32.4: Other Drugs, Supplements, and Herbal Remedies
By the end of this section, you should be able to:
- 32.4.1 Identify the characteristics of miscellaneous drugs and herbal supplements used for weight management.
- 32.4.2 Explain the indications, actions, adverse reactions, and interactions of miscellaneous drugs and herbal supplements used for weight management.
- 32.4.3 Describe nursing implications of miscellaneous drugs and herbal supplements used for weight management.
- 32.4.4 Explain the client education related to miscellaneous drugs and herbal supplements used for weight management.
Obesity is a global concern that may not be managed by diet and exercise alone. There are other adjunct medications and supplements that can promote weight loss in conjunction with diet and exercise.
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists
GLP-1 receptor agonist medications were originally developed to treat type 2 diabetes and control blood sugar; however, they have been found to also cause weight loss and decrease the risk of cardiovascular events such as heart attacks and strokes in clients with diabetes.
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/m 2 or greater (obesity) or an initial BMI of 27 kg/m 2 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.
Trending Today
Weight Loss Benefits with Semaglutide
Losing weight can positively affect many body systems, especially the cardiovascular system; however, semaglutide itself may also have cardiovascular benefits. A report by NBC News discusses a potential reduction of cardioembolic events such as a myocardial infarction or cerebrovascular accident (stroke) in clients taking semaglutide.
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.
| Drug | Routes and Dosage Ranges |
|---|---|
|
Semaglutide
( Wegovy ) |
Initial dose:
0.25 mg subcutaneously once a week for 4 weeks.
Weeks 5–8: 0.5 mg/week. Weeks 9–12: 1 mg/week. Weeks 13–16: 1.7 mg/week. Weeks 17 and onward: 1.7 mg or 2.4 mg/week. Maximum dose: 2.4 mg/week. |
|
Liraglutide
( Saxenda ) |
3 mL prefilled injection pen: 6 mg/mL. Initial dose: 0.6 mg/day subcutaneously. After 1 week, increase daily dose by 0.6 mg per week at weekly intervals to reach 3.0 mg. Maximum dose: 3.0 mg/day. |
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.
|
Drug Class
GLP-1 receptor agonist; incretin mimetic Mechanism of Action Stimulates insulin release in the body while decreasing the release of glucagon, delaying gastric emptying and lowering postprandial serum glucose levels |
Drug Dosage
Initial dose: 0.25 mg subcutaneously once a week for 4 weeks. Weeks 5–8: 0.5 mg/week. Weeks 9–12: 1 mg/week. Weeks 13–16: 1.7 mg/week. Weeks 17 and onward: 1.7 mg or 2.4 mg/week. Maximum dose: 2.4 mg/week. |
|
Indications
Adjunct therapy along with reduced-calorie diet and increased physical activity in weight management for adults with obesity or overweight and at least one weight-related comorbidity In pediatric clients age 12 or older with an initial BMI ≥95th percentile for their age and sex Therapeutic Effects Weight loss |
Drug Interactions
Sulfonylurea Insulin Food Interactions No significant interactions |
|
Adverse Effects
Acute pancreatitis Acute gallbladder disease Hypoglycemia Acute kidney injury Tachycardia/palpitations Suicidal behavior and ideation Nausea and/or vomiting Diarrhea Abdominal pain Flatulence Gastroparesis |
Contraindications
Personal/family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2 Prior hypersensitivity to the drug or other GLP-1 receptor agonist |
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.
Client Teaching Guidelines
The client taking a GLP-1 receptor antagonist should:
- Use proper SQ injection technique and rotate injection sites weekly (liraglutide).
- Monitor capillary blood glucose levels closely; immediately report hypoglycemia to the provider.
- Drink adequate fluids to ensure hydration.
- Avoid alcohol, which may interfere with weight-loss drugs and potentially cause hypoglycemia.
- Maintain an accurate food log that includes ingestion of water and physical activity. Handwritten logs facilitate clients staying on track and achieving success. Some clients use smartphone apps to log meals, water intake, and physical activity.
- Follow up with their provider as instructed.
FDA Black Box Warning
Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists
Semaglutide and liraglutide have been associated with thyroid tumors in animal studies; relevance to humans has not been established.
Other Drugs for Weight Management
Additional adjunct drugs and supplements target enzymatic and lipid metabolism to manage chronic obesity. These drugs do not fit into the previous categories of pharmacotherapeutics.
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.
Adverse Effects and Contraindications
Adverse effects of bupropion naltrexone include life-threatening anaphylactic reactions (pruritis, urticaria, hives, dyspnea, angioedema), homicidal/suicidal thoughts and behaviors, and seizures. Common adverse effects include nausea, vomiting, constipation, and headache. Clients should be instructed to contact their provider immediately if any abnormal symptoms occur. Clients with diabetes should monitor capillary blood glucose levels 3–4 times per day for hypoglycemia caused by the drug and/or weight loss.
