Drug therapy of obesity has harsh antecedent that many earlier introduced drugs are withdrawn from market. The drugs in present use lack sufficient long-term efficacy and safety data. The difficulty of reversing changing dietary habits and decline in physical activity, however, offers major scope for anti-obesity therapeutics, implied in managing the epidemic chronic inflammatory maladies and cardiovascular sequel. Metabolic syndrome, pre-diabetes and type 2 diabetes mellitus, commonly associate with obesity. Weight reduction is crucial to prevent and control type 2 diabetes. This emphasizes rational choice of therapeutic regimens that do not themselves cause weight gain, and better promote weight loss. Such an aspect is addressed briefly focusing upon the available newer anti-obesity drug options, in particular.

1. Obesity context of type 2 diabetes and medication
perspectives

2. Review Article
Obesity context of type 2 diabetes and medication
perspectives
Abha Pandit a
, Abhay Kumar Pandey b,
*
a
Department of Medicine, Index Medical College Hospital and Research Centre, Indore, MP, India
b
Department of Physiology, All India Institute of Medical Sciences, Bhopal MP, India
1. Introduction
Obesity epidemic is fast spreading associated with diabetes
mellitus, arterial hypertension and cardiovascular diseases.
Rapid evolution of unfavourable lifestyles, without the
availability of consistently safe and effective medications,
constitute a serious healthcare challenge. Medical attitude by
and large is treating the complications rather than obesity, e.g.
dyslipidaemia, hypertension, diabetes and cardiovascular
disorders. Weight reduction is integral to prevention and
control of diabetes. Reduction of 5–10% weight in the obese
diabetics improves glycaemic blood pressure and cholesterol
control.1
Many anti-diabetic medicines cause weight gain
making weight control difficult to achieve. Targeting of
physiological pathways without inducing weight gain may
be a proper therapeutic strategy. There is lack of adequate
long-term data on benefits and risks of currently used drugs.
The potential medical gains from treatment of obesity are
however, enormous.
2. Pathogenesis of type 2 diabetes
Genetic predisposition makes people mount positive energy
balance under exposure to certain environmental changes.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x
a r t i c l e i n f o
Article history:
Received 22 April 2015
Accepted 12 August 2015
Available online xxx
Keywords:
Type 2 diabetes
Obesity
Obese diabetics
Anti-obesity drugs
a b s t r a c t
Drug therapy of obesity has harsh antecedent that many earlier introduced drugs are
withdrawn from market. The drugs in present use lack sufficient long-term efficacy and
safety data. The difficulty of reversing changing dietary habits and decline in physical
activity, however, offers major scope for anti-obesity therapeutics, implied in managing the
epidemic chronic inflammatory maladies and cardiovascular sequel. Metabolic syndrome,
pre-diabetes and type 2 diabetes mellitus, commonly associate with obesity. Weight reduc-
tion is crucial to prevent and control type 2 diabetes. This emphasizes rational choice of
therapeutic regimens that do not themselves cause weight gain, and better promote weight
loss. Such an aspect is addressed briefly focusing upon the available newer anti-obesity drug
options, in particular.
# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
reserved.
* Corresponding author at: Department of Physiology, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462024, India.
Tel.: +91 9981087687.
E-mail address: abhay.tutorphysio14@aiimsbhopal.edu.in (A.K. Pandey).
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Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.08.001
0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

3. Their adipose tissue then expands and starts secreting
peptides that contribute to development of insulin resistance.2
Under insulin resistant state, plasma-free fatty acids rise in
obese people due to enhanced lipolysis. Their intracellular
uptake and oxidation also increase. This impairs insulin-
mediated glucose disposal in muscles. Production of glucose
and its release from the liver are also stimulated.3
Insulin resistant state precedes the occurrence of frank type
2 diabetes by few years. The pancreatic beta cells of genetically
predisposed individuals fail to fully compensate insulin resis-
tance, resulting in effective insulin deficiency. Proinflammatory
cytokines as TNF-alpha secreted by macrophages in adipose
tissue play significant role in obesity-related insulin resistance.
