Cases in the Community: Optimizing Treatment and Considering Weight Management as a Primary Goal in People with T2DM

Chair, Javier Morales, MD, FACP, FACE, discusses Type 2 diabetes in this CME/CE/AAPA activity titled “Cases in the Community: Optimizing Treatment and Considering Weight Management as a Primary Goal in People with T2DM.” For the full presentation, downloadable Practice Aids, and complete CME/CE/AAPA information, and to apply for credit, please visit us at . CME/CE/AAPA credit will be available until June 11, 2025.

1. Cases in the Community

Optimizing Treatment and Considering
Weight Management as a Primary Goal

in People with T2DM

Javier Morales, MD, FACP, FACE
Clinical Associate Professor of Medicine
Donald and Barbara Zucker School of Medicine
Hofstra Northwell Hempstead

Vice President

Advanced Internal Medicine Group, PC

East Hills, New York

ON
if

Go online to access full CME/CE/AAPA information, including faculty disclosures.

Copyright

2000-2024, PeerView

2. Our Goals for Today

Improve your ability to prioritize weight loss as a treatment
target in PwT2DM consistent with guideline recommendations

Enhance your skills to overcome therapeutic inertia to
intensify therapy in a timely and appropriate manner when
glycemic and weight goals are unmet

Refine your shared decision-making skills to develop
individualized management plans to address glycemia
and weight

Copyright © 2000-2024, Peerview

3. Evidence-Based Guideline
Recommendations for Prioritizing
Weight Loss in PwT2DM

Javier Morales, MD, FACP, FACE
Clinical Associate Professor of Medicine
Donald and Barbara Zucker School of Medicine
Hofstra Northwell Hempstead

Vice President

Advanced Internal Medicine Group, PC

East Hills, New York

Go online to access full CME/CE/AAPA information, including faculty disclosures.

000-2024, PeerView

4. Patient Case: Ruby, a Woman Aged 57 Years

+ 7-year history of T2DM, obesity, and
hypertension
+ AIC = 7.7%, BMI = 29 kg/m?,
BP = 141/91 mmHg
— These are all are slightly higher
than at her previous office visit,
6 months ago
+ Current medications
- metformin ER 1,500 mg/d
= lisinopril/HCTZ 20 mg/25 mg

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Ruby meets 3 different criteria in the
ADA Guidelines that would prioritize a
GLP-1 RA or GIP/GLP-1 RA as the next

Step in treatment

1. Indicators of high risk for cardiorenal
disease: aged 55 years or older with
two or more additional risk factors

. A1C exceeds the generally
recommended A1C goal of <7%

Overweight status

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5. ADA Standards: Priori

zation of Glucose-Lowering

Therapies to Meet Different Individualized Goals'

Reduce ASCVD Risk

GLP-1 RA with proven
CVD benefit
+ Dulaglutide
+ Liraglutide
+ Semaglutide injection

Alternative treatment
strategies
+ SGLT2i with proven CVD benefit
+ GLP-1 RA + SGLT2i
+ GLP-1 RA or SGLT2i + TZD

Consult ADA gui

“high-risk it

Reduce A1C

Choose approaches that provide the
efficacy to achieve goals
Metformin OR agent(s) including
COMBINATION therapy; prioritize
svoldance of hypostamia ln

jals

Efficacy for Glucose Lowering

Dulaglutide (high dose),
semaglutide, tirzopatide, insulin,
‘combination oral, combination
injectable (GLP-1 RAVInsulin)

GLP-1 RA (not listed above),
metformin, SGLT2i, sulfonylurea,

DPP-4i

1. American Diabetes Associaton Professional Practice Commitoo. Diabetes Caro. 2024:47(supp!1)5158:5178,

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Reduce weight

Consider glucose-lowering regimens
with high-to-very-high dual glucose
and weight efficacy

Efficacy for Weight Loss
Very High Somaglutido, tirzepatide

High Dulaglutide, liraglutide

Intermediate

GLP-1 RA (not covered above),
SGLT2i

Neutral DPP-4i, metformin

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6. ADA Standards and Weight Management

Improves health1-5
ADA Standards recommend’

Reverses some + Health-promoting nutrition

one] + Adequate physical activity

+ Behavioral therapy

Reduces CV events
and complications?

