Obesity is considered a modern epidemic with the overall numbers of people with excess weight having tripled globally in the last half century. The World Health Organization defines obesity as abnormal or excessive fat accumulation that presents a risk to health. Numerous health issues are linked to obesity which include metabolic diseases like Type 2 Diabetes, high blood pressure, high cholesterol levels; cardiovascular diseases such as heart attacks and heart failure, stroke, disease of the liver and joints (osteoarthritis of some joints), fertility issues and poor psychological health. Obesity may alsohave an adverse impact on other co-morbid conditions. More worryingly, obesity has been linked to certain cancers (breast and endometrial, colorectal, gall bladder and oesophageal cancers) and reduced life expectancy.Diagnosing obesityObesity can be determined by a number of ways, ranging from very high-tech machines that can precisely quantify the amount of fat and lean tissue in the body to the simple weighing scale at home. The two most common ways of detecting obesity in your doctor's office are by calculating the body mass index (BMI) and using a measuring tape to determine waist circumference. BMI, calculated as weight in kilograms divided by the square of height in meters, is an international measure to define varying degrees of obesity.Thresholds for meeting the criteria for obesity based on BMI and waist circumference vary as the risk is deemed higher for certain ethnic groups compared to others. For example; for a Caucasian woman, obesity is defined as a BMI greater than 30 Kg/m² or a waist circumference greater than 88 cm (for a man of the same heritage would be a waist circumference > 102 cm). Normal range of BMI for people from South and Southeast Asia is 18.5 to22.9 Kg/m2. While the thresholds for defining obesity in an Asian population are debated between 25 and 27.5 Kg/m², it is recognised that those alone are not as helpful in identifying those at risk as in the Caucasian polation. Probably more important for South Asians is the waist circumference, indicative of central obesity .with the current consensus of a waist circumference greater than 80 cm for Asian women and 90 cm for an Asian man as carrying higher risk.Call to armsIt is important to address this major public health issue that has been widening at its seams worldwide for the past few decades. The determinants of obesity in most individuals are food habits, level of physical activity and sleep patterns (affected by shift- work). Beyond these modifiable lifestyle factors is the role of genetics and their interaction with the environment, certain medications and imbalance of hormones regulating appetite, food intake and metabolism. The cornerstone of returning to healthy weight is to follow a diet that creates an energy deficit and to achieve physical activity or exercise of around 200 to 300 minutes per week, which can lead to individuals losing modest amount of their body weight. This may not be sufficient or as successful in many who will require help from other measures including surgery and medicines that target abnormal weight gain.Weight loss injectionsInjections for weight loss have skyrocketed in popularity since several influential and famous people have acknowledged using them, ranging from entertainment bigwigs like Oprah Winfrey, Amy Schumer and Whoopi Goldberg, to businessmen like Elon Musk and sportspeople such as Billy Jean King. While speculation has mounted about some famous names in the parallel Indian sphere, no such declaration has come forth as yet. These drugs are nevertheless making waves all over the world and have been touted as one of, if not The, most revolutionary in the history of medicine - by no less than The Economist in a recent edition..It is true because of the wide- ranging benefits they seem to offer people, with 'new' areas of benefits being reported almost regularly, underscoring the fact that obesity has consequences on the health of individuals somewhat beyond our current understanding. More importantly, it would soon be possible to reverse or reduce the impact of obesity with these medicines that are set to arrive in the Indian subcontinent this year.Semaglutide, marketed as Ozempic for people with Type 2 Diabetes and Wegovy for people with obesity, has been approved by the food and drug administration (FDA) for theseindications with the higher dose being approved for obesity than for Type 2 Diabetes. Wegovy is administered via a single-dose prefilled pen, while Ozempic is delivered through a prefilled pen with the option of dialing up a range of doses.Recent times have seen the emergence of a new agent tirzepatide, of which Mounjaro has been approved for Type 2 Diabetes and Zepbound for obesity (permits higher than Mounjaro dose). Tirzepatide is considered to be the most efficacious weight loss drug currently available commercially.Through this article we will learn about the established benefits from using anti-obesity injections for weight loss, benefits that are independent of weight loss and blood glucose control and touch upon the unexpected or emerging health