BU Today: Have you used semaglutide with your diabetic patients?

Ivania Rizo: It was FDA-approved for diabetes in 2017. It’s very effective in patients with diabetes. I’ve been using it at least since mid-2018 for diabetes. I consider it in all my patients who are Type 2 diabetics. Especially for Type 2 diabetes associated with obesity, [this class of drugs] is one of the things I consider first-line. We generally do see weight loss with the current dose of semaglutide, which is one milligram per week, versus the study. That was 2.4 milligrams per week.

BU Today: You’ve read the Northwestern study. Does it look solid?

Ivania Rizo: Yeah. It is the gold standard of looking at a new intervention, which is a randomized controlled trial. It has about 1,900 patients, so it’s a large study. Having familiarity with semaglutide, I think it is a solid trial that shows the effectiveness of a higher dose for even greater weight loss.

BU Today: Does semaglutide merit the term “game changer”?

Ivania Rizo: This a first step in moving forward in more aggressive weight loss with medication. The current weight-loss medications we have [achieve] about 4.9 percent to 10 percent weight loss. This study showed 15 percent weight loss, which is going to be significant also for decreasing a person’s comorbidities: diabetes, sleep apnea, hypertension. With surgery, we see about 20 to 30 percent weight loss; 15 percent is still less than we see in surgery, but we’re at least increasing the weight loss we’re able to accomplish [with drugs].

BU Today: Is there a danger in patients saying, “Well, now I’m not going to worry about diet or exercise. You’ve got this game-changing drug”?

Ivania Rizo: Even in this study, they emphasize in the first pages that healthy eating and exercise are the cornerstone to all weight loss and cardiovascular health. In every single weight-loss medication intervention trial I have read, lifestyle modifications are always done for the placebo and intervention group. Pharma-therapy is something that we add to lifestyle interventions. It’s not something that replaces lifestyle interventions.

BU Today: Does insurance cover semaglutide as a diabetic treatment? Are you worried that insurers might not cover it for obesity, given their general refusal to pay for weight-loss medications?

Ivania Rizo: Fortunately, semaglutide is covered. It’s not always the preferred [drug]. BMC has a large percentage of patients who have MassHealth or Medicaid [state and federal health programs for low-income people], and it’s not necessarily the preferred [treatment by insurers] for diabetes. We sometimes have to try other [drugs] and then we can request authorization for semaglutide.

Medicaid and MassHealth do not cover weight-loss medications for solely weight-loss purposes. With private insurances, some do cover weight-loss medications. We should strongly advocate that these medications be covered, given the significant reduction in comorbidities that this study showed—decrease in blood pressure, cholesterol, waist circumference, and improved physical function.

BU Today: You’re not worried about potential negative side effects from the higher dosage that Northwestern used to treat obesity?

Ivania Rizo: The medications are titrated. They start at a low dose, and semaglutide is increased every four weeks to get to your dose of 2.4 [milligrams]. The most common side effects are gastrointestinal—nausea, vomiting, diarrhea, constipation. I tell patients this and to let me know if it’s affecting their quality of life. Then we can increase the dose slower or find something else that works better. The nausea was experienced by 44 percent [of Northwestern subjects], so it’s not uncommon. There are things we can do to help—for example, if patients eat beyond [feeling] full, it’s when they start getting more nausea. There are ways to talk to patients to make sure they know the potential side effects.