Weight Loss Drugs and MS: What You Should Know

Weight Loss Drugs and MS: What You Should Know

Episode 189 – Podcast Transcript

[(0:00)] Stephanie Buxhoeveden: [Music] Welcome to the Can Do MS Podcast. I’m your host Stephanie Buxhoeveden. I live with MS, and I’m also a clinician and MS researcher. Today we’re joined by Dr. Alise Carlson, who’s a clinical neurologist at the Mellen Center for MS Treatment and research at Cleveland Clinic. Welcome, Alise. Can you tell us a little bit about yourself?

[(0:42)] Alise Carlson: Hi, thank you so much for having me today. Um, so I’m Alise Carlson. I’m a clinical neurologist at the Mellen Center at the Cleveland Clinic in Cleveland, Ohio. Um, I primarily treat patients with multiple sclerosis and other neuroinflammatory disorders, and I have a particular passion for the topics, uh, pertaining to women’s health, um, including family planning, sexual dysfunction, menopause and management of symptoms that span the female reproductive life cycle.

[(1:14)] Stephanie: Amazing. We have that in common. Such important issues. We’re gonna talk about weight loss medications today specifically, and it seems like everybody’s talking about this right now. So can you give us a quick overview of what these weight loss drugs are and how they work?

[(1:31)] Alise: Absolutely. So, um, these are, as you know, a very new class of medications. Um, there are a variety of different brand names and generic names that you may hear floating around out there. But essentially, um, to describe these as a class, basically these medications are what are called glucagon-like peptide-1 receptor agonists. Okay. And, uh, essentially what they are is they’re, uh, incretin based therapies that are used. They were originally developed actually for use in type 2 diabetes, but more recently have been used for obesity management. And what these medications do is they mimic the GLP-1 hormone that the body naturally makes. So essentially by giving the exogenous hormone, it enhances those glucose dependent insulin secretion. Um, and what that does basically is it suppresses something called glucagon in your system that, when that’s present, triggers your body to seek out a meal. Okay. Um, so that’s one way that it works by, um, uh, or an aiding in weight loss.

It also delays something called gastric emptying, which is how quick your stomach moves food from its, uh, reservoir into the small intestine. And that can help reduce appetite because it makes you feel fuller longer. Okay. And then it also, um, hormonally can help, um, increase something called satiety, which is, again, your body’s or your brain’s interpretation of feeling full. So all of these things work together to contribute to weight loss and can also lead to improved glycemic control, meaning keeping your blood sugar levels steadier longer.

[(3:09)] Stephanie: Perfect. Thank you for explaining that. I hear often people use the term food noise and, right. And that it basically like quiets down that part of your brain that’s always saying, I’m hungry, feed me, I’m hungry. Um, so I love that technical overview you gave, and those of us living with MS know that between fatigue, mobility challenges and heat sensitivity, living with MS makes exercise and weight management really challenging, more challenging than it is for the average person. So what are the potential impacts of weight gain in MS and why might these weight loss medications be a good option for some people?

[(3:48)] Alise: Absolutely. So we know that oftentimes following an MS diagnosis, patients experience new symptoms pertaining to how their body functions. It’s not necessarily the same body that you’ve been living with up until that point in your life. And you may have problems like, um, muscle weakness, problems with sensation, problems with balance or walking, um, dizziness and of course severe fatigue. And all of these things cont-, can contribute to one’s inability to exercise to the same extent that they were prior to their MS diagnosis. Um, and these changes in mobility and energy level can of course subsequently contribute to things like weight gain and in some cases obesity. Um, what we know is that obesity actually increases, um, increases the level of circulating female hormones, specifically estrogen in the system. Right. And that can over the long term, kind of contribute to a worsening disease course. So managing weight gain and mitigating development of obesity is very important, particularly in our female patients.

Um, some other things to consider pertaining to exercise, of course, um, are that a lot of patients with multiple sclerosis experience heat intolerance, exposure to heat or anything that raises the core body temperature, including exercise, can make those MS symptoms emerge to a more significant degree. And so, uh, you might imagine that as a person begins to exercise, they might feel good initially, but then they lose their stamina or lose their ability to maintain certain movements or, um, do certain exercises safely because their MS symptoms are kind of starting to become exacerbated. And then I think the-the final point to make here is that, um, hormonal shifts that occur in women throughout, again, the female reproductive life cycle can really cause um, shifts in the way our body stores and utilizes fat, right? It changes our body composition and all of this can contribute to problems or difficulties with exercise. So, um, making sure that we’re cognizant of these issues and-and counseling our patients appropriately, I think can help offset some of that risk.

[(6:05)] Stephanie: Absolutely. And we all know exercise is super important with MS, but the practicalities, like you mentioned, of living with the symptoms of heat, intolerance of fatigue, it really does have a significant impact and you are at times having to choose where to put your energy. And in addition, I’ve found that some of the medications I take for symptom management cause weight gain too. So it’s-it’s an ever present balance of trying to-to manage symptoms and get enough exercise. And I think it’s just really nice to have another tool that you can turn to. And these medications, I’m sure, uh, are being asked about at your clinic a lot, and I’m sure people are asking you are they safe? And what do we know so far about the safety of GLP-1 medications in people with MS?