improvements reported to date.Mechanism of actionA group of hormones, known as gut hormones, is manufactured in our body's digestive tract (intestine and pancreas), which act on the pancreas to regulate glucose levels and on the brain to modulate hunger and satiety. Currently available drugs predominantly mimic the action of the gut hormone glucagon-like peptide-1 (GLP-1), while others, including upcoming drugs promote effects of other gut hormones namely, glucose-dependent insulinotropic polypeptide (GIP), glucagon and amylin, in combination or alone. The overarching action of these peptides results in an individual feeling less hungry and more satisfied after a relatively smaller sized meal. These medicines are spectacularly effective in reducing between 5 and 21 per cent of starting weight, which is unprecedented and approaching the success of weight loss surgeries.Health Benefits of Weight loss InjectionsObesity and Type 2 DiabetesAlthough these medicines were primarily developed with the intention for them to be used for the purpose of improving glucose control in Type 2 Diabetes, the significant reduction in body fat has rebranded them as anti-obesity medicines. The quantitative weight loss is relatively more in people with obesity without Type 2 Diabetes compared to those with, and yet the health gains in the latter group are life-changing. Obese people treated with these injections report improved self-esteem and reduced weight- related stigma, enhanced energy levels and mobility.In people with obesity who do not have Type 2 Diabetes, these medications may delay or prevent its onset in close to 80 per cent people with prediabetes. If used early on, they may have protective effects on pancreatic beta cells of people with Type 2 Diabetes, which are essential for insulin production. They improve blood glucose levels directly by promoting insulin production in response to a meal, and indirectly by improving insulin sensitivity and reducing insulin resistance. The end result may be reduction or discontinuation of insulin therapy in some. The improvement in HbA1c, marker of Type 2 Diabetes control, can be up over 2 per cent, which is at par or above some of the medicines approved for treating Type 2 Diabetes.But weight is regained upon stopping weight management medication.Developing and maintaining healthy eating habits and increasing physical activity may help regain less weight and should be pursued alongside taking them.Heart and brain circulation problems Obesity and Type 2 Diabetes affect the heart in two ways, one by accumulating fat in the small blood vessels affecting blood supply to the heart (leading to heart attacks) and the other by impairing the pumping of blood from the heart to the rest of the body (leading to heart failure).Similar blockage of small blood vesselssupplying different parts of the brain can result in paralysis or stroke. These drugshave been proven to lower the risk of heart attack, stroke, and death due to these disorders in obese people with or without Type 2 Diabetes by up to 20 per cent. Theyalso improve wellbeing and functionality of people who experience significant limitation due to symptoms of heart failure..eliminate waste from the body. These medicines reduce protein leak in the urine, thus providing a protective effect on them.Fatty LiverFatty liver, a condition characterized by accumulation of excess fat in the liver, seen in obesity and Type 2 Diabetes, over time infiltrates healthy liver and may result in scarring of the liver (cirrhosis) ultimately causing liver failure. These drugs have shown significant reduction in fat content of the liver but very recently one of them has shown resolution of less severe degrees of cirrhosis, which is revolutionary for people with this condition.Sleep ApnoeaObesity contributes to sleep apnea by causing increased pressure on the upper airways. This pressure may result in partial obstruction leading to its other nameBloodpressureObesity can cause high blood pressure (hypertension), which increases the risk of disability and death. Leptin hormone released from the fat tissue sends signals to a part of the brain called the hypothalamus regarding the state of body's energy reserves. Raised leptin levels in obesity may be involved in the development of hypertension, which often accompanies both obesity and Type 2 Diabetes. These drugs lead to a small improvement in blood pressure having a positive impact on the heart and kidneys, as well as reduced requirement of blood pressure medications.Diabetic kidney diseaseLong duration of, and inadequately controlled, Type 2 Diabetes has a negative effect on the filtering function of the kidneys which exists to salvage protein and Obstructive Sleep Apnoea or OSA. OSA may lead to heart failure and other health problems. People who have mild to moderate degree of sleep apnoea along with obesity achieve significant benefit from losing weight through using these agents.Fertility problemsExcess weight, particularly excess abdominal fat, is linked to insulin resistance (when the body has to produce more insulin to keep blood sugar levels normal). Obesity is associated