CEimpact Podcast

Recent Updates on GLP-1 Therapies

• CEimpact

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 46:34

GLP‑1 receptor agonists continue to generate clinical and media buzz, with new formulations, new approvals, and expanding areas of research. This course explores key updates, including the FDA approval of the first oral GLP‑1 for chronic weight management and ongoing investigations into GLP‑1 therapies for conditions beyond diabetes and obesity. You will gain a timely overview of recent developments in GLP‑1s and how pharmacists can anticipate and support their evolving role in patient care.

HOST
Rachel Maynard, PharmD
GameChangers Podcast Host and Clinical Editor, CEimpact
Lead Editor, Pyrls

GUEST
Christine Schumacher, PharmD, BCPS, BCACP, BCCP, BC-ADM, CDCES, FCCP
Professor, Pharmacy Practice and Clinical Pharmacist
Midwestern University


GET CE FOR THIS LISTENING!
The GameChangers Clinical Update Series for Pharmacists delivers 52 expert-led podcast episodes and 30+ hours of clinically actionable continuing education, all for a one-time purchase of just $99—that’s less than $3 per hour for high-impact learning you can apply immediately in practice. Click here to enroll. 


PRACTICE RESOURCE
Receive the exclusive Practice Resource to use as a reference guide for this episode by purchasing the GameChangers Clinical Update Series.

 
CPE REDEMPTION
This course is accredited for continuing pharmacy education! Click the link below that applies to you to take the exam and evaluation to claim credit:


CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Summarize recent regulatory and clinical updates related to GLP‑1 receptor agonists, including new formulations.
2. Describe emerging areas of research into the use of GLP‑1 therapies beyond diabetes and obesity treatment.

Rachel Maynard has no relevant financial relationships with ineligible companies to disclose.

 Christie Schumacher is a speaker for and is on the advisory board for Abbott. All relevant financial relationships have been mitigated.

0.1 CEU/1.0 Hr
UAN: 0107-0000-26-081-H01-P
Initial release date: 3/9/2026
Expiration date: 3/9/2027
Additional CPE details can be found here.

Follow CEimpact on Social Media:
LinkedIn
Instagram

Welcome And CE Credit

SPEAKER_02

Here on Game Changers, we're all about helping you stay ahead of pharmacy practice. But why stop at listening? You can earn CE credit for this episode and hundreds more by visiting CEimpact.com and logging into your account or creating a new one. Get credit, get inspired, and make your learning count. Hey CE Impact subscribers! Welcome to the Game Changers Clinical Update Podcast. I'm your host, Rachel Maynard. And today we'll be chatting about GLP1 agonists or glucagon-like peptide one receptor agonists, but much easier to say GLP1s. So these GLP1s continue to be a really hot topic among clinicians, patients, and the media. Seems like every day there's a new headline about these meds. So on today's podcast, we're going to chat about some of the latest updates that are impacting our patients and our practices. And to help us get up to speed on some of those recent developments and what pharmacists need to know, I'm very excited to introduce Dr. Christy Schumacher as our expert guest today. So welcome, Christy. Thank you. Glad to be here. Excellent. And Christina, you've got a lot of experience in this area. So maybe you could share a little bit about your background and your current role and why you're interested in this topic with our listeners.

SPEAKER_00

Yeah, absolutely. So I have been working now for about, I guess, 16 or 17 years. I work at Midwestern University's College of Pharmacy in Downers Grove, Illinois. I'm also a clinical pharmacist at Northwestern Medicine. And for the entirety of my career, I've actually been an ambulatory care pharmacist working in primary care clinics, first specializing in cardiology and then branching into diabetes. So a lot of CKM type management. And so in general, helping people with diabetes, helping people with cardiovascular disease. And really now we're seeing GLP1s be a game changer for everyone, especially people with diabetes, people with obesity or that are overweight. So they've been great to work with in clinical practice. We have new tools coming out all the time to really help us take better care of patients. So I use a lot of these in clinical practice, and I'm really excited to be here today to share some knowledge and what I've learned.

SPEAKER_02

Excellent. Yeah, I'm super excited to hear your best practices and lessons learned because I'm sure you've got a lot of them to share. You know, you mentioned an acronym there, CKM, and I'm not sure everyone's familiar with that. So could you, I think it ties in well with our discussion. So if you wouldn't mind just explaining that for those who might not be familiar.

SPEAKER_00

Absolutely. So cardiovascular kidney metabolic syndrome. So it's a new term that was created in 2023 by the American Heart Association. They released a presidential advisory. So if you're not familiar, I'd recommend just doing a search for the 2023 presidential advisory on C CAM syndrome. But really, it talks about starting early with stage one C CAM, just being people with overweight or obesity, and starting to manage early. And that would be, of course, where GLP1s might fit play a role. And in preventing the progression of cardiovascular disease, preventing the progression to diabetes and other chronic conditions. So it really does start to basically encourage earlier therapy, earlier interventions to help keep people more healthy.

Oral Semaglutide For Weight Loss

SPEAKER_02

Excellent. Well, like I say, I that ties in so well. And it is this, it's just so interesting how diabetes management has evolved, you know, from beyond focusing on glucose and this whole cardiometabolic, that CKM concept is just something that I think we're all still maybe wrapping our heads around a little bit. So I'm really glad you clarified that. But I do think that ties in well with where we wanted to start with one of the updates today, which is the approval and launch of oral semaglutide for weight loss specifically. So we had injectables for weight loss for GOP1s previously, and we also had an oral semaglutide for diabetes, but more recently now we have the oral semaglutide for weight loss specifically. And so I imagine that's probably already making a splash in your practice. I think it's something that people are probably really interested in. So maybe you could share a little update on what this product is for those who might not be as familiar and what its impact on weight is, what what your experience has been so far with it.