Contraindications include a known hypersensitivity to bupropion or naltrexone, uncontrolled hypertension, end-stage renal disease, severe hepatic impairment and concurrent use of CYP2B6 inducers, seizure disorders, anorexia or bulimia, pregnancy, and in children. Concurrent use is contraindicated within 14 days of the use of an MAOI or use of opioids or other bupropion medications and antidepressants including selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs). Bupropion naltrexone should be used cautiously in older adults secondary to possible adverse CNS effects and decreased renal excretion. Dosages are often decreased in cases of renal and hepatic impairment. Use of other bupropion-containing products may increase the risk of seizures. Bulimia and anorexia nervosa may also increase the risk of seizures.
Table 32.6 is a drug prototype table for other weight-loss drugs featuring bupropion naltrexone. It lists drug class, mechanism of action, adult dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
|
Drug Class
Dopamine and norepinephrine reuptake inhibitor and opioid antagonist Mechanism of Action Stimulates and inhibits various pathways of the central nervous system (CNS), resulting in weight reduction and maintenance of weight loss |
Drug Dosage
Extended-release tablet, bupropion 90 mg/naltrexone 8 mg: Initial dose: 1 tablet in the morning for 1 week. Week 2: 1 tablet in the morning and 1 tablet in the evening. Week 3: 2 tablets in the morning and 1 tablet in the evening. Week 4+: 2 tablets in the morning and 2 tablets in the evening. Onset: within 4 weeks; peak: 6 months. Maximum dose: 32 mg naltrexone/360 mg bupropion orally daily. |
|
Indications
Weight loss and maintenance Therapeutic Effects Weight loss |
Drug Interactions
MAOIs Drugs metabolized by CYP2D6 Digoxin Concomitant use with CYP2B6 inhibitors CYP2B6 inducers Dopaminergic drugs Food Interactions No significant interaction |
|
Adverse Effects
Nausea/vomiting Constipation/diarrhea Headache Dizziness Insomnia Dry mouth |
Contraindications
Uncontrolled hypertension Seizure disorder Anorexia nervosa or bulimia Clients undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, and antiepileptic drugs Use of other bupropion-containing products Chronic opioid use During or within 14 days of taking an MAOI Known allergy to any ingredients |
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.
Client Teaching Guidelines
The client taking bupropion naltrexone should:
- Immediately report any increase in depressive symptoms and/or suicidal ideation to provider.
- Report any signs or symptoms, such as headache, palpitations, dizziness, nervousness, irritability, to the provider.
- Drink adequate fluids to ensure hydration.
- Avoid alcohol, which may interfere with weight-loss drugs and potentially cause hypoglycemia.
- Maintain an accurate food log that includes ingestion of water and physical activity. Handwritten logs facilitate clients staying on track and achieving success. Some clients use smartphone apps to log meals, water intake, and physical activity.
- Follow up with their provider as instructed.
FDA Black Box Warning
Bupropion
Bupropion has been shown to increase the risk of suicidal thoughts and behavior in short-term trials.
Supplements and Herbal Remedies for Weight Management
Supplements such as chromium picolinate, conjugate linoleic acid, glucomannan, green tea extract, guarana, and hoodia have been credited with supporting weight loss. The success of these supplements, just like drugs, relies on their being adjuvant to low-calorie meals and exercise. A successful weight-management plan is individualized and client centered and may include natural food or herbal supplements to aid in weight loss. Stress-reduction techniques also play a role in lowering cortisol levels and improving mental well-being because stress may impede weight-loss success.
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.
Client Teaching Guidelines
The client taking a supplement or herbal remedy for weight management should:
- Maintain an accurate food log that includes ingestion of water and physical activity. Handwritten logs facilitate clients staying on track and achieving success. Some clients use smartphone apps to log meals, water intake, and physical activity.
- Incorporate healthy meal planning and physical activity in their overall weight-management plan.
- Learn about the safety and efficacy of products because they are not medically investigated or regulated.
- Talk with their health care provider for a fully informed weight-loss plan.
- Follow the manufacturer’s and provider’s guidelines.
The client taking a supplement or herbal remedy for weight management should not:
- Use weight-loss products without consulting a health care provider experienced in weight management. All supplements are not the same.
Case Study
Read the following clinical scenario to answer the questions that follow.
Ellen Normandy is a 58-year-old female client who has been “watching” her diet and exercising at the local fitness club for the past 12 months to lose weight. She has lost 6.7 pounds. Frustrated, she arrives at her health care provider’s office to ask for medication. The provider takes vital signs and a fasting capillary blood glucose (CBG) level.
History
Laparoscopic cholecystectomy due to cholelithiasis
Laparoscopic total hysterectomy and oophorectomy
Mild hyperlipidemia
Current Medications
Multivitamin daily
| Vital Signs | Physical Examination | |
|---|---|---|
| Temperature: | 97.9°F |
|
| Blood pressure: | 148/96 mm Hg | |
| Heart rate: | 88 beats/min, regular | |
| Respiratory rate: | 16 breaths/min, regular | |
| Oxygen saturation: | 99% on room air | |
| Height: | 5'9" | |
| Weight: | 278 lb | |
| BMI: | 41.1 kg/m 2 | |
| CBG: | 157 mg/dL |
Based on the information above, the nurse anticipates which primary medical diagnosis by the health care provider?
- Answer
-
Metabolic syndrome
Which of the following indicates Ellen’s BMI classification?
- Answer
-
Class III obesity