with irregular menstrual cycles, which in turn reduces fertility. It is speculated that these peptides restore fertility by addressing hormone imbalance resulting from obesity. In men too, obesity may lead to lower fertility through mechanisms not clearly understood as yet.Women with polycystic ovary syndrome, a condition often seen in presence of obesity, benefit from improvement in menstrual cycles and in natural conception rates when treated with these medicines. In fact, the term “Ozempic babies” has been coined for the children of women taking Ozempic, who got unexpectedly pregnant having struggled to do so for years prior to that, often coinciding with significant weight loss. The drug is also under investigation for improving sperm production in obese men.OsteoarthritisObesity affects more than one third of Americansandrepresentsoneofthe biggest risk factors for developing osteoarthritis.Byputtingadditionalstress on weight-bearing joints and increasing inflammation, obesity can worsen osteoarthritis. For every additional pound of weight, your knees gain three to four added pounds of stress that can pressure cartilageto break down. As a result, individuals who are obese are more likely to need joint replacement. In addition to the increased stress on your joints, extra body fat has been shown to increase inflammation, a common cause of osteoarthritic pain.These drugs have demonstrated benefit in the less severe cases of knee arthritis by reducing their chances of progressing to require knee replacement, and improve mobility..Alzheimer's disease and Parkinson's diseaseEarly signs indicate the possibility of amelioration or delay in the development of Alzheimer's disease, an incurable memory disorder which can only worsen with time, in people taking this class of medicines, giving it a potential neuroprotective role.The drug's neuroprotective role is being explored in another disabling neurological disease in which people experience mobility problems and weakness of muscles that help us breathe and cough. People treated with these drugs in Type 2 Diabetes trials appear to be protected from the changes seen in Parkinson's disease resulting in delay of or improvement in symptoms.Substance misuse/ addiction and Other Emerging areas of BenefitStudies have reported reduction in smoking and alcohol consumption in people taking these medicines. Furthermore, people taking these drugs were noted to use significantly lower doses of painkiller medicines called Opiates, which carry a high potential for addiction. These peptides may therefore come to be used in substance use or addiction.Their roles in preventing infections and in delaying ageing are being explored among a range of areas about which little verifiable detail is available at this stage.Side-effectsThe peptides work by slowing down the passage of food through the stomach, which some have called stomach paralysis, but that is an inaccurate representation of facts. Common, usually transient, side effects of the injections are nausea, vomiting, diarrhea, and constipation. They are experienced usually in the early treatment days and improve after the initial phase. Slow escalation to its maximum effective dose may be required for resolution of the symptoms, and a few people might need a relatively lower dose. Discontinuation of the medicine due to side effects is uncommon.These medicines by themselves do not cause low blood sugar (hypoglycaemia) unlesstheyarecombinedwithotherType2 Diabetes treatments that lower glucose levels, particularly insulin or a class of medicines called sulphonylureas. A specialist would adjust the Type 2 Diabetes medicine doses when initiating these peptides and monitor progress carefully to avoid the chances of hypoglycaemia.Significant amount of weight is lost overall on commencing these drugs and the short time taken to achieve this result causes what has become known as the “Ozempic face”. The change results from the loss of facial tissue including collagen, fat and muscle, which also accompanies naturally ageing. As this occurs over a short period of time and in younger individuals, the “early ageing” has caused concern amongst treating clinicians and users, with some resorting to plastic surgery..Situations where these medicines should not be used or used with caution• Medullary thyroid cancer (MTC): These peptides must not be given to people with this rare condition, either occuring alone or as part of multiple endocrine neoplasia syndrome type 2 or if their blood relations have the condition.Although no human cases of MTC have been found anew in many years of use, pre-clinical studies suggest a link with the condition and so they must be avoided in this situation.• People with a history of pancreatitis: There is a risk of reactivating pancreatitis in people who have had it, and in rare instances new cases may develop for which vigilance is advised, hence the importance of supervision by an experienced, qualified doctor in this field.• Type 1 Diabetes: These medicines are currently not recommended for use in people with Type 1 Diabetes.