Type2 diabetesisthereforeastate bothofinsulin resistanceand
insulin deficiency. Type 2 diabetics with obesity bears higher
serum total cholesterol, LDL, VLDL and triglyceride and
decreased HDL compared to non-obese T2DM.4
3. Therapeutic perspectives in type 2 diabetes
Addressing lifestyle aspects, e.g. diet, exercise and weight loss,
has great significance in diabetes management. Intensive
programmes addressing diet, physical activity and behavioural
factors render valuable benefits.5–7
Medical history should be
obtained for assessing the multiple determinants of obesity,
including dietary and physical activity patterns, psychosocial
factors, weight-gaining medications and familial traits. Empha-
sis on the complications of obesity to identify patients who will
benefit the most from treatment is more useful than using body
mass index (BMI; calculated as weight in kilograms divided by
height in metres squared) alone fortreatment decisions. Weight
loss is achieved by creating a negative energy balance through
modification of food and physical activity behaviours. Treat-
ment can be implemented either in a clinician's office or by
referral to a registered dietician or commercial weight loss
programme. Weight loss of 5–10% is the usual goal. It is not
necessary for patients to attain a BMI of less than 25 to achieve a
health benefit.8
The physical activity is judged adequate for
daily 30-minute non-stop activity, at least five days in a week.
High wellness standards have also been formulated as walking
10,000 steps a day, etc.
Comparative study spanned over one and half year,
reported in obese individuals of 22–72 year age range. Matched
groups were assigned to take diet categories defined as
carbohydrate restriction, macronutrient balanced, calorie
restriction and fat restriction. Although strict adherence was
low, each defined diet patterns yielded modest loss of body
weight and reduction in associated cardiac risk job assessment
at 1 year. More adhering individuals had superior benefits.9
Cochrane review of weight reduction drug trials indicated
superior results with drug therapy combined with diet and
lifestyle modification, yielding overall 3 kg or greater weight
loss over 12- to 18-month therapies.10
Diet and lifestyle control
over 4 years achieved 5% weight loss only in less than half of
the people and after discontinuation of the intensive pro-
gramme tendency to regain weight was manifest, particularly
attributable to depression.11
Weight loss drugs are indicated
for people with BMI more than 30 or above 27 with obesity
associated comorbidity.12
Diabetes medications range from mono-therapy or combi-
nation of oral anti-diabetic drugs to the insulin replacement
regimens. The sulfonylurea drugs lower glycosylated haemo-
globin (HbA1c) level by 1.5–2%. The nonsulfonylurea (repagli-
nide, nateglinide etc.) is lesser in effect.13
These insulin
secretagogue drugs cause around 2–3 kg of weight gains.14
Thiozolidinediones, which enhance insulin sensitivity of
tissues, take longer for similar decrease of HbA1c. They also
cause weight gain of 1.5–4 kg.15,16
Insulin, the most efficient
anti-diabetic, increases weight by about 1.8 kg per 1% reduc-
tion in HbA1c.17
4. Weight neutral or weight lowering anti-
diabetic drugs
The weight neutral category of anti-diabetic drugs includes
DPP4 inhibitors, acarbose and miglitol. This aspect is consid-
ered for making therapeutic choices. Metformin, a biguanide,
reduces insulin resistance without weight gain. It is difficult to
use due to frequent adverse effects. Metformin is also used in
preventing disease in pre-diabetics, obese and women with
history of gestational diabetes.18
The drug enhances insulin
responsiveness and decreases hepatic glucose production.
HbA1c is reduced by 1.5–2%, also improving the lipid profile.
Metformin is contraindicated in renal impairment, congestive
heart failure and in persons predisposed to developing
metabolic acidosis. Other anti-diabetics causing weight loss
include pramlintide, exenetide and liraglutide.
5. The incretin hormones
Glucagon, such as peptide 1, affects blood glucose control
through several mechanisms including enhancement of
glucose dependant insulin secretion, slowing of gastric
emptying, regulation of post-prandial glucagon and reduction
of food intake. Incretin effect implies greater insulin stimulant
effect of oral glucose, compared to intravenously given glucose.
This illustrates gluco-homiostatic influence of GLP1.19
A likely
deficiencyofGLP1 indiabetesdecreasestheincretineffect.GLP1
is secreted from intestinal L cells, in response to nutrients
causing the glucose-dependant insulin release. The dipeptidyl
peptidase 4 enzyme (DPP4) rapidly degrades GLP1, restricting it
to very short half life.20
Analogues of GLP1, exenatide and
liraglutide are available to treat type-2-diabetes as first line
drugs for the obese patients, in whom metformin cannot be
used. These are injectables with available option of slow release
formulationandavoidedinpatientswithhistoryofpancreatitis.
Exenatide is avoided in renal dysfunction with creatinin
clearance under 30 ml.
