Helping Prevent Weight Gain After Discontinuation of GLP-1 Receptor Agonists

Weight loss medications have become extremely popular in recent years, mainly because they actually work. Patients using glucagonoid peptide 1 (GLP-1) receptor agonists, such as liraglutide, semaglutide and tirzepatide — the latter also a glucose-dependent insulinotropic polypeptide (GIP) agonist — may lose 10%, 20% or even 25% of their body weight.

However, if these patients stop taking the GLP-1 receptor agonist, they tend to regain much of that weight within a year, according to studies.

“These drugs act biologically in the body, leading to changes in appetite,” said endocrinologist Dr. Robert Kushner, a specialist in obesity medicine and professor linked to Northwestern University Feinberg School of Medicine, in the United States. “Therefore, when the medicine is withdrawn, the disease returns.”

Continuous treatment may seem like the obvious solution, but the reality is not so simple. In many cases, high costs, supply gaps and lack of coverage by health plans can make these medicines inaccessible.

Often, “insurers tell patients that they will no longer cover GLP-1 receptor agonists for the treatment of obesity,” said Dr. Carolyn Bramante, MD, a master of public health and assistant professor at University of Minnesota Medical School, In the USA. She also sees patients at the clinic M Health Fairviewspecialized in weight control.

Other barriers are the side effects of medications, such as nausea, diarrhea, dyspepsia and vomiting. Furthermore, some patients simply do not want to take a medication for life, choosing to take risks and try to maintain weight loss without pharmacological treatment.

If your patient needs to stop using a GLP-1 receptor agonist or wishes to stop taking the medication, here are some tips on how to help them.

Find out what’s behind the desire to stop treatment. Talk to the patient and ask them to help you understand the situation, suggested Dr. Jaime Almandoz, MD, associate professor of internal medicine and clinical director of the Patient’s Weight-Related Wellness Program. University of Texas Southwestern Medical Center, In the USA. Sometimes, the patient or their family members are concerned about aspects related to the safety of the medication, said Dr. Jaime. “They may be concerned about the risks [do tratamento] and maybe they didn’t have the opportunity to ask questions.” Dr. Jaime always analyzes drug safety data and reports that studies show that, on average, patients regain two-thirds of the weight lost within a year. You are not trying to persuade them, but rather to enable them to make an informed choice.

Don’t let prejudice affect therapeutic decisions. Patients taking GLP-1 receptor agonists often ask, “How long will I have to take this medicine?” The reason behind this question is that “we tend to believe that [a obesidade] is not a pathological state, but a character flaw,” said Dr. Sean Wharton, MD, PhD in Pharmacology and Clinical Director at Wharton Medical Clinic, in Canada, specializing in weight control. Remind your patient that obesity is not a personal flaw, but a complex mix of genetic and biological factors.

Guide about the basic biological aspects of obesity. Science shows that when we lose weight, our body reacts, trying to return to a state of greater fat mass. Changes in neurohormones, gut hormones, satiety mechanisms, metabolism and muscle function converge to promote the recurrence of weight gain, said Dr. Jaime. To explain these processes to patients, he compares fat gain to the act of depositing money into a savings account. “When we try to lose weight, it’s not as simple as withdrawing money,” he tells patients. “It’s almost as if the money we put into savings is now tied up in investments and can’t be redeemed as easily.”

Prepare patients for an increase in appetite. When patients stop taking the GLP-1 receptor agonist, hunger and food cravings tend to increase. “I explain that the medications mimic a hormone released by the intestine when it ‘senses’ that we have eaten,” said Dr. Jaime. This signals to the brain and body that there is food in the gastrointestinal tract, reducing appetite and cravings for food. Ask patients what hunger and satiety feel like when using the medication, Dr. Jaime suggested. “Many will say they have little hunger and few cravings, and that they currently feel indifference towards food,” he said. These questions can help patients become more aware of the effects of the GLP-1 receptor agonist. “This provides a clearer dialogue if these medications are discontinued,” said Dr. Jaime.

Help patients’ bodies adjust. “If possible, reduce the dose slowly to avoid a large [efeito] rebound in hunger,” said Dr. Carolyn. If your patient has time (let’s say they received a letter from their health plan that their drug coverage will be suspended in three months), use this period to gradually reduce the dose to the lowest possible level before withdrawing completely. The slower and more gradual the suspension, the better. Dr. Jaime evaluates patients at four to eight week intervals. If individuals are maintaining weight, he considers decreasing the dose again and continuing the reduction at follow-up visits.

