It reduces A1C and fasting glucose. Monitor blood glucose and for signs and symptoms of pancreatitis. Discontinue if pancreatitis is suspected. Do not restart if pancreatitis is confirmed. Don’t combine with other GLP-1 agonists. Generally, avoid use in patients taking a dipeptidylpeptidase-4 inhibitor (e.g., saxagliptin), as combining these two classes of medications is unlikely to improve weight loss and is not cost-effective. Risk of medullary thyroid carcinoma and multiple endocrine neoplasia syndrome type 2. Rare reports of gall bladder disease specially in patients rapidly losing weight.
Liraglutide (Saxenda)	For patients 12 years and older: 3 mg subcutaneously once daily (start with 0.6 mg once daily, increase dose weekly by 0.6 mg to goal of 3 mg once daily). For adults, discontinue after 16 weeks if < 4% (after 12 weeks if < 5% [Canada]) weight loss achieved.	~ 3.7 to 5.2 kg (8.1 to 11.4 pounds) (3 mg once daily at 56 weeks). ~ 44% to 62% of patients met weight loss goal (≥ 5%) at 56 weeks compared to 16% to 34% with placebo.	Discontinuation rate due to adverse effects: one out of every 18 patients.

New Alternatives: Maestro "Stomach Pacemaker"

You will also hear about Maestro, a new "pacemaker for the stomach" for some patients with a BMI ≥ 35. It's implanted in the abdomen and interrupts signals between the vagus nerve and stomach to decrease hunger. For more information, read our guidance to help your , "7 Diet, a professional guide for weight loss". And see our video below...

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References

1. The Weight Loss Cycle. [online] Available at: https://www.saxenda.com/about-obesity/the-weight-loss-cycle.html.
2. Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342-362.
3. Medication Guide for Saxenda, Available at: https://www.novo-pi.com/saxenda.pdf.
4. Liraglutide (Saxenda) for weight loss. Med Lett Drugs Ther. 2015 Jun 22;57(1471):89-90.
5. Liraglutide (Saxenda) for Weight Loss. Am Fam Physician. 2016 Jul 15;94(2):161-166.
6. GoodRx. Saxenda Medicare Coverage and Co-Pay Details. [online] Available at: https://www.goodrx.com/saxenda/medicare-coverage
7. Mehta A, Marso SP, Neeland IJ. Liraglutide for weight management: a critical review of the evidence. Obes Sci Pract. 2017;3(1):3-14.

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