Dosing, Bioavailability And Counseling

SPEAKER_00

Yeah, good question. I mean, of course, I manage a lot of people. My primary role is managing people with diabetes. So historically, I've had a lot of experience with oral cemaglide marketed as ribelsis, where now we have oral cymaglide marketed as the Wagovi pill. So when we think about oral cymagalotide in general, really this is ribelsis. So if we're familiar with this as clinicians, pharmacists, whatever your role is, the wagovi pill is really just rebranded for weight loss. And it's our old ribelsis that we're so familiar with. Now I will say there is small differences because if you think about oral smagalotide marketed as ribelsis, it's available as a three milligram tablet, seven milligram tablet, and 14 milligram tablet. And when we think about the wagovi pill, or oral somagaltide, I guess, marketed as the wagovi pill. Sorry, just trying to balance all these brand names here. Um, but in general, when we think about the tablets for the Wagovy pill, they're 1.54 milligrams and 9 milligram tablets with the opportunity to go up to a 25 milligram tablet. So you will notice the dosing is a little bit different. And we'll probably see the ribelsis tablets as well start to shift over to that dose because what it is is they actually improve the absolute bioavailability. So one of the big issues with oral somagalitite or ribelsis that we saw with people with diabetes is we know that it has the snack protein around it. It really gets disintegrated easily in the stomach if we're not careful. So we have to counsel patients to take it with the smallest sip of water possible, wait 30 minutes, then go ahead and eat, drink, take the rest of their medications. We still have those same counseling points with the Wagovi pill as well, but the absolute bioavailability is a little bit better with the Wagovi tablet as opposed to the Ribelsis tablets, because it went from 0.4 to 1%, I believe, with Ribelsis, to now about up to 1% to 2% more bioavailable with the Wagovi tablet. So they are trying to improve the overall oral bioavailability of it. But still, when you think about these new Wagovie pills, even though the doses are slightly different and it is more bioavailable, it's only really still one to two percent. So we still have to ensure those same counseling points, everything really stays the same as oral semaglotitis raibelsis. That 30 minutes with this, I usually say with the smallest sip of water possible that they could basically ingest to take the pill. It says four ounces or 120 milliliters. But when you tell a person that, what does that really mean? So when I counsel, I usually just say with the smallest sip of water and then wait 30 minutes to eat, drink, and take other medications. So I think in general, it's not necessarily that new to a lot of us that have been managing diabetes for a while, because really it's very similar to it is ribelsis, basically, just in a new formulation.

SPEAKER_01

Yeah.

SPEAKER_00

And then actually the 25 milligram tablet is still the original formulation.

SPEAKER_02

What what do you mean by that exactly?

SPEAKER_00

What do you mean by the original or for the Oh because well, because the tablets are 1.54 and 9, they're like the new, slightly more bioavailable formulation.

SPEAKER_02

I see. Okay.

SPEAKER_00

The 25 milligram tablet is actually still the original formulation.

SPEAKER_02

Okay.

SPEAKER_00

Okay, got it.

Brand Alignment And Avoiding Mix Ups

SPEAKER_02

Yeah, so I a couple of things to clarify there. So I think it's great that you're calling out that oral summagotide has been available for diabetes. Now we have it approved for weight loss. There are the different strengths available. So for the oral smaglatide rebelsis product, that was the 3714 strengths available. And then the Wagovi oral smaglide for weight loss is 1.549 and 25. I did see something about, you know, looking at the 25 milligram strength for diabetes potentially getting approved for that too. So that might also come into play here. And then, but as you said, it is it is the same administration considerations. I love how you said just take it with a sip of water because no more than four ounces, but you know, what does that mean? Yeah. Take it with enough water to swallow, but don't overdo it. So I love that counseling point. And yeah, we do need to make sure if a patient's interested in the oral product, making sure they're taking it properly so they get the most benefit from it. So I'm glad you drove that point home. One other thing to mention, sort of along these lines, is that there is an oral semagletide for diabetes, that basically the rebelsis, there's going to be a rebranding to Ozempic in part because we know the injectable semaglatide Ozempic has been available. And I don't I think there's been some concern that patients may not have realized that there was also an oral semaglatide for diabetes rebelsis available because they had different names. So we're gonna see some alignment in the products as well. So the oral semaglaltide and the injectable semaglantide specifically for diabetes will now both be going by the osempic name instead. And so all of that to say, I think there's potential for errors and confusion here, especially if people are switching. And so I don't know if you've run into that at all in your practice or any thoughts about how to help mitigate some of that concern when patients are switching between formulations, either injectable to oral or between these oral forms.

SPEAKER_00

Yeah, no, absolutely. And especially too, as cost continues to change, we see people switching products, especially formularies as well. So we do get quite a few questions about switching. I actually got a question about switching cymaglotide and trosepatide yesterday. So we get these questions all the time. Yeah. And really it's patient specific, honestly. I when I look at it, how well is the person tolerating the medication? Is it someone that's having severe GI upset for the first week that they're on it and then it goes away as they get used to the dose? Or is it someone that struggles with GI upset every dose? Or is it someone that has no GI upset at all? Because if someone has no GI upset at all, then when I switch, I'm comfortable at switching over to a higher dose.

SPEAKER_01

Okay.