• Women who are pregnant or breastfeeding: Due to lack of adequate safety information regarding use in these women, it should be avoided altogether or used cautiously under the careful supervision of a specialist.• People with mental health disorders: These drugs must be considered by experienced clinicians and with utmost care in people diagnosed with anxiety, depression and especially those at risk of suicide as their use may make the underlying condition worse in some people with severe disease.• Eye conditions: Within the last month, a study has been reported that raises the possibility of worsening vision to the point of blindness in some patients treated with these injections. As this study was published in the days before this article was being sent to print, the information available is limited other than to say that this occurred in an extremely small proportion of people with Type 2 Diabetes treated with the peptide.Availability in India and Around the WorldThe Government of India has approved exenatide, lixisenatide, liraglutide, semaglutide and most recently, tirzepatide. There is limited availability of liraglutide in some parts of India, but others are yet to arrive in the Indian market. Part of the delay has resulted from unregulated use of these medicines by people without specialist supervision, some of whom have had disastrous consequences including death, and hence the importance of consulting an Endocrinologist cannot be overemphasized.GLP 1 based drugs approved by the FDA (USA) and available currently for use include once-daily preparations like exenatide (Byetta), lixisenatide (Adlyxin), and liraglutide (Victoza/Saxenda), and once- weekly preparations like albiglutide (Tanzeum), dulaglutide (Trulicity), semaglutide (Ozempic/Wegovy). Dual GLP- 1/GIP agonist tirzepatide (Mounjaro/Zepbound) is also a once weekly preparation and is the most potent medicine for weight loss to date.Cagrilintide harnesses the effects of compound Amylin and is also a once- weekly medicine.Semaglutide is the only medicine of this class that exists in a tablet form (Rybelsus) taken once-daily while all the other medicines are to be injected under the skin on a weekly basis using a drug-specific injector pen. Rybelsus is currently available in India. Other hormone effects are being harnessed in research studies and so more drugs may hit the market in the coming years.Dr Ragini Bhake is a Consultant Endocrinologist. Dr Bhake has completed her endocrinology degree and PhD in neuroendocrinology from the UK following her MBBS in India. She has a decade of experience in the field as a Consultant across both countries
Obesity is considered a modern epidemic with the overall numbers of people with excess weight having tripled globally in the last half century. The World Health Organization defines obesity as abnormal or excessive fat accumulation that presents a risk to health. Numerous health issues are linked to obesity which include metabolic diseases like Type 2 Diabetes, high blood pressure, high cholesterol levels; cardiovascular diseases such as heart attacks and heart failure, stroke, disease of the liver and joints (osteoarthritis of some joints), fertility issues and poor psychological health. Obesity may alsohave an adverse impact on other co-morbid conditions. More worryingly, obesity has been linked to certain cancers (breast and endometrial, colorectal, gall bladder and oesophageal cancers) and reduced life expectancy.Diagnosing obesityObesity can be determined by a number of ways, ranging from very high-tech machines that can precisely quantify the amount of fat and lean tissue in the body to the simple weighing scale at home. The two most common ways of detecting obesity in your doctor's office are by calculating the body mass index (BMI) and using a measuring tape to determine waist circumference. BMI, calculated as weight in kilograms divided by the square of height in meters, is an international measure to define varying degrees of obesity.Thresholds for meeting the criteria for obesity based on BMI and waist circumference vary as the risk is deemed higher for certain ethnic groups compared to others. For example; for a Caucasian woman, obesity is defined as a BMI greater than 30 Kg/m² or a waist circumference greater than 88 cm (for a man of the same heritage would be a waist circumference > 102 cm). Normal range of BMI for people from South and Southeast Asia is 18.5 to22.9 Kg/m2. While the thresholds for defining obesity in an Asian population are debated between 25 and 27.5 Kg/m², it is recognised that those alone are not as helpful in identifying those at risk as in the Caucasian polation. Probably more important for South Asians is the waist circumference, indicative of central obesity .with the current consensus of a waist circumference greater than 80 cm for Asian women and 90 cm for an Asian man as carrying higher risk.Call to armsIt is important to address this major public health issue that has been widening at its seams worldwide for the past few decades. The determinants of obesity in most individuals are food habits, level of physical activity and sleep patterns (affected by shift- work). Beyond these modifiable lifestyle