Parallel trends in diabetes and obesity have led clinicians to think about these metabolic disorders as 2 parts of a whole, calling the umbrella condition “diabesity” (obesity-related diabetes). Diabesity is quickly transforming into a global health crisis that is no longer limited to developed countries. 
 
Existing guidelines do not address optimal medical management of diabesity. A review article published in Current Diabetes Reports discusses current therapy options.
 
Diabesity’s pathogenesis is complex and involves neurochemical, genetic, inflammatory, and lifestyle factors. To best treat these patients, pharmacists must balance adequate glycemic control with the risk of further weight gain. 
 
The authors’ recommendations include the following:
 
■ Clinicians should reserve insulin—which is anabolic in nature—for episodes requiring rapid glycemic control, or when diabesity is refractory.
 
■ Metformin is the first-line option for all patients with diabesity. It has a moderate weight benefit, and is associated with improvements in comorbid conditions.
 
■ Glucagon-like peptide-1 receptor agonists have the greatest weight loss benefit and offer improvements in comorbid conditions. Despite initial concerns of pancreatitis, high-dose liraglutide (3 mg daily, now FDA approved) is safe and can help some patients achieve weight loss of more than 15%.
 
■ Dipeptidyl peptidase-4 inhibitors and sodium glucose co-transporter 2 inhibitors are effective oral agents for reducing HbA1c without weight gain.
 
■ Clinicians should avoid thiazolidinedione and sulfonylureas as first line due to associated weight gain. They may be useful as adjunct in refractory patients when combined with weight loss interventions.
 
■ Insulin-metformin therapy has insulin-sparing effect, and is associated with significantly less weight gain than insulin alone. 
 
■ Metformin may be used with GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT-2 inhibitors.
 
■ GLP-1 receptor agonists and SGLT-2 inhibitors have synergistic mechanisms of action that help mitigate the adverse metabolic effects of one another. 
 
■ The anti-obesity drugs phentermine/topiramate ER, orlistat, and lorcaserin can help patients reduce body weight by 5% when coupled with lifestyle modifications. 
 
■ Clinicians need to individualize glycemic control targets with consideration of the patient’s age, comorbidities, preferences, and long-term goals. 
 
Patients who repeatedly fail to improve glycemic control and weight may ultimately become candidates for bariatric surgery, which is the most promising treatment modality for diabesity. 
 
Reference
 
Pappachan JM, Viswanath AK. Medical management of diabesity: Do we have
realistic targets? Curr Diab Rep. 2017 Jan;17(1):4.