SPEAKER_00

And so you really have to start having patient-centered conversations because in general, let's say someone wanted to switch to the Wagovi semaglide pill, then and they were already on injectable Wagovie, let's say at 2.4, if they were doing well on it, then you know, maybe you could just switch them over to the nine milligram tablet and then titrate up to 25 milligrams. So I'm usually actually a little bit more aggressive, I think, with my cross crosses when we're switching products based on how well they tolerate the medication in general. So I don't actually have a set algorithm. I feel like for how I do it, our colleagues always ask, you know, how do you decide? Like, is it do you always, even when switching to injectable trusepatide, do you always go back down to 2.5 or back to five? And it's like, well, if they were tolerating a really high dose of semaglotide really well and had no GI upset, no nausea, no vomiting every time they took a dose, then I'd feel more comfortable just switching over to trusepatide 10 if they keep if they want to keep using it for weight loss and then titrate up 12 and a half and 15. So in general, I think every time I switch over, it's really a conversation with the patient about how well they're tolerating the medication. And then I decide do I want to do it start a lower dose and go up slowly or a moderate dose and go up. So okay.

SPEAKER_01

Yeah.

SPEAKER_00

I don't know if I have a great answer for that. I think it really is patient specific because as you know, some patients feel great on these and other patients have not great first experiences. So it depends on the person.

Switching Agents And Tolerability

SPEAKER_02

Right. And that's a great point, too, making sure that the patient, especially depending on how they did with their titration, too, initially with the original drug they might have been on. You know, I we don't want to turn them off of the drug altogether if they're not having a good experience. So absolutely getting that patient-centered, you know, approach is is critical. So I'm glad you shared that perspective. I think also, you know, the thing that comes to my mind is about errors, like if if the prescriptions are coming over, if if there's any change in therapy, always double checking with the patient too to make sure that they're getting what they intended, that this was supposed to be a switch, because I could see, especially as that rebel system osempic name change is happening, and as people are maybe switching between oral and injectable or vice versa, just cross-communications, you know, can happen. And so, you know, just making sure we're communicating with patients when those changes are happening.

SPEAKER_00

Absolutely. I think it's gonna be so important for us as pharmacists, especially as we go from oral semegalotide ribelsis to the osempic pill, because now we're talking about with ribelsis, we have three milligrams, seven milligrams, and 14 milligrams, and that's gonna switch to 1.5, 4, and 9 milligrams. So when people come into their pharmacies or into your clinic or what whatever work setting that you're in, they're gonna have a lot of questions. Why is my dose different? Or, you know, you have someone on three milligrams of ribelsis that goes to 1.5, for example, of the Ozempic pill. Every time you think about doses, people have you know doses in their mind as so go, am I getting a less of my am I getting less strength? Like I even think about it when I switch potentially even arbs, like low Sartan 100 to almost artin 20, for example. People are like, wait, what? That's so much less drug.

SPEAKER_01

And it's like, yeah, yeah, yeah.

SPEAKER_00

You know, so we have to think about those counseling points too. So people aren't inappropriately doubling up on Ozempic when they get it. Like two 1.5s is a three. I need to be great.

SPEAKER_02

That's a great point. I I didn't even think of that. And that is, and you're right, that the perception of doses varies so widely by patients who they might think, oh, well, I'm not getting as potent of a product, so I need to make taking more to make sure I get the same effect. Yeah, excellent point. In terms of the weight loss expected with the oral semaglide, I guess, with the the one approved for weight management specifically, what kind of experience have you had with that? And what can you, what do you usually tell patients to expect and how long do you expect them to take to see that effect?

Setting Realistic Weight Goals

SPEAKER_00

Yeah, great question. I mean, some people, first off, there's again, for me, there's just so many different variables. I think when we look at clinical trials, we have like set numbers, like 11% weight loss, 15% weight loss, but really it depends, in my opinion, how much weight does the person have to lose? If you have a female that's maybe, you know, 5, 7, 160 pounds, they're not going to lose, you know, 50 pounds. But if you have someone that's 300 pounds, they could lose a substantial amount of weight. So I think the first thing you need to think about when talking to people about these medications is realistic goals. The study, you know, when you look at some of these newer studies, the average weight is over 100 kilograms. So for someone that's only 70, 80 kilograms, they might not see the same effect as what you saw in clinical trials. So might not see as much weight loss just because there's not as much weight to lose, which is completely fine. So I think in general, just a lot of counseling around these in terms of like what to expect. I will say too, it's interesting. There's about 10% of the population that just doesn't respond at all to these. So I will have patients that just don't lose any weight on these agents. Sometimes in, and especially in diabetes too, they'll like improve their A1C, but not a lot. But then you'll also have people where maybe their A1C was 13 or 14, and then you start one and all of a sudden their A1C is sick. So there's also a different level of response, probably depending on the person's basically increotin deficiency at baseline and all sorts of other genetic factors that play a role too. So I guess in to summarize all that, lots of different things to think about. But when you're counseling, I think set realistic expectations. I also think it's important too, and how much weight could be lost also depends on how much lifestyle they're using with it. So um, are they going to change their diet? Does it help them curb their appetite? Are they ready to eat smaller, more healthy meals? Are they starting to exercise with it to prevent that muscle wasting that we sometimes worry about? So there's a lot of different things that can play a huge role in terms of expectations for weight loss. So I usually will just start with, you know, how much weight you lose is really how much weight do you want to lose? How much effort do you want to put into this? Do you want to also maintain a healthy diet, lifestyle, get adequate sleep, go to the gym? You know, what are your goals in general? So I think that can also play a role in how much weight you'll see people lose. But we've seen people lose, you know, 100, 150 pounds if they've had a lot of weight to lose. So yeah, I it really just depends on the person and how motivated they are to just kind of change their life.