[(6:57)] Alise: Yeah, so that’s a really good question and I think at the forefront of the minds of both providers and patients that are considering use of these medications. Um, so far the evidence for use of GLP-1 receptor agonists in MS is generally reassuring. It’s quite limited, you know, there haven’t been widespread studies on this, but based on the available preclinical and early clinical data, things look really good. I also get a lot of questions about how, um, how these medications might actually benefit patients with MS from a neuroprotective perspective. Um, again, limited studies, but what I can share with you is that there have been several animal studies using experimental models of MS that have consistently shown that GLP-1 receptor agonists, um, do not exacerbate disease activity. Meaning they do not necessarily cause an increase in MS relapses or worsening, and they don’t seem to indu-induce adverse neurological events, but they-they may in fact do the inverse. They-they’ve demonstrated that there are some neuroprotective and anti-inflammatory properties, um, in these animal models.

So that’s really fascinating and I think something that, you know, we’ll have to explore more deeply, of course, through human clinical trials. There have been smaller, um, human cohort studies kind of retrospective meaning when clinicians look-look back in the past at patients who have been treated with these medications. One publication, um, that included a cohort of about 50 patients with MS treated with GLP-1s, um, again, primarily for diabetes, but obesity as well. Um, found that, um, patients with MS tolerate these medications, um, to a similar degree is the general population. Again, the primary side effects of these are usually gastrointestinal, meaning stomach upset or nausea, and about a third experience those side effects, again, very similar to the general population. Um, but again, importantly in this human cohort, there was no increased signal for increased MS disease activity attributable to these medications. Um, and most of these patients were able to continue with treatment.

And then I think the other thing important to mention here, just because we previously touched on the fact that obesity, um, can increase the risk of, uh, developing MS early on in-in life and can exacerbate, um, uh, inflammatory disease activity, I think it’s important to mention that, uh, Mendelian randomization study, meaning look at ca-, looking at causal effects for disease, did not find, um, an association between exposure to GLP-1 receptor agonists and the development of MS. So again, that kind of further supports this neutral safety profile.

[(9:47)] Stephanie: Fantastic. So it sounds like you at least have some experience now using these medications in your patients. Generally, how are they feeling?

[(9:55)] Alise: So anecdotally, I think these patients tolerate the medication really well. Um, of course, again, speaking from a class effect of these medications, meaning in patients both with multiple sclerosis and without, um, the most common side effect are gastrointestinal side effects, um, meaning stomach upset or nausea. And those are the most common things people experience and they’re usually pretty short-lived following, uh, dosing of these medications. Um, and uh, I, again, I think that it kind of also depends on the formulation, right? So there are both short-acting and long-acting formulations of this medication. The long-acting agents provide more sustained glycemic control, right? So keeping that blood su-sugar level smooth and uh, providing more, um, sustained weight effects. And I think we generally prefer those, um, for their convenience and efficacy and-and tolerability profile compared to the shorter acting formulations.

[(10:53)] Stephanie: Perfect, thank you. So as we said in the beginning, I absolutely share your passion for women’s health and MS and I think this is such an important topic to touch on. And we know hormones can affect weight, affect fat distribution and MS symptoms as you already let us know earlier. And then when you layer in concerns about bone density and things like birth control interactions, it gets really complicated quickly, especially if someone’s on a DMT that’s not safe during pregnancy. So can you walk us through what people, especially women should be thinking about when it comes to hormone changes, bone health, and contraception while using weight loss medications?

[(11:33)] Alise: Absolutely. So I think we’ll kind of approach this chronologically. So early on in life, right, during the childbearing years, so young women which comprise of-of the vast majority of our MS population, there are a lot of things to, um, to consider here. And you already mentioned one of the big ones, which is effectiveness of oral contraception. Um, so some of those agents, um, can, uh, have reduced effectiveness if used in combination with a GLP-1 because as you might recall at the beginning we talked about how these medications slow down the emptying of the stomach through the intestine, right? And, um, the way oral medications worked and were developed are typically so that they release a steady amount of medication at a given time. So if we disrupt that, it can in theory reduce the effectiveness. Um, so if you are thinking about starting one of these medications and you’re on a disease modifying therapy for MS, which again generally are not considered safe for use throughout pregnancy, it’s important to let your MS provider know that, um, so that they’re aware that you’re starting these medications and can counsel you effectively on appropriate birth control methods to avoid an-an undesired or unplanned pregnancy.