Diabetes Caro. 2011;34:1481-1486. 2. Lazo M ot al. Diabotes Caro. 2010;33:2156-2163. 3. Phelan Sot al J Url 2012:187:990-044
Diabetos Caro. 201336:2937-2944. 5. Wing RR eL al J Sox Med. 2010.7.156-165. 6. Engel SG et al. Obes Res. 2003:11:1207-1213,

7. Promrat K et al Hepatology. 2010:51:121-120. 8, Foster GD et al. Arch Intern Med. 2009:169:1619-1626. 9. Després JP ot al. BMJ. 2001:322:716-720. Désert

10. American Diabetes Association Professional Practice Committee. Diabetes Core. 2024:47(suppl 1)S145-S158, eerView.com

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7. Evidence From Look AHEAD!

Amount and Durability of Weight Loss, by Category

100 — Intensive lifestyle
intervention
La =-- Diabetes support and
g 80 education
E
2 0%-5% loss
É 60
5
©
5 25% loss
2 40 |
2
5
2 20 } 210% loss
a + 215% loss
0
Time, y
4. Madden TA tal. Obosiy (Siver Spring) 2008:17:713:722 2, Wadden TA et al. Obesty(Sivor Spring. 2011:19-1987-1998. a
3! Look AHEAD Research Group. Obosiy (Sivor Spring) 2014:22:5-13.4. Look AHEAD Research Group. N Engl J Med. 2013:369:145-154, PeerView.com

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8. Weight Loss Efficacy of Glucose-Lowering

Medications for T2DM!
Pa
SS rn rn
a ES © 3
AR > tg eo S
LPP Ed PSS oe AO KMS # &
e 4 25 28 33
ez
E call
55
BE 0 a
Si 2 [I a a og 04
a rire
33 “ : I GP/GLP-1 or GLP-1-based agent
se ©
Oe BB Other agents
40 -86

1.SWQ etal. BMJ, 2025:381:0074068,

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9. Patient Case: Galen, a Man Aged 70 Years

+ Remote history of stroke

+ BMI = 27 kg/m?, eGFR = 50 mL/min/1.73 m2, UACR = 40 mg/g, and a
15-year history of T2DM (A1C = 8.8%)

« Current medications: basal insulin and an SGLT2i

+ Blood glucose monitoring recordings indicate that he would benefit from
the addition of an agent that will reduce postprandial glucose levels

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10. Adding a GLP-1 RA With Proven CVD Benefit Is
Recommended in the 2024 ADA Standards of Care’

+ Galen is at high CV risk, given
his history of stroke, T2DM,
and CKD

+ Adding a GLP-1 RA may offer
Galen multiple glycemic and
non-glycemic benefits,
including lower A1C and
weight reduction

Goal: Cardiorenal Risk Reduction in High-Risk Patients With
T2DM (in addition to comprehensive CV risk management)*

+ CKD (on maximally tolerated
dose of ACEi/ARB)

PREFERABLY
SGLT2P with primary evidence of reducing CKD progression
Use SGLT2i in people with an eGFR 220 mL/min per
1.73 m?, once initiated should be continued until
ialysis or transplantation
OR

GLP-1 RA with proven CVD benefit if SGLT2i not tolerated or contraindicated

IFAIC above target

r patients on SGLT2i, con:
RA or vice versa

"In people with HF, CKD, established CVD, or mutiple risk factor for CVD, the decision to use a GLP-1 RA or SGLTAI wth proven benefit should be independent of
‘background use of metformin. For SGLTZL CVIrenal outcomes nals demonstrate où effeacy in reducing the ik of composite MACE, CV death, alrcause mortal,

"MI, HF, and renal outcomes in individuals with T2DM wih etabishodíigh sk of CVD.
1. American Diabetes Association Professional Pracice Committee. Diabetes Caro. 2024:47(suppl 1) S158-S178.

