32.4 Other Drugs, Supplements, and Herbal Remedies

Semaglutide

Semaglutide, which mimics the GLP-1 hormone that is released in the gut in response to eating, is the newest medication for weight management. Semaglutide is approved for weight loss only under the brand name Wegovy. Semaglutide is also the active ingredient in several medications used to treat diabetes (Ozempic, Rybelsus). However, due to differing doses and differences in how the drug is packaged, prescribers should take caution when prescribing off-label.

Semaglutide is intended for use in adults with an initial BMI of 30 kg/m² or greater (obesity) or an initial BMI of 27 kg/m² or greater (overweight) and at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia (DailyMed, Wegovy, 2023). Semaglutide may be used in pediatric clients over age 12 who have an initial BMI at or above the 95th percentile for their age and sex. According to UCLA Health (2023), semaglutide emphasizes treating obesity as a chronic metabolic disease rather than solely a condition that requires lifestyle/behavioral changes.

When the blood glucose levels rise in response to ingested food, semaglutide mimics the GLP-1 hormone to stimulate insulin release and decrease glucagon release. This action lowers serum glucose levels and delays gastric emptying. A decrease in blood glucose and delayed gastric emptying suppress the appetite, which aids in weight loss. Note that because semaglutide delays gastric emptying, it may alter the absorption of other medications and supplements.

Liraglutide

Liraglutide has been shown to be an effective treatment to reduce weight in clients with obesity. Liraglutide is an injectable medication classified as a glucagon-like peptide receptor agonist and incretin mimetic that triggers increased insulin release and decreased glucagon release, lowering post-prandial blood glucose levels. By causing a glucose-dependent release of insulin and a decrease in blood glucagon levels, there is a delay in gastric emptying, leading to appetite suppression and weight loss. This action also causes an ancillary increase in heart rate of 10–20 beats per minute above the client’s baseline.

Liraglutide is highly bound to protein, has a large distribution area, and has a half-life of approximately 13 hours. This allows for a once-a-day subcutaneous (SQ) injection (abdomen, thigh, upper arm) without regard to meals to be effective. Double gloves and a protective gown (and goggles if necessary) should be worn during preparation and SQ administration to avoid unintentional absorption through the skin. Liraglutide has caused thyroid C-cell tumors in mice (DailyMed, Saxenda, 2021).

Table 32.4 lists common GLP-1 drugs for weight loss and typical routes and dosing for adult clients.

Adverse Effects and Contraindications

Both semaglutide and liraglutide are contraindicated in clients with a personal or family history of medullary thyroid carcinoma (MTC), multiple endocrine neoplasia syndrome type 2 (MEN 2), serious hypersensitivity to liraglutide, diabetic ketoacidosis (DKA), pancreatitis, suicidal attempts/ideation, pregnancy, and lactation. Semaglutide and liraglutide should be used cautiously in clients with alcohol use disorder, severe hypoglycemia, gastroparesis, renal and/or hepatic impairment, or history of angioedema. Caution should be exercised when used concurrently with insulin and insulin secretagogues like sulfonylureas. They should also be used cautiously in older adults. Safety in children under age 10 has not been established.

Table 32.5 is a drug prototype table for GLP-1 receptor agonists featuring semaglutide. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.

Nursing Implications

The nurse should do the following for clients who are taking GLP-1 receptor antagonist drugs:

• Consistently monitor the client’s weight, blood pressure, and serum lab values associated with obesity (e.g., lipids, glucose, and hepatic function tests).
• Monitor clients with diabetes closely for hypoglycemia and/or the need for medication reduction or elimination. With weight loss, a client’s need for medications to treat diabetes may be reduced or eliminated.
• Teach clients to monitor for signs and symptoms of hypoglycemia that may occur from weight loss and/or the supplement such as headache, nervousness, irritability, sweating, clammy skin, shakiness, and palpitations.
• Monitor client’s weight every 3 months for dosage changes as needed.
• Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.

Bupropion Naltrexone

Bupropion naltrexone (Contrave) is a combination of an antidepressant (bupropion) and an opioid antagonist (naltrexone). Bupropion is commonly used for adult depression, seasonal affective disorder (SAD), and smoking cessation. Naltrexone is commonly used for substance use disorders because it blocks opioid receptors and the euphoric effects of alcohol and opioids. In combination, these two drugs have been found to promote weight loss as a dopamine reuptake inhibitor by affecting two different areas of the brain involved in hunger and satiety stimuli—the hypothalamic appetite regulatory center and the mesolimbic dopamine circuit reward system. The resultant decreased appetite results in therapeutic weight loss.

Bupropion naltrexone is indicated for chronically overweight clients or those with chronic obesity with at least one other comorbidity (hypertension, type 2 diabetes, or dyslipidemia). This drug is used as an adjunct to a low-calorie diet and increased exercise in clients with obesity. Both drugs are well-absorbed orally, and a low-fat meal enhances absorption.

Nursing Implications

The nurse should do the following for clients who are taking bupropion naltrexone:

• Consistently monitor the client’s weight, blood pressure, and serum lab values associated with obesity (e.g., lipids, glucose, and hepatic function tests).
• Monitor clients with hypertension closely. With weight loss, a client’s need for medications to treat hypertension may be reduced or eliminated.
• Monitor client’s weight every 3 months for dosage changes as needed.
• Monitor for worsening signs of depression or suicidal ideation that may occur with some weight-loss supplements. It is critical that clinicians assess clients’ mental status, mood changes, and significantly increased signs of depression (depressed mood, loss of interest in usual activities, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, irritability, hostility, suicide attempt, or suicidal ideation), especially during the initial few months of therapy.
• Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.