DPP4 inhibitor drugs incretin system boosts up the role of
DPP4 inhibitor drugs like sitagliptin, saxagliptin, linagliptin,
alogliptin, etc. These inhibit degradation of endogenous GLP1
and GIP (glucose dependant insulin-otropic peptide). They
reduce HbA1c level with very little risk of hypoglycemia or
weight gain. DPP4 inhibitors are safe and effective treatment
option for an obese diabetic. They synergise with metformin in
combination regimen. Caution required as renal dysfunction
and rarely serious allergic reactions can occur. Liraglutide, a
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2
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4. GLP.1 analogue antidiabetic, causes weight loss.21
Amylin is
satiety inducing peptide co-secreted with insulin and is
deficient in the diabetics. Injectable amylin analogue pramlin-
tide is indicated in diabetics on insulin treatment, exhibiting
poorly controlled postprandial hyperglycaemia.22
Low efficacy
profile of the drug limits its use in obese patients with
mealtime insulin.
SGLT2 (sodium glucose linked transporter 2) inhibitors are
new class of novel anti-diabetic agents. In diabetic patients,
overactive SGLT2 present in proximal convoluted tubule
curtail glycosuria during hyperglycaemia. SGLT2 inhibitors
thus selectively facilitate the excretion of excess glucose in the
diabetics. The effect has no relation to insulin. The calorie loss
is desirable in the obese diabetics. Treatment with SGLT2
inhibitors such as canagliflozin and dapagliflozin is shown to
significantly reduce waist circumference of obese patients.23
These agents however associate all adverse consequences of
glycosuria. They may raise serum creatinin and LDL-choles-
terol and can cause hyperkelemia in cases with renal
impairment or those taking potassium sparing drugs. Alfa
glucosidase inhibitors – these oral anti-diabetic drugs inhibit
intestinal carbohydrate digestive enzymes. These are weight
neutral and useful in control of postprandial hyperglycaemia.
Their efficacy is minimal as adjuncts to check weight gain in
obese diabetics.24
They are administered just prior to meals.
Other agents: Additional drugs showing some utility for
glycaemic control without risk of causing weight gain include
colesevelam, a bile acid sequestrating agent,25
and the anti-
Parkinsonian drug bromocriptine.26
Their action mechanisms
are not yet characterized.
6. Anti-obesity drugs
Orlistat is the most used anti-obesity drug for long-term
management, and it primarily inhibits gastric and pancreatic
lipases preventing the absorption of dietary fat. Orlistat
therapy with exercise yields synergic benefit for weight
reduction and prevention of diabetes, and its progression.
Four-year-long prospective orlistat therapy study in 3305
obese people resulted in significant weight loss (5.8 kg versus
below 3 kg in placebo group), and net 37% reduction of diabetes
acquiring risk.27
Orlistat therapy also improves control of
diabetes, systolic blood pressure, LDL and total cholesterol
levels.28
Orlistat administration at 120 mg thrice daily, studied
over 2 years reduced fat absorption by 30% and reduced 3%
bodyweight on average, along with improved glycaemic, blood
pressure and lipid control in obese diabetics.29
A Korean study
of 24 weeks treatment resulted in average 2.73 kg (3.5% body
weight) loss, along with significant improvements in lipid
profile, fasting insulin, waist circumference, blood pressure,
fasting blood glucose and glycosylated haemoglobin.30
Possi-
bility of induced deficiencies of fat soluble vitamins and
interaction with oral drugs need watch. Orlistat is avoided in
malabsorption and cholestasis. Newer congener cetilstat is
better tolerated.
Phentermine + Topiramate: Antiepileptic drug Topiramate
(Top) causes weight loss in the obese. Combination dosage
form of phentermine hydrochloride with topiramate extended
release may be used in overweight individuals bearing at least
one weight related comorbidity.31
Phentermine (PT) is option
for short-term weight loss in obese adults who exercise and eat
a reduced calorie diet. It acts via hypothalamic catecholamine
release towards reducing appetite. Topiramate induced weight
loss may relate to effect on sodium channels, enhanced GABA
activated ClÀ
channels and inhibition of carbonic anhydrase
isozyme. The drug significantly reduces incidence of type 2
diabetes in obese persons. Standard dose is PT 7.5 mg + Top
46 mg daily. Usually it is started with PT 3.75 + Top 23 mg daily.
It may be increased to PT 15 + Top 92 if weight loss of 5% body
weight is not obtained, at 3 month, and subsequently
discontinued if fails. One thousand two hundred and seven-
ty-six adult obese, type 2 diabetic patients received 56-week
therapy with PT + Top combination. Minimum dose level
3.75PT + 23Top led to 5.1% loss while 15PT + 92Top yielded
10.9% loss in bodyweight, as against only 1.6% loss in placebo
group.32
Another 2487 obese individuals with 2 related
comorbidities (e.g. Hypertension, prediabetes, type 2 diabetes,
dyslipidaemia or abdominal obesity) received in groups, PT7.5/
Top 46 or 15/92 or placebo for 56 weeks. The average losses in
body weight were 7.8% for PT7.5/Top 46; 9.8 for PT15/Top 92
and 1.2% for placebo.33
The weight losses were maintained in
another 52-week extension (till 108 weeks total) of the trial,
with respective 54% and 67% reduced risk of diabetes
development for lower and higher dose regimens.34
Risk of
metabolic acidosis due to bicarbonate loss (due to inhibition of
carbonic anhydrase enzyme) needs concurrent address.