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11. Considerations for Choosing a GLP-1-Based Therapy*?

Exenatide Exenatide Semaglutide Semaglutide
Indications Dulaglutide BID ER Liraglutide Lixisenatide sc PO

Adjunct to diet and
exercise to improve Y
glycemic control in

adults with T2DM

Y Y Y Y Y Y

Adjunct to diet and
exercise to improve

glycemic control in Y Y
patients aged 210 years

Reduce risk of MACE in
adults with T2DM with Y = = VA = V2 =
established CVD

Reduce risk of MACE in

adults with T2DM with SÍ
multiple cardiovascular

risk factors

1. aps www accessdata.da govscrptscderidal, 2. Sattar N ot al. Nat Med. 2022:28:591-598. ñ
3. Gragnano F et al. Eur Heart J Cardiovasc Pharmacother. 2024:10:7-. PeerView.com

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12. What About an Insulin/GLP-1 RA
Fixed-Ratio Combination for Galen?‘

+ 2FRCs are available: glargine/lixisenatide and
degludec/liraglutide

— Glargine and degludec are basal insulins
+ Switching from a GLP-1 RA to an insulin/GLP-1

+ Remote history of stroke

+ BMI = 27 kg/m?, eGFR = 50 RAFRC would offer glycemic benefits but not
mL/min/1.73 m2, UACR = 40 weight benefits
mg/g, and a 15year history of + Dedicated CVOTs haven't been reported for
T2DM (AIG 5:8.8%) either FRC, but
+ Current medications: basal — Glargine, lixisenatide, and degludec have
insulin and an SGLT2i neutral effects on CV outcomes
— Liraglutide reduces MACE at the 1.2 and
1.8 mg doses
1,8 run orgno een) Per aman Nn acetal oia socal 2029 200570409 A ap nan
gargheraghuide)Prescring Information. ts ww acossdata 1a gowcrugsatida_docstabel/2023120858350211 pdf. 3. Gerstein HC et al. N Engl J Med.
oz ser 3109284 Pater MA tt N Eng Mod. 201839 2247-2287 5 Maso SP etal N Engl] Med. 2017377 1297-6 Maso SP ea, NEnglu Ned. :
201637531122. PeerView.com

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13. Weight Loss Efficacy of Glucose-Lowering
Medications for T2DM!

Il GIP/GLP-1 or GLP-1-based agent

46

Weight Reduction vs
Standard Treatments, %

BB Other agents

86

1. Shi Q eta. BMJ. 2023:381:0074068, PeerView.com

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14. Timely Treatment Intensification
to Achieve Personalized Glycemic
and Weight Loss Goals

Javier Morales, MD, FACP, FACE
Clinical Associate Professor of Medicine
Donald and Barbara Zucker School of Medicine
Hofstra Northwell Hempstead

Vice President
Advanced Internal Medicine Group, PC
East Hills, New York

Go online to access full CME/CE/AAPA information, including faculty disclosures.

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15. How Effective Is Intensive Lifestyle Intervention in PwT2DM?
Lessons From the Look AHEAD Study!

Minimal Long-Term Change in A1C*

Glycated Hemoglobin a

Intervention

Main effect -0.22 (95% Cl,-0.28to 0.16)

ss P<.001

Timo, y

No statistically significant between-group
difference in CV events, despite improvements
in all CV risk factors except LDL-C

N= 5,145 patients with T2DM and overweight or obesiy followed fr up to 13.5 years.» P< 05 for the between-grou
AHEAD Research Group. N Eng Y Med, 2013:200 145-184. 2 Wadden TA ot al. Obesty (SWver Spring) 2009.11 710722.

1: Look
3. Wadden TA et al. Obesity (Siver Spring). 2011;19:1987-1996. 4. Look AHEAD Research Group. Obesty (Siver Spring) 2014:22:-13.