Um, that being said, I also think it’s important to be aware that, um, family planning can be coordinated if approached, um, again, proactively, right? So if you know that you might be wishing to have a pregnancy, um, you’re on disease modifying therapy and may also be using one of these GLP-1, uh, medications, uh, that’s okay, we can manage that. It just takes a little bit of-of planning with your provider and then transitioning to the later phase in life, right? When, um, women begin entering the perimenopausal and menopausal period, we start to have additional concerns, um, outside of the, uh, the neurologic system, right? Including bone health and bone density. We know that women are at risk for bone density loss as they age. Um, this is a process that can be expedited or accelerated with use of GLP-1s. Um, so being aware of those risks and thinking about ways to mitigate that risk is really important. And the two primary things that you can do to help with that are increase weight bearing activity. And it can be something as simple as, uh, a risk walk a few times a week and increasing your protein intake right alongside these medications can really help us to avoid some of those pitfalls.

[(14:10)] Stephanie: Those are really great and easy tips for staying healthy. Of course, all of this sounds amazing, but we do have to address one concern, and that’s that these medications can be incredibly expensive and I’ve heard from people who were excited to try them, but then got really discouraged by the price tag or ran into insurance denials. So how accessible are these drugs right now for people using them purely for weight loss? And what options do people have if they’re struggling to get insurance coverage?

[(14:41)] Alise: Yes, I’m-I’m happy you brought that up because that is again, uh, the main barrier. I would say, you know, you might, you might get to the point of making a decision that you want to use one of these medications with your providers, but then when it actually comes to procuring the medication and getting you started on it, there can be a lot of barriers that are outside of our hands. And unfortunately, a lot of this falls onto the type of insurance plan that each individual patient might carry. Um, and that varies quite significantly between plans. Um, we know that of course if there are other indications that might support your use of one of these medications such as concomitant diabetes, elevated BMI or um, heart disease, those are things that the insurance company will look at and say, okay, there’s something here beyond weight loss that might support the use of this medication.

Um, but I do think that, you know, that as these-these medications become more widely used, their safety and advocacy profiles are improved upon, I anticipate that’ll change with time. Um, but as you mentioned, uh, a here and now, the out-of-pocket costs can be prohibitive sometimes for a weight loss only indication. Um, so I think it’s important to be aware of that going in. Um, and again, um, along the lines of speaking about insurance, of course access disparities can impact to benefits from these medications, which is an unfortunate truth. Um, but um, I think, again, speaking to someone who has some experience in managing and prescribing these medications would be useful in helping you obtain them if this is something you wanted to pursue. Um, and of course, um, I think the last point to make here is making sure that both your neurologist and your primary care provider or your endocrinologist, whoever’s kind of helping you with the weight management aspect of things are coordinating and making sure that your overall treatment plan is safe and, um, tailored to your individual needs.

[(16:43)] Stephanie: That’s great. Thank you so much. So at Can Do MS, we always like to focus on what people can do, so I want to leave our listeners with some next steps. So if somebody with MS listening is considering a weight loss medication, what should they talk to their healthcare provider about and what other strategies should they think about combining it with?

[(17:03)] Alise: I think that’s an excellent question. Um, if this is something that you’ve come to a-a decision yourself that you might be interested in pursuing, it’s important to breach that topic with your MS provider just so they’re aware that you might be introducing this variable into your treatment plan. And so they can kind of look at things very comprehensively for you, right? Look at what other medications you’re on, what other medical problems you might have, or risks you might have going on these medications so that we can implement some of these mitigation strategies early and effectively. Um, and then I think it’s also important again to-to create a comprehensive approach to your weight loss, right?

So these GLP-1 medications are not a magic bullet. They should not be used in isolation for weight loss. Um, they should be combined with, um, w-with a combination of diet, whether that be, um, an MS protocol diet, which there’s lots of good information, um, on the web pertaining to that, or even meeting with a registered dietician, um, to kind of develop a nutritional plan that-that fits your needs. And then complimenting all of this with exercise, right? So, um, either doing self-directed exercise of capable or if you’re someone who kind of struggles to know what exercises might be right for you, meeting with a physical therapist can oftentimes be helpful, especially if you have motor limitations or gait limitations related to your multiple sclerosis. They can help you develop an exercise plan that’s safe for you to perform that will, um, avoid you causing additional injury or putting yourself at risk specifically for falls. Um, so I think, again, all of these things in combination should be considered and put into place simultaneously to give you the best chance of success. [Music]

[(19:03)] Stephanie: Thank you for that really thorough and informative overview. I know I learned a lot and hope our listeners did too. And just wanna thank you for your time.

[(19:13)] Alise: It’s my pleasure. Like I said, I think these are very important topics and, um, hopefully with the, with the addition of these treatments to our regimen, we’ll be able to help keep our MS patients healthy and active longer into their lives.

[(19:30)] Stephanie: That would be ideal. Thank you Again. Thank you for listening to this episode of the Can Do MS Podcast. If you like this episode, please leave us a rating and review on Apple Podcasts or Spotify. We really appreciate your feedback. We’d also like to thank all of our generous sponsors for their support of this episode of the Can Do MS Podcast. Until next time, be well and have a great day. [Music]

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