SPEAKER_02

Well, and I think for a lot of people, what we're seeing is that these even if they were doing lifestyle changes previously, it's the medications are giving them a maybe you can speak to that a little bit. Yeah, the gem start. Yeah. Yeah, exactly. That gem start. Maybe you can speak to to how it how it works for that and how what kind of effect you've seen with with that. Because it can be so frustrating, I think, when people are have tried their whole lives to be losing weight and have been on the cycle and just nothing nothing has ever worked. And now people are seeing effects. So yeah, speak to that a little bit.

SPEAKER_00

Yeah, absolutely. So I actually love these agents early on in therapy. Excuse me. I think they do provide, I call it the jump start. So I actually always start them early on. Like, yes, absolutely everyone should see a nutritionist if they have type 2 diabetes or a type 1 or type 2 diabetes, any sort of diabetes, but I do recommend that people do still see a nutritionist, do work on exercise. However, sometimes people just don't even know where to start. And they also just need mentally that encouragement of I can do this. So they start taking whether it be the Bagovi pill or one of the injectable medications for weight loss, and they start to lose weight. Well, now you have less weight on your joints, so it's easier to go out for a walk now. It's easier to go to the gym. You're starting to get more motivated mentally because you're just like, okay, I am starting to lose weight. I'm feeling better about my image. I'm ready to go to the gym and try to start working out. There's less stress on my joints because I have less weight on my joints. And honestly, we see that even with step nine with osteoarthritis, it showed a benefit, subcutaneous hemegalotide and osteoarthritis. I mean, we're starting to see different benefits just from the weight loss, people kind of getting up, getting going. So I would say I start these early, and I definitely feel like you can use them as a tool to get people motivated to want to further do lifestyle interventions.

Using GLP-1s As A Jump Start

SPEAKER_02

Yeah, yeah, that's that's excellent. And glad to hear that perspective too, because it it can be so frustrating and for people to start seeing a benefit can be so empowering and as you say, really help them then take additional steps to improve their lifestyle. So that's great. I do wonder from a patient care process perspective, if you have a new patient with diabetes or obesity, if we just think about those two sort of conditions and you're sort of thinking about how all the GLP1 stack up now that we have this oral product for weight loss specifically, what goes through your mind in terms of that patient decision-making process and what are pros and cons? When would you think about terzepitite or major or zep bound versus the semaglitite or any other GLP one? What was your decision-making process there?

SPEAKER_00

Yeah, great question. I mean, so in terms of weight loss, I still, even though the oral pill is available, I'm still a big proponent of the once-weekly injectables. I actually prefer those for people with diabetes too, even when I manage them, just because I do think it's a lot easier to take a shot one day a week than it is to go through these different administration requirements. So, and I think that is a reason why people honestly kind of forgot about ribelsis, is because it's really hard for someone to wake up every morning, take the pill, wait 30 minutes, eat or drink, especially. We know a lot of people have concomitant hypothyroidism or different things where they have to take pills such as levothyroxin, or if you have osteoporosis, maybe you have to take a laundronate and then think about those administration requirements. So it really depends what's realistic for the person. Now, I think because the Wagovi pill is starting at a lower cost that point, it's going to gain more traction and more popularity because it is becoming a little bit, I have to say, I guess, more affordable than some of the injectables. But I think if you have someone that has a lot of weight to lose, I still do gravitate more towards the injectable. I think the Wagovy pill is probably great for that person where their BMI is maybe like, I don't know, 27 to 35. They're kind of in that, I hate to say like lower over in a weight range. Yeah, sure. Yeah, yeah. They don't have quite as much weight that they want to lose. I think when you start to see people with BMIs over 35, you really, and I know we're not supposed to be thinking BMI numbers anymore, but the basically the more obese person really for success, I would start on an injectable. I think the Wagopi pill is going to be great for those people that are kind of in that like slightly overweight, obese range where they just need a little bit more weight to lose and they want to do a pill, they're not really open to a shot. So that would kind of be where the population that I would use it in. And then of course you have to make sure they can do the administration requirements because I will say we didn't talk about this earlier, but if you have someone come in and it's not working, like we'll have people come in and they'll say Ribelsis doesn't work, and I'll be like, okay, that's the first thing in my mind is check the administration requirements. It does work, you just have to take it correctly. So if patients say it doesn't work, then I mean, sure, they could be part of that responder population. But okay, but but I would say it's probably has something to do with the administration.

Choosing Oral vs Injectable

SPEAKER_02

At least first and foremost, rule that out. But when you did mention the, I think up to 10% was what you said, that don't respond. I was like, huh, how how many of those are actually problems with administration or adherence or whatever, you know, that could be contributing to that? And sure, but definitely an important point to rule that out first. In terms of the, so that's that's good to know uh your your experience with the injectable versus oral as well, and sort of thinking about who would be potential better candidates for injectable. It even between the GLP ones, the injectables, let's say, is there uh do you sort of have a a similar thought process in terms of the weight intended to lose, desire to lose, and thinking about cheers epitite, perhaps for that versus the samaglotite. Or a different GLP one, how does that sort of stacking up happen?