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Modest Long-Term Change in Weight?
Weight

Controt®

Intervention

Main effect: -4 (95% Cl, 5 10-3)
P<.001

Ce a res +
Time, y
25% 680% 136%
210% 377% 33%

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16. Early Glycemic Control Matters’

Consequences of Delayed Intensification

Patients Without Previous CVD

Retrospective cohort study of 105,477 patients from the UK Clinical Practice Research Datalink, 1990-2012

At 5.3 y, significantly increased risk of
+ MI 67% (CI 39%-101%)

85 + Stroke 51% (Cl 25%-83%)
+ HF 64% (CI 40%-91%)
y + Composite CVE 62% (Cl 46%-80%)
S 75
< Patients with A1C 27% not
70 receiving IT within 1 y
65 Patients with A1C <7% who
Dysglycemic legacy Drive risk for complications received IT before 1 y of diagnosis
T T T T 1
6 12 48 54 60
Time, mo

4. Lateorapong N et al. Diabetes Care 2019:42:416-426. 2. KhuntK, Milr.Jones D. Prim Caro Diabotos.2017:11:3-12.
3. Paul SK et al Cardovase Disboto 2015:14:100.

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17. Overcoming Therapeutic Inertia in T2DM:
Clinician/Practice-Level Interventions!

Recognize
Treatment Inertia

+ Check for barriers
- Diabetes distress

Understand Impact
of Treatment Inertia

+ Schedule “diabetes only” visits where
you and your patients can focus solely
on diabetes

+ Ask office staff to remind patients to
bring their glucose logs, list of
medications, and monitoring devices

— Depression
— Low health literacy
Social determinants of health

+ Aim to adjust therapy any time a
+ Schedule follow ups based on A1C

patient's ATC or other targets are

not at goal — Every 6-8 weeks for those at
+ Consider making changes 9% or higher

between A1C tests based on — Every 2-3 months for those at

monitoring results 7% to 8.9%

— Every 3-6 months for those less than
7% or at their personal target

1. hips twa therapeutcinerta diabetes og/aboutherapouteinerta.

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Plan With

+ Develop a diabetes care plan
that includes a personal
AIC target

+ Take into account patient
needs, concems, and wishes

+ Review and update regularly

+ Refer all patients for diabetes
self-management education
when diagnosed or if they have
not been before

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18. Clinical Inertia Is Dangerous and Deadly’

PwT2DM, mean A1C 8.1% and 11% with CVD at diagnosis —
7.1% had at least one MI, stroke, or HF event over 5.3 y foll

Among PwT2DM and A1C istently 27%, 26% did not receive
therapeutic intensification during follow-up

For every year at A1C 27% (vs A1C <7%)

100
Be 80 67
SS
2S 20 t
0
MI Stroke Composite
Pau Sora Coronas Daba! ARO OT" PeerView.com

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19. Duration of Overweight/Obesity Matters’:2»

CVD Risk Increases With Longer Duration
of Overweight and Inactivity

& 20 1.89
S 18
316 IM Active
e + Ml Inactive
E 14 1.25
e 12 1.00
0.95 .

S 10
B os
so
x 06 0.43
a 04
5 O

0

Healthy weight Healthy weight Overweightnow Overweight now Overweight now
now and 10y ago nowandi0yago butnoti0yago and 10 y ago and 10 y ago

1443 adults aged 36-85 years, NHANES 2003-2006. > CVD isk core ranged from 0-6 based on the total numberof CVD ik factors: (1) hypertension
{140/90 mio). (2) dabeles lasting gucoso 2126 mol. or ANC 28.5%) (5) hgh ed col ditrbuton width {14 8%). (4) gh CRP (0.3 moi) (5) ow HOL (males

<40 mg. females <50 mpl} (6 high TG (150 moi) —

1. Danke! $3 otal. Int J Cardo. 2015:201:P88-P89, PeerView.com

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20. ADA Standards: Weight Management Assessment
Recommendations!

May need to monitor
weight more frequently

Use person-centered
nonjudgmental
language

Be understanding;

up to 80% of obesity

might be genetically
determined?