Replace one intervention with another. In general, keeping the weight off requires some intervention, Dr. Sean said. “However, this intervention does not need to be the same one that led to weight loss [inicial].” If the patient cannot continue the GLP-1 receptor agonist, consider using an alternative medication, cognitive behavioral therapy, or a combination of the two. In some cases, when patients lose coverage on GLP-1 receptor agonists, Dr. Carolyn prescribes an older, less expensive medication, such as phentermine, topiramate, or metformin. Additionally, in some situations, insurers who do not cover GLP-1 receptor agonists (such as Medicarehealth insurance paid by the U.S. federal government to elderly or vulnerable patients) covers bariatric surgery, which may be an option depending on the patient’s body mass index, general health and comorbidities, Dr. Jaime said.

Create a ‘habit template’. Typically, Dr. Robert asks patients who have successfully lost weight to keep a journal of everything they are doing in order to support their efforts. The doctor asks them to describe how they plan their diet, what types of foods they eat, how much and when. Additionally, it also asks about physical activity, exercise patterns, and sleep. He then records all these habits in a list and gives a printed version to the patient before the end of the consultation. “That’s your model,” he says. “That’s what you’re going to try to maintain as best you can, because that’s what works in your case.”

Prescribe physical exercises. “Increased exercise is typically not effective in initial weight loss, but is important for maintaining weight loss,” says Dr. Carolyn. Instruct patients to start immediately, preferably while they are still taking the medication. In a study published in February 2024, patients taking liraglutide (Saxenda) and exercised four days a week were much more likely to maintain their weight after stopping the medication than those who did not exercise. (The study was partially funded by Novo Nordisk Foundationa philanthropic organization linked to New Nordiskmanufacturer of Saxenda and semaglutide [Ozempic e Wegovy].) By establishing strong exercise-related habits while taking the medication, these individuals were able to maintain higher levels of physical activity after they stopped taking the GLP-1 receptor agonist. Ask the patient to identify someone or something to help them follow the plan, “whether it’s finding a coach or committing to a friend, family member, or yourself through daily journaling,” Dr. Robert said. Learn more about prescribing exercise for your patients.

Help them create a supportive ‘microenvironment’. Dr. Robert often asks patients which of the recommended weight loss eating habits are hardest to follow: eating more vegetables? Cut out ultra-processed, fatty foods, fast food and/or sugary drinks? Depending on the patient’s responses, he tries to recommend strategies—perhaps going meatless a few days a week or keeping tempting foods out of the house. “If the patient stops taking the medication, foods may become more appealing and they may not feel as satisfied eating less,” said Dr. Robert. “Make sure that what we call the microenvironment, that is, the home environment, is full of healthy foods.”

Use multidisciplinary experience to your advantage. Obesity is a complex and multifactorial disease, so call in reinforcements. “When I see someone, I’m always evaluating which other team members could help them,” said Dr. Robert. If the patient does not have good nutritional knowledge, the doctor refers him or her to a nutritionist. If there are problems related to self-blame, low self-esteem and emotional eating, the individual is referred to a psychologist. This can make a difference. A 2023 study showed that patients who lost weight and received support from professionals such as fitness trainers, nutritionists, and psychologists regained less weight over two years compared to those who did not receive this same assistance.

Reassure patients and let them know that you will help them no matter what. Ask patients to return one month after stopping the medication or to contact you sooner if they gain 5 pounds. Patients who stop taking a GLP-1 receptor agonist often report that they are less satisfied when eating or that they think about food more. It is at this point that Dr. Robert asks if they want to go back to taking the medication or would they prefer to focus on other strategies. Sometimes patients who gain weight become embarrassed and postpone follow-up appointments. If this happens, embrace these individuals and tell them that all chronic illnesses come and go. “I constantly remind patients that I am here to help them and that there are many tools or resources that will help them,” the doctor said. “Furthermore, I seek to dispel the thought that it is somehow their fault.”

Dr. Robert Kushner reported serving as a member of the advisory board or consultant at Novo Nordisk, WeightWatchers, Eli Lilly and Company, Boehringer Ingelheim, Structure Therapeutics and Altimmune. He added that he does not own shares in any of these companies nor participate in any speaker groups. Dr. Jaime Almandoz reported serving as a member of the advisory board of Novo Nordisk, Boehringer Ingelheim and Eli Lilly and Company. Dr. Sean Wharton reported serving as an advisory board member and receiving compensation for academic lectures and clinical research from Novo Nordisk, Eli Lilly and Company, Boehringer Ingelheim, Amgen, Regeneron and BioHaven.

This content was originally published on Medscape