SPEAKER_00

Yeah, absolutely. So in our practice, so because I mentioned I do manage a lot of people with diabetes, I like to get a GLP one on board regardless. So the first thing I think about if I have, let's say, an individual that doesn't really want to lose any weight, but I do want a GLP one still for like kidney protection, decreased inflammation, cardiovascular protection, I'll actually go towards delaglide um trilogy. Yeah. Okay. So it's a little bit weaker. And we know the 1.5 milligram dose reduces cardiovascular risk. We saw that in the Romine trial. So actually, if someone's like, I don't really want to lose a lot of weight, but I know I want to use a GLP one for cardiovascular protection, that I might just actually just stick with trilogy, delaglide 1.5 milligrams weekly.

SPEAKER_01

Okay.

SPEAKER_00

Now, if someone is kind of in that mid-range, I'll do ozumpic or subcutaneous semagliotide. And then if someone comes in, they have a lot of weight to lose, they're really like, I need to lose this weight, then I'll just go straight to Terzepatite or Monjaro. So I have to sit down with people. What's realistic? How much weight do you want to lose? I will say too, sometimes we look at someone's profile and just assume they want to lose a lot of weight. I have had patients that don't want to lose weight, that don't want to get down. They'll tell me, you know, sometimes they'll even just say, I don't want to look like you. And it's like, okay, that's fine. That's fine. But yeah, so I think we again we have to meet the patient where they are. Yeah. Exactly. Yeah. So I think in general, it's like, what are their weight loss goals? Where do they want to be? I think if it's, you know, less weight loss, then you look at something like the legaltide 1.5 milligrams weekly. If it's kind of like moderate, I'm not sure. Maybe you gravitate more towards subcutaneous semaglotide and then titrate up and see how well they do. And then if someone wants to lose a ton of weight, then you just go with trzepatide. And then I know we'll talk about this later, but if there's plateau on trusepatide 15, then you could potentially be one of the new ones, such as Reditrutide, which would be a triple agonist. So we've got stuff in the pipeline too for people that are starting to plateau that want even more weight loss. So yeah.

SPEAKER_02

Okay. Well, thank you for sorting through those a little bit more. And that's interesting perspective too on the dulagum side. The older GLP ones are not necessarily older and worse. You know, they have their own role too.

SPEAKER_00

They still protect you from cardiovascular.

Picking Among GLP-1 Options

SPEAKER_02

That's right. And I appreciate you calling that out too. That the the kidney cardiovascular benefits of some of these also is an important consideration. And like you say, a reason why you'd probably go to these early on in your patients with diabetes. Chris, you did sort of allude to the potential benefits, not only in the potentially losing weight and allowing the patient to exercise better and continue on their lifestyle changes, but you also alluded specifically to osteoarthritis as a as a an outcome that has been looked at with semaglictin and potentially improved. So let's transition into another sort of update, which is the various indications we're seeing with these GLP ones now. We've seen FDA-approved indications for other conditions beyond diabetes and weight management with sleep apnea, the kidney benefits, the cardiovascular benefits, the metabolic associated state-to-hepatitis mash for some of these. And so we're seeing just a lot of additional approvals. You know, I heard a colleague say, like, there's they're going to be approved for hypertension and all these different things. So can you speak a little bit to some of these expanded indications, what we're seeing, where you see these going, and why we're seeing benefit in some of these other uses? What's the research leading towards?

Expanding Indications And Evidence

SPEAKER_00

Yeah, no, it's interesting because a lot of these expanded indications do have to do with weight loss. But what we're seeing too is possibly this decrease in inflammation, inflammatory component, really also contributing to some of these benefits. So it's been interesting. I mean, you look at the studies and they have so many different studies and so many different disease states. So we have surmount OSA, which is the participants with moderate to severe obstructive sleep apnea. And we know that terzepatide really improved the indexes for people with sleep apnea in addition to using their CPAP. So we know that some of the weight loss with sleep apnea has been really helpful. And I do think in general, I mean, this is a whole nother day conversation, but sleep apnea is really underdiagnosed and underscreened for. I think it's hard to get people to want to go somewhere and do a sleep study. So in general, knowing that some of this is going to help with something like obstructive sleep apnea, we have semaglatide for mash in the essence trial, which showed basically benefit in those with mash and moderate and advanced liver fibrosis. It improved histologic results for that. So we have great data now. Well, I guess one really great randomized control trial, the essence trial, looking at subcutaneous semaglatide in people with MASH. Overall, we've had recent studies looking at these different agents in people with heart failure-preserved ejection fraction. So it is kind of interesting. We haven't had great data yet in heart failure-reduced ejection fraction. That's been a more of a controversial population, but we do have for heart failure-preserved ejection fraction, we have like the step HEF-PEF trial with subcutaneous semaglatide. We also have the summit trial with terzepatide showing benefit in that heart failure-preserved ejection fraction population. Again, patients benefiting from the weight loss, but also in that HEF-PEF population, we have decreased inflammation. We have improvement in nitric oxide, which improves overall endothelial function, that decrease in body weight and visceral adiposity, improvement in ventricular compliance, decreased fibrosis, overall decreasing filling pressures and improving diastolic relaxation. So we're seeing a really like a fascinating benefit as well in the heart failure-preserved ejection population, especially our well, I guess the obesity-driven heart failure-preserved ejection population. Um, I mean, there's so many different areas we're seeing benefit in peripheral vascular disease, kidney disease with the flow trial. And then as you mentioned, I keep talking here, but because there's just so many different things. Yeah, yeah, yeah. Hypertension, I mean, it's so interesting because there is no dedicated hypertension trial. But if you think about the hypertension guidelines, and this has been in there forever, for every one kilogram of weight loss, if you look at the lifestyle recommendations in the hypertension guidelines, it says every kilogram of weight loss, your blood pressure will lower one millimeter of mercury. So if someone loses 10 kilograms on one of these agents, like theoretically their blood pressure should go down 10 millimeters of mercury or 10 points. So if you lose 20, it goes down 20. So we are seeing this in clinical practice too, where you start these people start to lose weight. And it's not just about, you know, managing weight, it's we have to start de-escalating therapy as well. So we de-escalate insulin a lot, we de-escalate blood pressure medications in general. Cholesterol medications usually kind of stand still. We always want our patients on a statin that need to be on one. But I do think it's it's kind of something we don't think about is that weight loss does cause blood pressure reduction. So we need to start thinking about do we need to de-escalate antihypertensive therapy? So a lot of different things to think about here with some of the benefits of these.