1. American Diabetes Associaton Profesional Practico Commitee, Diabetes Care. 2024 47( supp 1) 158-5176. —
2:Abury etal Lanon bats Endocinal 2020 8447-15: Plan SH all Obes So Prat 2022610048 4, Hamed Set al BIC Pub Has. 202222500. PeerView.com

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21. Shared Decision-Making:
What It Is and Why We Use It14

Use shared decision-making to identify appropriate and individualized
glycemic targets and reach agreement on treatment changes

Employ SDM to collaborate with dh, o ‘SDM can help improve decisions,
patients on individualized &D } patient knowledge, and patient risk
diabetes plans perception
SDM helps to acknowledge ‘SDM has been linked to better
and address emotional needs self-care (eg, improved diet,
of PwT2DM foot care)

1. Booder Sot a. Dabets Thor. 2023:14:425-448, 2: Siebinga VY e al Pant Edue Couns. 2022105 2145-2160 6

3, Resnicow K et al. Med Decision Making. 2022:42.755-764. 4. Kunneman Metal Endocrine, 2021.75:-377-391. PeerView.com

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22. Why Not Just Max Out the Metformin Dose?

Mean Changes From Baseline in A1C and FPG at Week 16 in PwT2DM'

Metformin ER

500 mg 1,000 mg 1,500mg 2,000mg 1,000mg Placebo
Once Daily Once Daily Once Daily Once Daily Twice Daily

Hemoglobin A1C, % (n=115) (n=116) (n=11) (n=125) (n=112) (n= 111)
Baseline 82 84 83 84 84 84
[_ Change at FINAL VISIT -04 -0.6 -0.9 0.8 EX 01)
P <-001 <-001 <-001 <-001 <-001 =
FPG, mg/dL. (n=126) (n=118) (n=120) (n=132) (n=122) (n= 113)
Baseline 182.7 183.7 178.9 181.0 181.6 179.6
Change at FINALVISIT -15.2 19.3 -28.5 -29.9 33.6 76
P <.001 <.001 <.001 <.001 <.001 -
1. ps wn aocosadataf6a.govidrugsatisa_ docslabe/2017/0203670375039,021202302120230 pdf. PeerView.com

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23. Simplified Management of Glucose-Lowering Medications
in T2DM: DCRM Multispecialty Practice Recommendations!

Lifestyle therapy

Recommended Hierarchy
HFFEF/HFPEF Stroke/TIA =
LAGLP-1RA SGLT2I SGLT2i LAGLP-1 RA er
SGLT2i LAGLP-1RA Pioglitazone Metformin E
Pioglitazone Desc ES
=> Insulin | A
Younger, Manage Hyperglycemia to Individualized Goal Older; sal!
healthier, 6.5% 7% complex, 2
at lower at higher 8
CV risk Most patients CV risk LE
Y
Bromocriptine QR | %
+ Use initial combination therapy for patients with A1C >1%-2% above goal Pramlintide x |

+ Assess glucose management with A1C (3 m), CGM or SMBG, glycated albumin or fructosamine (3 wk)

+ Add agents with complementary MOA to maintain glucose control at goal*

+ Choose agents according to recommended hi Ys risks, benefits, preferences,
Chose agents aeg recommended harry based on patents sks, beets, ri Il isst cvorts

+ Insulin is necessary for patients with diabetes symptoms E Hypoghyesinia andor HF rat

Do not combine GLP-1 RA and DPPAL Use caution whan combining insulin + SU or insu + TZO.