factors is the role of genetics and their interaction with the environment, certain medications and imbalance of hormones regulating appetite, food intake and metabolism. The cornerstone of returning to healthy weight is to follow a diet that creates an energy deficit and to achieve physical activity or exercise of around 200 to 300 minutes per week, which can lead to individuals losing modest amount of their body weight. This may not be sufficient or as successful in many who will require help from other measures including surgery and medicines that target abnormal weight gain.Weight loss injectionsInjections for weight loss have skyrocketed in popularity since several influential and famous people have acknowledged using them, ranging from entertainment bigwigs like Oprah Winfrey, Amy Schumer and Whoopi Goldberg, to businessmen like Elon Musk and sportspeople such as Billy Jean King. While speculation has mounted about some famous names in the parallel Indian sphere, no such declaration has come forth as yet. These drugs are nevertheless making waves all over the world and have been touted as one of, if not The, most revolutionary in the history of medicine - by no less than The Economist in a recent edition..It is true because of the wide- ranging benefits they seem to offer people, with 'new' areas of benefits being reported almost regularly, underscoring the fact that obesity has consequences on the health of individuals somewhat beyond our current understanding. More importantly, it would soon be possible to reverse or reduce the impact of obesity with these medicines that are set to arrive in the Indian subcontinent this year.Semaglutide, marketed as Ozempic for people with Type 2 Diabetes and Wegovy for people with obesity, has been approved by the food and drug administration (FDA) for theseindications with the higher dose being approved for obesity than for Type 2 Diabetes. Wegovy is administered via a single-dose prefilled pen, while Ozempic is delivered through a prefilled pen with the option of dialing up a range of doses.Recent times have seen the emergence of a new agent tirzepatide, of which Mounjaro has been approved for Type 2 Diabetes and Zepbound for obesity (permits higher than Mounjaro dose). Tirzepatide is considered to be the most efficacious weight loss drug currently available commercially.Through this article we will learn about the established benefits from using anti-obesity injections for weight loss, benefits that are independent of weight loss and blood glucose control and touch upon the unexpected or emerging health improvements reported to date.Mechanism of actionA group of hormones, known as gut hormones, is manufactured in our body's digestive tract (intestine and pancreas), which act on the pancreas to regulate glucose levels and on the brain to modulate hunger and satiety. Currently available drugs predominantly mimic the action of the gut hormone glucagon-like peptide-1 (GLP-1), while others, including upcoming drugs promote effects of other gut hormones namely, glucose-dependent insulinotropic polypeptide (GIP), glucagon and amylin, in combination or alone. The overarching action of these peptides results in an individual feeling less hungry and more satisfied after a relatively smaller sized meal. These medicines are spectacularly effective in reducing between 5 and 21 per cent of starting weight, which is unprecedented and approaching the success of weight loss surgeries.Health Benefits of Weight loss InjectionsObesity and Type 2 DiabetesAlthough these medicines were primarily developed with the intention for them to be used for the purpose of improving glucose control in Type 2 Diabetes, the significant reduction in body fat has rebranded them as anti-obesity medicines. The quantitative weight loss is relatively more in people with obesity without Type 2 Diabetes compared to those with, and yet the health gains in the latter group are life-changing. Obese people treated with these injections report improved self-esteem and reduced weight- related stigma, enhanced energy levels and mobility.In people with obesity who do not have Type 2 Diabetes, these medications may delay or prevent its onset in close to 80 per cent people with prediabetes. If used early on, they may have protective effects on pancreatic beta cells of people with Type 2 Diabetes, which are essential for insulin production. They improve blood glucose levels directly by promoting insulin production in response to a meal, and indirectly by improving insulin sensitivity and reducing insulin resistance. The end result may be reduction or discontinuation of insulin therapy in some. The improvement in HbA1c, marker of Type 2 Diabetes control, can be up over 2 per cent, which is at par or above some of the medicines approved for treating Type 2 Diabetes.But weight is regained upon stopping weight management medication.Developing and maintaining healthy eating habits and increasing physical activity may help regain less weight and should be pursued alongside taking them.Heart and brain circulation problems Obesity and Type 2 Diabetes affect the heart in two ways, one by accumulating fat