SPEAKER_02

I I that's a really important point about de-escalation because these meds are meant to be used long term. You know, I I know that's I think um well pretty well established now, but maybe still still some confusion around the idea of obesity overweight being a chronic condition that needs long-term management. It's not something you're necessarily going to stop. And therefore that could affect the other meds that you're taking, and and those meds may need adjustment. Do you think that's a fair statement? Is that how you approach it?

SPEAKER_00

Yeah. I mean, I think in general, yes, like obesity, in my opinion, is a chronic disease. I do think these agents work really great in managing it. I think very similar to someone with diabetes as well, there's all sorts of other things you manage. You don't just manage diabetes, and in my opinion, you don't just manage obesity. And so I think there's so many other things we have to think about and all the added benefits that go with it. So when I pick medications now for people, like which one is gonna help me improve the person's overall profile, is what I'm thinking about. So when I start these, I'm thinking about protecting their kidneys, protecting their heart, as well as weight loss, diabetes management, whatever it may be. If they have peripheral vascular disease, just improving their walk distance. We saw in the stride trial with subcutaneous cymagliotide, just little differences where you're starting to see benefit with these agents, protecting them from developing MACL D. So the liver disease there, the metabolic associated zeatotic liver disease. I mean, we know these have been shown to treat it, but also what you're seeing is if you put these on early on, our patients aren't even getting it. Like our Fib 4 scores are going down because we're screening those every visit. And what we're seeing is basically protecting people with diabetes and potentially overweight and obesity from even developing it. Now, that data is not out. That's just something I'm observing in our clinic. But I do think like starting these early, you're protecting against future other chronic complications that you're not even thinking about. There's so many just benefits down the road that are gonna that you're protecting people from.

SPEAKER_02

Yeah, super interesting. And and just how all of those conditions do often go hand in hand and it goes back to your CKM uh abbreviations. Like just to tie that all together. One of the other indications that I think has gotten some interest or a little bit of buzz lately is about the potential use for GLP1s in alcohol or substance use disorder. And I'm very interested in the the theory behind that. You know, you talked about inflammation and some of these other markers, but how what is the potential benefit of benefit for a GLP one agonist in substance use disorders? Have you seen that in your practice? Or what what do you know about that?

De‑escalating Other Therapies

SPEAKER_00

Yeah, no, it has been interesting because these GLP1s actually kind of work on reducing the consumption and warding properties of various substances. So this includes, you'll see alcohol, opioids, nicotine, as well as psychostimulants. So basically GLP1s, they're mediated through the modulation of reward pathways. So they also help with stress regulation, cognitive function in the central nervous system, and then obviously a host of functions in the periphery. So we don't have a lot of robust clinical studies yet. But what we're starting to see for a variety of different things like alcohol, opioids, nicotine, they're also reducing cravings for substance use, which has been interesting. So I think that's also something to keep an eye out for. There's not great data yet on it. But in general, we do see people that'll say, like, oh, I want to smoke less now that I'm on it, which is interesting too, that it's I notice it more with smoking than drinking. But in general, I will say, like, our patients do want to smoke less, which has been nice. And then in general, when you're trying to get someone to quit smoking, I mean, the biggest thing, right, is then they gain weight, which is why they don't want to quit smoking. So I think this is actually, I know we talk about it with substance use disorders. We see decrease in alcohol cravings and in general, just cravings altogether. But I think it's also going to be a useful tool for smoking cessation, like preventing that rebound weight gain, decreasing the nicotine cravings. I think it can be a great supplement as well for smoking cessation. Again, not a lot of robust data yet, but the way things are going, I wouldn't be surprised if things start popping up in the literature. Yeah.

SPEAKER_02

Yeah, interesting. I think it's one of those things just to be aware of and keep an eye on some of the publications research coming out, because as you say, I think it they have sort of all these downstream potential benefits that maybe we aren't recognizing until we see them more in the real world and in practice, and we get all this real world data and that can generate new research, you know, to start. So yeah, very interesting. What do you think about like let's think about crystal ball sort of predictions here? And where what do you think are some of the outside of the indications potentially coming, where do you think are some of the next steps that we might see with GLP1s in general? New drugs or new products? What what what are some of the forthcoming announcements that we're expecting to see with some GLP1s?