1-Handelsman Y otal. J Diabetes Complcatons. 2022.36-108101 Bom PeerView.com

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24. ADA Standards: Priori

zation of Glucose-Lowering

Therapies to Meet Different Individualized Goals'

Reduce ASCVD Risk

GLP-1 RA with proven
CVD benefit
+ Dulaglutide
+ Liraglutide
+ Semaglutide injection

Alternative treatment
strategies

+ SGLT2i with proven CVD benefit
+ GLP-1 RA + SGLT2i
+ GLP-1 RA or SGLT2i + TZD

Consult ADA guidelines foi

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Reduce A1C

Choose approaches that provide the
efficacy to achieve goals
Metformin OR agent(s) including
COMBINATION therapy; prioritize
avoidance of hy lycemia in

nera neva

Efficacy for Glucose Lowering

Dulaglutide (high dos
somaglutido, tirzepatide, insulin,
‘combination oral, combination
injectable (GLP-1 RAVInsulin)

GLP-1 RA (not listed above),
metformin, SGLT2i, sulfonylurea,

Reduce weight

Consider glucose-lowering regimens
with high-to-very-high dual glucose
and weight efficacy

Efficacy for Weight Loss
Very High Somaglutido, tirzepatide
High Dulaglutide, liraglutide

Intermediate

GLP-1 RA (not covered above),
SGLT2i

Neutral DPP-4i, metformin

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25. DPP-4is Should Not Be Used With a
GLP-1 RA or GIP/GLP-1 RA!

ADA and DCRM guidelines advise against using these combinations
GLP-1 RAwith GIP/GLP-1 RA
GLP-1 RA with DPP-4i
GIP/GLP-1 RA with DPP-4i
GLP-1 RAwith another GLP-1 RA
DPP-4i with another DPP-4i

Evidence from a randomized crossover trial of PwT2DM treated
with metformin and liraglutide 1.2 mg (N = 16)

Intervention Results Conclusion
Sitagliptin or + Meal-induced incretin responses ? in lira group GLP-1 receptors were
placebo - 178% GLP-1 already maximally stimulated
administered - 190% GIP by liraglutide; adding
60 min before + No significant difference in insulin, glucose, sitagliptin didn't make any
ameal glucagon, or C-peptide difference
Boon 36108101 Nove et a Diabetes Obes Neto, 20TT OAD INT, A SUP TYSIEESITR.2- Handelsman Y etal. Janene om PeerView.com

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26. Why Not Use CGM?'

7 CGMs are wonderful tools to troubleshoot
6 ( the causes elevated A1C, but CGMs are
ih not recommended as interventions for

elevated weight

+ The ADA guidelines recommend CGMs to monitor blood glucose in PwT2DM
after therapeutic intensification
— Professional CGMs are ideal where there is a temporary need for close
monitoring of glycemia
— Personal CGMs show patients very clearly how food choices and physical activity
affect glycemia but are less accurate at near-normal blood glucose levels and
may overestimate hypoglycemia

1 American Diabetes Associaton Professional Pracice Committee, Diabetes Coro. 2024:47(supp 1) 5158-5178. PeerView.com

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27. Shared Decision-Making
in PwT2DM and

Overweight or Obesity

Javier Morales, MD, FACP, FACE
Clinical Associate Professor of Medicine
Donald and Barbara Zucker School of Medicine
Hofstra Northwell Hempstead

Vice President

Advanced Internal Medicine Group, PC

East Hills, New York

Go online to access full CME/CE/AAPA information, including faculty disclosures.

Copyright © 2000-2024, PeerView

28. Weight Loss Is Critical for Diabetes Remission: DiRECT

Diabetes Remission: Mii 46% a
Endocrine ieve
fo
Society/EASD/Diabetes 2 remission

UK/ADA Consensus Weight loss of 10-15 kg: 57% achieved diabetes remissions
Definition! Weight loss of 215 kg: 86% achieved diabetes remissions

1. Sustained metabolic

le 4400000090 24% 1000090000 11%

2. Return of A1C <6.5% Maintained 210 kg weight Maintained 215 kg weight
persisting for 23 mo loss loss
without glucose-lowering
medications®»

3. Annual testing thereafter Aare 64% HT’ 70%
tovassess long-term Achieved diabetes remission Achieved diabetes remission

maintenance of remission

mega tate an usb mata ron Omi control a par pan. FPG 128mg or «EN cts fom COM ate.
* Tes A st porto an tren (am a DD, surgical, ese) and no sone han 3 mont ar an and wihdrwal of any coe Lori A
Re MS etal Diabetes Coro. VA DISE 264 2 Loan ME etal Lance 2016 001 541-401 9, Lean ME etal Lance! Dabeles éme 20187510355 PeerView.com