Chromium Picolinate

Chromium is an essential mineral involved in glucose metabolism and is often called glucose tolerance factor (GTF). It is found in various foods such as beef, chicken, eggs, dairy products, broccoli, potatoes, and garlic, but it is poorly absorbed, prompting some clients to use supplements. Picolinate acid, an amino acid, is added to chromium to improve the absorption and aid insulin function. However, excessive supplementation can lead to toxicity. Research indicates that chromium picolinate can lower blood glucose and serum cholesterol, promote fat loss, and increase lean muscle mass, especially in clients with type 2 diabetes. Clients who are dependent on insulin should use it under medical guidance and monitor their capillary blood glucose levels (Balch, 2023).

Conjugated Linoleic Acid

Conjugated linoleic acid (CLA) is a polyunsaturated fatty acid found naturally in animal food products such as beef, lamb, butter, and dairy products. Synthetic CLA may be produced from safflower, sunflower, corn, and soybean oils. This essential fatty acid has been found to have antiobesogenic and antiatherosclerotic properties (den Hartigh, 2019). The metabolic mechanism of action of CLA reduces lipogenesis while promoting lipolysis to improve body composition. Studies have found that CLA increases lipolysis significantly in human fat cells (adipocytes) while decreasing the synthesis of fatty acids (Basak & Duttaroy, 2020). The use of CLA may interfere with CYP enzyme functions. It may also interfere with the effectiveness of tamoxifen, a breast cancer medication.

Glucomannan

Processed foods have removed much of the natural fiber in the American diet. Fiber supplements are often used for overall health and wellness. Glucomannan is a dietary fiber extracted from the konjac (elephant yam), a Japanese root vegetable. Glucomannan passes unchanged into the colon, where it works as a dietary fiber. It is one of the most potent fibers because it can absorb up to 50 times its weight in water; therefore, a smaller amount is taken than for other fiber supplements.

Some research has shown that supplementing with glucomannan may reduce body weight but not BMI in the short term in otherwise healthy adults with overweight or obesity. Other research has shown that daily 4-gram doses of glucomannan consumed over 8 weeks did not lead to weight loss or changes in body composition, did not lead to feelings of hunger or meal satiation, and did not impact cholesterol or blood sugar levels (MacPherson, 2022).

Glucomannan reduces weight in the same way as other water-soluble, fermentable fibers do—through low energy density and bulking properties causing a laxative effect. The absorption of water expands glucomannan in the gastrointestinal tract, producing satiety. Additionally, glucomannan, like all fiber foods, stabilizes blood glucose levels and reduces total cholesterol and LDL levels through fecal excretion. As with all fiber supplements, adequate water intake is essential to avoid constipation.

Green Tea Extract

Second to water, tea is the most consumed beverage globally. Green tea is one of the healthiest teas available for consumption. Green tea contains polyphenols and phytochemicals with antioxidant and antiviral properties. The health-enhancing properties of green tea are numerous. One of the polyphenols in green tea helps protect the DNA in the body’s cells from oxidative stress. This boosts the body’s immune system to combat many conditions and illnesses, including cancer. A study in South Korea found that consistently drinking green tea reduced abdominal obesity by 44% (Kwak & Shin, 2022).

The natural pharmacological effects of green tea are related to the increased fatty acid oxidation that reduces body and abdominal fat. Additionally, green tea lowers concentrations of total cholesterol, serum free fatty acids, and leptin levels. These effects may decrease the incidence of metabolic syndrome.

Guarana

Guarana is a seed with stimulant and phytochemical properties containing caffeine as the active ingredient. It is used as a general intestinal detoxification herb and stimulant to improve mental alertness and increase metabolic rate. Guarana is rich in antioxidants and is like green tea in its properties. Consumers can find guarana in energy drinks, soft drinks, smoking-cessation products, and vitamin supplements. Guarana alone does not significantly promote weight loss; it must be combined with a low-calorie diet and exercise. Due to the stimulant effects, guarana should not be used by clients with hypertension or cardiovascular conditions such as dysrhythmias. A disadvantage for consumers is that it is not easy to determine how much caffeine content any specific product contains.

Hoodia Gordonii

Hoodia gordonii, commonly called hoodia, is an African cactus that the San Bushmen used historically as an appetite suppressant. There are several hoodia supplements marketed as weight-loss supplements. According to the National Center for Complementary and Integrative Health (2020), there has been little research on the weight-loss properties of hoodia in humans and its efficacy in weight loss.

Nursing Implications

The nurse should do the following for clients who are taking supplements and herbal remedies for weight management:

• Teach clients to monitor for signs and symptoms of hypoglycemia that may occur from weight loss and/or the supplement. Signs of hypoglycemia include headache, nervousness, irritability, sweating, clammy skin, shakiness, and palpitations.
• Educate clients that some over-the-counter (OTC) products may not be safe and can interact with other prescribed medications, including increasing the risk of hypoglycemia. Recreational alcohol ingestion may also cause hypoglycemia.
• Monitor for worsening signs of depression or suicidal ideation that may occur with some weight-loss supplements. It is critical that clinicians assess clients’ mental status, mood changes, and significantly increased signs of depression (depressed mood, loss of interest in usual activities, insomnia or hypersomnia, psychomotor agitation or retardation, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, irritability, hostility, suicide attempt or suicidal ideation), especially during the initial few months of therapy.
• Provide client teaching regarding the supplement or herbal remedy and when to call the health care provider. See below for client teaching guidelines.