GLP-1s And Substance Use Signals

SPEAKER_00

Yeah, I mean, I think the big one that's probably coming that people are pretty excited about is the other oral GLP1 receptor agonist, so orphoglypron, which is made by Eli Lilly or marketed by Eli Lilly. And it's a non-peptide small molecule GLP1 receptor agonist. So what that means is non-peptide, it has a higher bioavailability and can be administered without restrictions on food or water intake. So you're going to see an easier administration compared to oral semaglide. So I think this one is going to be probably the most interesting one to come to the market. So when the they did a trial called the Achieve One trial, for example, and people lost in the 36 milligram dose group about 7.6% change in body weight. And I know Eli Lilly already has planned to seek regulatory approval for weight loss already and will do diabetes this year in 2026. So that one I think is going to be exciting on the horizon. Now, that being said, it does have higher bioavailability. It'll be interesting to see as it kind of rolls out into the real world setting, if there are more side effects with it. Do people have more GI side effects? Some of that started to show up in clinical trials, but I always find our patients are quite a bit different than even what's reported in clinical trials. And as I mentioned, everyone responds to these so differently. So I am excited to see the oral GLP1 orphoglypron come out and just see how if it's a game changer or if people are like, the shots still work better and that we still stick on the injectable agent. So that one I think will be interesting. Another one that I'm also interested in is gangrolinotide semaglide. So we call it cangricema. And so canrolinotide is a long-acting amylene analog and it binds to the calcitonin receptor and all three of the amylene receptors, and it helps with reducing food intake and weight loss. So one of the things I do think, and we'll talk about they're coming out with new doses too of subcutaneous semaglide, potentially even up to 7.2 milligrams. But one thing I'll probably still gravitate more towards is combining different agents that all work together in a complementary manner to provide greater weight loss. So I am excited about Kangricema as well and the potential to provide further weight loss for those on semagalotide that need a little extra benefit.

SPEAKER_01

Okay.

Pipeline: Orforglipron And Beyond

SPEAKER_00

Yeah. And then another option is retitrutide. So this is also in the pipeline coming out in the next year or two for weight loss and hopefully people with diabetes, but it's a GIP GLP1, just like trzepatide, but now you add on the glucagon receptor agonist to that too. So this is our new triple agent retitrutide. So that one will be interesting too. So if someone again plateaus with trzepatide, you could potentially step them up to retitrutide if they could tolerate it. So that one also in the pipeline, which will be interesting. And then actually, I find this one the most fascinating because it's a once-monthly GLP1 receptor agonist. It's known as meritide. It's a long-acting one, so it just has to be administered every month because the half-life is about 21 days.

SPEAKER_01

Wow.

SPEAKER_00

And it combines GLP1 agonism with GIP receptor antagonism. So when we think about trzepitide, for example, that's a GLP1 agonist with a GIP agonist. And this one, the once monthly meritide, is actually a GIP receptor antagonist. So I find that one to be fascinating and really just tells me we don't know quite what GIP does yet in terms of benefits that we can have an antagonist and an agonist portfolio out there. So those are some of the ones that I'm excited about coming along the pipeline that I think are getting pretty close to the finish line.

SPEAKER_02

Yeah, there's a it's just sort of fascinating to see how how much, like you say, is in the pipeline and coming down even in the next year. And like I said, you know, at the beginning, we are seeing headlines about these drugs every single day, regardless. And so more is just on the way. We're gonna have to have you back, you know, in a few months when all this starts to come out. One other hot topic that relates, I think, to some of the products that you mentioned, actually, that are not yet FDA approved are the regulatory issues coming up with some of these GLP ones too. We've seen some FDA announcements about compounding and concerns around that. So, what is your take on all that and and how do you help patients navigate some of those concerns?

SPEAKER_00

Yeah, absolutely. So hopefully some of the now direct-to-consumer marketing has decreased people's desire, we'll call it to purchase compounded products. So I actually, I mean, the FDA allows it if there's a shortage, for example. However, even when there was a shortage of these, I mean, there's still a lot of questions. So, okay, so semaglitides in shortage. So how do these compounding companies even have it to begin with? Well, because they're using salt forms of semagalatide, they're not using the regular form of semagalotide, the base form in the FDA products, they're using these salt forms. So semaglatide sodium, semagalotide acetate. So you have to think to yourself, okay, this isn't even the FDA-approved product that was being used in the shortages. So I definitely was not a proponent of that. So I tried my best to, you know, lengthen out dosage regimens or like intervals between doses and do different tips and tricks to kind of get around different drug shortages. Because I mean, the FDA doesn't recommend it. The American Diabetes Association definitely doesn't recommend it. They don't find it safe. So I really stay away from the compounded products. It's definitely something if someone says they're using a compounded product, then I try to steer them more towards, okay, let's get you on track with the regular FDA-approved product made by the manufacturer so I can ensure safety and efficacy. Because we've also had some horror stories where, you know, someone used a compounded terzepatite and had 20 gallstones, had to have their gallbladder removed because it was starting to necrotize. I mean, you hear these like horror stories. We see these horror stories, unfortunately, with compounded products because we just can't ensure safety and efficacy with them. So I actually never recommend them in clinical practice. And if a patient comes in and they are using one, I do immediately switch it to the FDA-approved product because I just they scare me that they're not. And even if it is from a reputable company, I do still have some reservations about compounding these, especially if they're using the salt forms and not the base forms.

Compounding Risks And Safety

SPEAKER_02

Yeah, and there is, I mean, there's a whole FDA page on compounding GLP ones and considerations with them. And as you say, there have been adverse events reported. Part of it is uh contamination issues or counterfeit issues, but also the salt form, as you said, or even some of these unapproved products, like the I'm forgetting the R word, the Richard Chat or the when you're true tide, yeah.

SPEAKER_00

I mean, they're not done in it, it's not even available yet, but that's not approved yet.