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29. Maintaining Lower A1C and Weight Significantly Reduces
the Incidence of CVD Events: Lessons From Look AHEAD

Association of Duration of Diabetes Remission
With CKD or CVD Events! Maintaining weight
loss and higher

HR 1.0 0.76 0.73 0.45 10 0.66 0.59 0.51 =
physical activity

g = mNone m1 Visit m2 Visit m24 Visits was associated
$ 20 with lower risk of
5 CVD events, even
das in individuals who
$ did not have
= 10 diabetes
[4 remission?
= 05
a

CKD (High or Very High Risk) Composite CVD
1. Grogg EW et al. Diabetologi. 2024:67:459-469. 2. Huang Z et al. JAMA Netw Open. 2024:7:0240219. PeerView.com

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30. Bariatric Surgery Is Superior to Medical Therapy/Lifestyle Intervention
at 7 to 12 Years of Follow-Up, but Remission Is Not a Typical Outcome’

1. Courcoulas AP ot a JAMA, 2024:331:654-664

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Participants Achieving Remission, %

No. of Participants
MochcatMesyie
Bart surgery

Diabetes Remission

e
e
e
O © Bariatric surgery
eee e e
Medicallifestyle e e
ateC © we 6

Annual Visit

a 7 82 7% M 7% 77 nn oF s 3
164 181 19 HD 16 108 11 116 12 117 9 82

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31. Establishing a “Virtuous Cycle” in
Comprehensive T2DM and Obesity Management?

— Plan is

Use shared Goal is met Rati

decision-making to

choose which goal
to pursue first

In a clinical trial program
for a GIP/GLP-1 RA
therapy in PwT2DM,

improved glycemic

Develop a Distress is
Pee manageable Intervention control and reduced u
realistic. goals plan to is attempted weight was associated benefits are
reach goals with adoption of other noticed
healthful behaviors
(dietary modifications,
increased exercise)
Encourages
New gools adherence
— °°"
1. Vals M. Int J Clin Pract. 2016:70:196-208. 2. Matza LS et al. Patient. 2022:15:367-377. PeerView.com

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32. How Much Weight Loss Is Needed to Improve Health?

+ Notas much as many patients would like
Improves
health to lose! o |
— Unrealistic weight loss goals are common and
self-defeating!0-13

Reverses some + Weight loss of 5%-10% may be disappointing

disease to patients’

procesos — Itis better to set a 5% goal and celebrate that
success than to set a 20% goal with

Reduces CV inadequate resources and quit in frustration

events and

complications?

Diabetes Caro. 2010:332156-2163. 3. Phelan S etal J Url 2012:187:939.044,
Diabetos Caro. 201336:2937-2944. 5. Wing RR eL al J Sox Mod. 2010:7.156-165.6. Engel SG et al. Obes Ros. 2003:11:1207-1213.

‘Hopatology. 2010.51:121-129.. Foster GO etal. Arch ntom Med. 2009:169:1619-1620. 9. Després JP ot al. BMJ. 2001:322716-720.

10. Pété Bot al. Prov Mod Rep. 2018:12:12-19. 11. van Riswik AS at al. Surg Obes Rlat Dis. 2021:17:139-146, peerview:

12. Conceigáo EM ot a. Surg Obes Relat Dis. 2020.16932999. 13 Black Cet al. Psycho! Heath 2021:36:934-961. eerView.com

Diabetes Caro. 2011:34:1481-1486.2. Lazo M

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33. Shared Decision-Making:
What It Is and Why We Use It14

Use shared decision-making to identify appropriate and individualized
glycemic targets and reach agreement on treatment changes

Employ SDM to collaborate with dh, o ‘SDM can help improve decisions,
patients on individualized &D } patient knowledge, and patient risk
diabetes plans perception
SDM helps to acknowledge ‘SDM has been linked to better
and address emotional needs self-care (eg, improved diet,
of PwT2DM foot care)