in the small blood vessels affecting blood supply to the heart (leading to heart attacks) and the other by impairing the pumping of blood from the heart to the rest of the body (leading to heart failure).Similar blockage of small blood vesselssupplying different parts of the brain can result in paralysis or stroke. These drugshave been proven to lower the risk of heart attack, stroke, and death due to these disorders in obese people with or without Type 2 Diabetes by up to 20 per cent. Theyalso improve wellbeing and functionality of people who experience significant limitation due to symptoms of heart failure..eliminate waste from the body. These medicines reduce protein leak in the urine, thus providing a protective effect on them.Fatty LiverFatty liver, a condition characterized by accumulation of excess fat in the liver, seen in obesity and Type 2 Diabetes, over time infiltrates healthy liver and may result in scarring of the liver (cirrhosis) ultimately causing liver failure. These drugs have shown significant reduction in fat content of the liver but very recently one of them has shown resolution of less severe degrees of cirrhosis, which is revolutionary for people with this condition.Sleep ApnoeaObesity contributes to sleep apnea by causing increased pressure on the upper airways. This pressure may result in partial obstruction leading to its other nameBloodpressureObesity can cause high blood pressure (hypertension), which increases the risk of disability and death. Leptin hormone released from the fat tissue sends signals to a part of the brain called the hypothalamus regarding the state of body's energy reserves. Raised leptin levels in obesity may be involved in the development of hypertension, which often accompanies both obesity and Type 2 Diabetes. These drugs lead to a small improvement in blood pressure having a positive impact on the heart and kidneys, as well as reduced requirement of blood pressure medications.Diabetic kidney diseaseLong duration of, and inadequately controlled, Type 2 Diabetes has a negative effect on the filtering function of the kidneys which exists to salvage protein and Obstructive Sleep Apnoea or OSA. OSA may lead to heart failure and other health problems. People who have mild to moderate degree of sleep apnoea along with obesity achieve significant benefit from losing weight through using these agents.Fertility problemsExcess weight, particularly excess abdominal fat, is linked to insulin resistance (when the body has to produce more insulin to keep blood sugar levels normal). Obesity is associated with irregular menstrual cycles, which in turn reduces fertility. It is speculated that these peptides restore fertility by addressing hormone imbalance resulting from obesity. In men too, obesity may lead to lower fertility through mechanisms not clearly understood as yet.Women with polycystic ovary syndrome, a condition often seen in presence of obesity, benefit from improvement in menstrual cycles and in natural conception rates when treated with these medicines. In fact, the term “Ozempic babies” has been coined for the children of women taking Ozempic, who got unexpectedly pregnant having struggled to do so for years prior to that, often coinciding with significant weight loss. The drug is also under investigation for improving sperm production in obese men.OsteoarthritisObesity affects more than one third of Americansandrepresentsoneofthe biggest risk factors for developing osteoarthritis.Byputtingadditionalstress on weight-bearing joints and increasing inflammation, obesity can worsen osteoarthritis. For every additional pound of weight, your knees gain three to four added pounds of stress that can pressure cartilageto break down. As a result, individuals who are obese are more likely to need joint replacement. In addition to the increased stress on your joints, extra body fat has been shown to increase inflammation, a common cause of osteoarthritic pain.These drugs have demonstrated benefit in the less severe cases of knee arthritis by reducing their chances of progressing to require knee replacement, and improve mobility..Alzheimer's disease and Parkinson's diseaseEarly signs indicate the possibility of amelioration or delay in the development of Alzheimer's disease, an incurable memory disorder which can only worsen with time, in people taking this class of medicines, giving it a potential neuroprotective role.The drug's neuroprotective role is being explored in another disabling neurological disease in which people experience mobility problems and weakness of muscles that help us breathe and cough. People treated with these drugs in Type 2 Diabetes trials appear to be protected from the changes seen in Parkinson's disease resulting in delay of or improvement in symptoms.Substance misuse/ addiction and Other Emerging areas of BenefitStudies have reported reduction in smoking and alcohol consumption in people taking these medicines. Furthermore, people taking these drugs were noted to use significantly lower doses of painkiller medicines called Opiates, which carry a high potential for addiction. These peptides may therefore come to be