SPEAKER_02

So, you know, I think the importance, you know, for anyone who is compounding, making sure that you're following all the federal regulations and laws around that and recommendations and the recommendations from ADA if appropriate. So just it it is one of those messy areas where unfortunately it can be something that gets patients into trouble. Um, and there are a lot of because there's not a shortage now, there's a lot of options available. So good to be, yeah, good to be aware of.

SPEAKER_00

And actually, I think the pill is going to kind of mitigate any potential shortage issues, honestly. We've got, you know, even now we have the trzepatide quick pen. So we're getting also too a lot of the shortages is due to all the delivery devices, right? So now we have these medications and different delivery devices, like the trzepatide quick pen just came out. Now we're getting more tablets, we're getting more options. So yeah, right. I I do think we're not gonna really have to worry about a shortage. There's gonna be something that we can use that'll be available.

SPEAKER_02

So absolutely. So we've talked about a lot of really exciting things, like you say, a lot more to come. What do you think in general are some of the most maybe the most top barriers that you see with these drugs in general and how you help patients work through that, or top counseling tips? What are some of the take-home messages that pharmacists should be aware of when supporting patients with these meds, whether starting them out because we may have more patients starting, or in terms of maintenance? What what are some of the key things that you like to drive home to your patients?

Cost, Tolerability And Key Counseling

SPEAKER_00

Yeah, I mean, obviously the top barrier is cost, right? So even though some of these have direct to consumer options now, I mean, if you look at the price tag, it's still not affordable for a lot of people. Yeah. And then now, unfortunately, a couple of the companies too have removed the patient and persistence program from Medicare patients now that the Medicare coverage has changed. So thinking about for those people recommending the M3P program and just spacing out the copay throughout the year. So I think in general, probably the biggest barrier to using some of these is cost. And then the second biggest barrier would be tolerability. So, in general, I think the most important thing is when you start one of these, it's not just like, okay, here's this drug, you're gonna lose some weight. You have to talk to them about like how to healthy, do like a healthy balance of weight loss. So, how are you gonna eat like reducing fat consumption? Because we know someone still eats like a lot of fat or sits down and eats even when they feel full. I mean, it slows down your stomach emptying. So there's nowhere else for it to go but up, right? So I think that in general, like the patients that are getting the GERD, that are getting the vomiting, I mean, we really have to start talking to them about smaller, more frequent meals, having less fat at each meal. I think it's not just this great miracle drug that just drives weight loss. I mean, it kind of is, but at the same time, we still need to counsel on diet and lifestyle, which I think is the most important part is really just making sure they understand how to tolerate the medication, how to use it successfully, and just in general, how to make how to help them make their lives healthier. So I would say those are the key, some of the key takeaways. And then for pharmacists, I think when we do switch from the ribelsis pill to the osempic pill, just keeping in mind that three milligrams, seven milligram, and 14 will go over to the 1.5, 4, 9, and 25 milligram doses. So really counseling patients, don't double up on the 1.5. It doesn't equal the three, like this is the new dose. So just keeping an eye out for just some of those potential confusion areas.

SPEAKER_02

I think those are great points to highlight. And I do appreciate the cost considerations as well, because as you said, even though a lot of these are being promoted because they're there's costs are coming down, the costs are still high for a lot of people, especially if there's no insurance or limited insurance coverage. And so cost, they're not going to work if people can't afford them, right? So we have to make sure they we can help navigate some of those too. Well, Christy, this has been awesome. We've chatted about so much, and I think that you had a lot of great takeaways and practical points for our listeners. I do want to wrap up with just maybe one game changer. It's our game changers podcast. So what would you say? I I you started off the conversation, I think, saying GLP1s are sort of a game changer in and of themselves. But maybe if there's is there anything else that you want to sort of drive home as a game changer for us to walk away with?

SPEAKER_00

I mean, honestly, yeah, these are the game changers, right? I mean, for the first 10 years of my career, I managed people with diabetes with just insulin. And now my goal in life is to take everyone off insulin that has type 2 diabetes by using these and maintaining a healthy diet and lifestyle. So in general, I think these are the game changers. But for us as pharmacists, I mean the game changers are really just making sure we are the gatekeepers, making sure they know how to take these, making sure you're telling someone if they, you know, because we talked about like the Wagovi pill is still not that cheap, right? So if they're going to pay for it, make sure they're taking it correctly. So 30 minutes before eating, drinking, taking any of their other medications, it's our job to make sure that people know how to take their medication appropriately and make sure that they can be successful with it. So while these medications are fantastic and they cover a plethora of disease states and show value across the board and across the spectrum, I think in general it's also our job to make sure they're taking them appropriately.

SPEAKER_02

So absolutely. So they can get that benefit, right? Yeah. And and I think the other sort of takeaway for me is how much things are changing, how much we need to be keeping on top of it as pharmacists and staying educated on some of the updates because we want to be aware of these things before our patients are and able to handle some of these questions. So definitely a moving target, but as much as we can try to stay on top of any of those updates as they're coming out. So that was great, Christy. Thank you so much for your time. Really appreciate it. Yeah, thanks for having me here today.

SPEAKER_00

I had a good time. Excellent.

Final Takeaways And CE Resource

SPEAKER_02

Well, to wrap up our discussion, I do want to just make sure listeners know we do have a practice resource that will be going along with this topic uh on the CE Impact website. We talked about so many great things. I want to make sure you have a good summary of our takeaways for the podcast today. And so that will be on the CE Impact website for you to get along with the CE. And you can be sure to claim your CE credit on CEimpact.com. As always, have a great week and keep learning. And I can't wait to dig into another game changing topic with you all next week.