1. Booder Sot a. Dabets Thor. 2023:14:425-448, 2: Siebinga VY e al Pant Edue Couns. 2022105 2145-2160 6

3, Resnicow K et al. Med Decision Making. 2022:42.755-764. 4. Kunneman Metal Endocrine, 2021.75:-377-391. PeerView.com

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34. Weight Trajectories in PwT2DM:
SURMOUNT-2 and SURPASS-1

SURMOUNT-2' H SURPASS-12
‘ i
4 i 3%
É ig
a ido
E i € Tirzepatide 10 mg
pa Tirzopatide 10 mg | 8,
4 wa tas id
S154 Tirzepatide 15mg Par 135
@ a — À 84
oimlal wae © % téóneiesm os 8 em à +
102 pri 1 4
Time Since Randomization, wk Time, wk
1. Gary WT etal Lance 2023:02:619-6262. Rosenstock Jat al. Lancet 2021908:49-15. | PeerView.com

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35. Weight Trajectories in PwT2DM:
STEP-2 and SUSTAIN FORTE

STEP-2' SUSTAIN FORTE?

o mean baseline weight = 99:3 kg,
#
Fe
3
ds
8% Semaglutide 1.0 mg
5 n=403 Semaglutide 1.0 mg
ö 937 kg
Ze
5 5.6%
$ Semaglutide 2.0 mg
Somaglutide 2.4 mg
10
3 n= 404 44%
2
ots nem 2 % à + © © 0 4 nom E o
Time Since Randomization, wk Time Since Randomization, wk
1. Davies M et al. Lancet, 2021;287:971-984. 2. Fras JP etal. Lancet Diabetes Endocrinol. 2021:9:563:574. PeerView.com

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36. Weight Trajectories in PwT2DM:
SCALE Diabetes and AWARD-11

SCALE Diabetes! { AWARD-112
o :
i} ”
À Primary
x ! ‘endpoint
= poo
3? H
E Placebo | BS
3 |
D 4 15%
E 13 ú
2 Liragutido | À & + —
£ u. H El Dulaglutide 3.0 mg ©
8 « ¡ae PET
z Liraglutido !
> 3.0 mg : CI 50
4 o
0248 62% % D 8 % H o4 8 2 1 2% ES
Time, wk H Time, wk
1. Davies Md et al JAMA, 2015:314:687-699.2.Bonora E etal. Diabetes Obes Metab. 2021,23242-2250. PeerView.com
PeerView.com/ZKT827

Copyright © 2000-2024, PeerView

37. Setting Appropriate Expectations for 20% Weight Loss
With GLP-1 RAs and GIP/GLP-1 RAs in PwT2DM

SURMOUNT-2' STEP-22
100
M Tirzepatide 10 mg M Semagiutide 2.4 mg (n = 388)
MM Tizopatice 15 mo = BE. Semagutide 1.0 mg (n = 380)
® Placebo ga IE Placebo (n = 376)
i i*
Ej Zo
i Es
H H
i le
é é
2
Bodyweight Reduction Threshold, Bodyweight Reduction Threshold, %
1. Garvey WT et al Lancet. 2023:402:613-626. 2, Davies Met al. Lancet. 2021:397:971-984, PeerView.com

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38. Weight Loss With GLP-1 RAs and GIP/GLP-1 RAs May Be
Smaller in Clinical Practice Than Those Observed in RCTs!

Weight Loss Outcome: 21,653 Patients With T2DM and Overweight/Obesity
Initiating Semaglutide
3 3

Ms
& CET
£ D 1o%10<20%
3
220%
E a
i
3
7
=
¿months ” Gmonths — 12months | 3 months 12months | 3months — Smonths 12 months
T2DM i No T2DM H Overall
1. Avenatt E et al. J Am Coll Cardiol 2024;89(Suppt A): 1791, Abstract 1116-09. PeerView.com

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