used in substance use or addiction.Their roles in preventing infections and in delaying ageing are being explored among a range of areas about which little verifiable detail is available at this stage.Side-effectsThe peptides work by slowing down the passage of food through the stomach, which some have called stomach paralysis, but that is an inaccurate representation of facts. Common, usually transient, side effects of the injections are nausea, vomiting, diarrhea, and constipation. They are experienced usually in the early treatment days and improve after the initial phase. Slow escalation to its maximum effective dose may be required for resolution of the symptoms, and a few people might need a relatively lower dose. Discontinuation of the medicine due to side effects is uncommon.These medicines by themselves do not cause low blood sugar (hypoglycaemia) unlesstheyarecombinedwithotherType2 Diabetes treatments that lower glucose levels, particularly insulin or a class of medicines called sulphonylureas. A specialist would adjust the Type 2 Diabetes medicine doses when initiating these peptides and monitor progress carefully to avoid the chances of hypoglycaemia.Significant amount of weight is lost overall on commencing these drugs and the short time taken to achieve this result causes what has become known as the “Ozempic face”. The change results from the loss of facial tissue including collagen, fat and muscle, which also accompanies naturally ageing. As this occurs over a short period of time and in younger individuals, the “early ageing” has caused concern amongst treating clinicians and users, with some resorting to plastic surgery..Situations where these medicines should not be used or used with caution• Medullary thyroid cancer (MTC): These peptides must not be given to people with this rare condition, either occuring alone or as part of multiple endocrine neoplasia syndrome type 2 or if their blood relations have the condition.Although no human cases of MTC have been found anew in many years of use, pre-clinical studies suggest a link with the condition and so they must be avoided in this situation.• People with a history of pancreatitis: There is a risk of reactivating pancreatitis in people who have had it, and in rare instances new cases may develop for which vigilance is advised, hence the importance of supervision by an experienced, qualified doctor in this field.• Type 1 Diabetes: These medicines are currently not recommended for use in people with Type 1 Diabetes.• Women who are pregnant or breastfeeding: Due to lack of adequate safety information regarding use in these women, it should be avoided altogether or used cautiously under the careful supervision of a specialist.• People with mental health disorders: These drugs must be considered by experienced clinicians and with utmost care in people diagnosed with anxiety, depression and especially those at risk of suicide as their use may make the underlying condition worse in some people with severe disease.• Eye conditions: Within the last month, a study has been reported that raises the possibility of worsening vision to the point of blindness in some patients treated with these injections. As this study was published in the days before this article was being sent to print, the information available is limited other than to say that this occurred in an extremely small proportion of people with Type 2 Diabetes treated with the peptide.Availability in India and Around the WorldThe Government of India has approved exenatide, lixisenatide, liraglutide, semaglutide and most recently, tirzepatide. There is limited availability of liraglutide in some parts of India, but others are yet to arrive in the Indian market. Part of the delay has resulted from unregulated use of these medicines by people without specialist supervision, some of whom have had disastrous consequences including death, and hence the importance of consulting an Endocrinologist cannot be overemphasized.GLP 1 based drugs approved by the FDA (USA) and available currently for use include once-daily preparations like exenatide (Byetta), lixisenatide (Adlyxin), and liraglutide (Victoza/Saxenda), and once- weekly preparations like albiglutide (Tanzeum), dulaglutide (Trulicity), semaglutide (Ozempic/Wegovy). Dual GLP- 1/GIP agonist tirzepatide (Mounjaro/Zepbound) is also a once weekly preparation and is the most potent medicine for weight loss to date.Cagrilintide harnesses the effects of compound Amylin and is also a once- weekly medicine.Semaglutide is the only medicine of this class that exists in a tablet form (Rybelsus) taken once-daily while all the other medicines are to be injected under the skin on a weekly basis using a drug-specific injector pen. Rybelsus is currently available in India. Other hormone effects are being harnessed in research studies and so more drugs may hit the market in the coming years.Dr Ragini Bhake is a Consultant Endocrinologist. Dr Bhake has completed her endocrinology degree and PhD in neuroendocrinology from the UK following her MBBS in India. She has a decade of experience in the field as a Consultant across both countries
