제2형당뇨병과 비만/과체중 - 체중 감량, 도움이 되는 약제들

 

● 제2형 당뇨병과 과체중 또는 비만이 있는 사람에서 5% 이상의 체중감량이 권고된다. 임상적 이득은 3-5% 체중 감량 시 시작되고 체중 감량이 점점 될수록 그 이득도 점점 커진다.

● 비만 약물 치료 3개월 후 5% 이상 체중 감량이 없으면 다른 약물 또는 치료 방법을 고려한다.

● 과체중 또는 비만이면서 당뇨병이 있는 경우 체중 감량에 도움이 되는 약제는 metformin, α-glucosidase inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, dual glucagon-like peptide 1/glucose–dependent insulinotropic polypeptide receptor agonist (tirzepatide), amylin mimetics가 있고 체중 중립적인 약제는 Dipeptidyl peptidase 4 inhibitors이며 체중 증가와 관련이 있는 약제는 insulin secretagogues, thiazolidinediones, insulin이다. ★★ 메트포민을 체중 감량에 도움이 되는 약제 또는 중립적인 약제로 소개한 책, 가이드라인이 있는데 해리슨 (18, 19, 20, 21판)과 ADA 2023에서는 체중 감량에 도움이 되는 약제로 소개되어 있다. Metformin reduces fasting plasma glucose and insulin levels, improves the lipid profiles, and promotes modest weight loss.

 

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• 8.6 Nutrition, physical activity, and behavioral therapy to achieve and maintain ≥5% weight loss are recommended for most people with type 2 diabetes and overweight or obesity. Additional weight loss usually results in further improvements in the management of diabetes and cardiovascular risk. B
• 8.16 Obesity pharmacotherapy is effective as an adjunct to nutrition, physical activity, and behavioral counseling for selected people with type 2 diabetes and BMI ≥27 kg/m2. Potential benefits and risks must be considered. A
• 8.17 If obesity pharmacotherapy is effective (typically defined as ≥5% weight loss after 3 months’ use), further weight loss is likely with continued use. When early response is insufficient (typically <5% weight loss after 3 months’ use) or if there are significant safety or tolerability issues, consider discontinuation of the medication and evaluate alternative medications or treatment approaches. A

 

Significant weight loss can be attained with lifestyle programs that achieve a 500–750 kcal/day energy deficit, which in most cases is approximately 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men, adjusted for the individual’s baseline body weight. Clinical benefits typically begin upon achieving 3–5% weight loss (20,51), and the benefits of weight loss are progressive; more intensive weight loss goals (>5%, >7%, >15%, etc.) may be pursued if needed to achieve further health improvements and/or if the individual is more motivated and more intensive goals can be feasibly and safely attained.

 

Agents associated with varying degrees of weight loss include metformin, α-glucosidase inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, dual glucagon-like peptide 1/glucose–dependent insulinotropic polypeptide receptor agonist (tirzepatide), and amylin mimetics. Dipeptidyl peptidase 4 inhibitors are weight neutral. In contrast, insulin secretagogues, thiazolidinediones, and insulin are often associated with weight gain