Lorcaserin, a selective serotonin 2C receptor agonist acts
centrally via melanocortin receptor 4, to induce satiety. It was
approved for 10 mg twice daily dosing schedule in 2012. Six
hundred and four obese type 2 diabetes patients on metfor-
min + sulfonylurea regimen, received 5 mg BD or 10 mg BD
drug for one year and accrued over 3% reductions of body
weight on average.35
Only half the placebo group individuals
attained such a weight loss. Mean glycosylated Hb was greatly
reduced, but incidence of hypoglycaemias were increased. The
drug outcome is assessed in the 12th week and weight loss of
3–5% body weight suffices to discontinue treatment. The drug
also associates risk of causing serotonin syndrome.
Naltrexone + Bupropion sustained release combined therapy
was approved in late 2014 for obesity treatment. Bupropion
reduces energy intake and increases expenditure. Naltrexone
blocks the counter compensatory mechanisms that would
hamper sustaining weight loss. Non-diabetic obese individua-
ls received NT32/BP 360 mg daily treatment. There was more
than 4% body weight reduction on average, after one year.36
In
505 obese diabetics evaluated over 56 weeks on similar
regimen, the average body weight loss was 5% in contrast to
1.8% in placebo group.37
There was significant higher reduc-
tion in glycosylated Hb levels as well.38
In a large study, obese
type-2 diabetics on oral antidiabetic therapy were benefited by
significant loss of body weight and improved HbA1c profile
consequent to administration of naltrexon SR/bupropion SR
regime.39
Liraglutide is an agonist of Glucagon-like Peptide.1 receptor
(GLP.1) in incretin, the endogenous satiety inducer gut
hormone. Thirteen-hour long half-life of liraglutide allows
once daily dosing at 1.2 and 1.8 mg in diabetes. Fifty-two-week
study in 746 type 2 diabetics, compared liraglutide (1.2 and
1.8 mg), with 8 mg of glimipiride. Liraglutide consistently
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3
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5. reduced body weight by 2–2.5 kg while glimipiride caused
weight gain over 1 kg. Glycosylated Hb was reduced 0.84% and
1.14% by two dose liraglutide regimens.40
The recommended
dose is now 3 mg daily. Obese non-diabetic 3731 persons
received 3 mg daily liraglutide over 56 weeks. Average 8% body
weight loss was seen in treatment group as opposed to 2.6% in
placebo control. A third of cases lost more than 10% body
weight. In 846 obese diabetics, liraglutide 3 mg and 1.8 mg or
placebo treatment for 56 weeks gave respectively 6%, 5% and
2% reduction of body weight. Sixty-nine percent of patients
receiving 3 mg liraglutide achieved under 7 HbA1c level.41
A selective cannabinoid.1 receptor antagonist rimonabant
exhibits central suppression of appetite as well as beneficial
peripheral metabolic effects. It is very risky in patients with
depressive tendancy or suicidal ideation.42
Newer congeners
lacking neurotoxicity are under research, due to sound
promise of the group.
7. Bariatric surgery
The option is for T2DM cases with higher than 35 BMI or those
with BMI above 27 but having obesity linked comorbidity, and
difficult control of diabetes.43
In non-diabetics, respective
levels of BMI are 40 or 35 with comorbidity. Gastric restriction
and/or gut diversion surgery in obese case series followed over
10 years demonstrated amelioration of insulin resistance,
metabolic syndrome and other comorbidities. Mortality rates
were also lower.44
Prospective study of 4047 obese persons in
matched groups of conventional medical versus bariatric
surgery treatment, over 11 years, revealed moderately greater
reduction of overall mortality in surgery group. Myocardial
infarction rate was reduced to half and cancer to 60%
compared to medical treatment group. Weight losses at 10-
year assessment were stabilized in bariatric surgery to around
80% of the maximum reductions obtained within 1–2 years
following surgery.45
Bariatric surgery gives 25–33% body
weight loss and frequently remissions in diabetes.46
Problems
include dumping syndrome, hypoglycaemia, micronutrient
dysmetabolism and cholelithiasis.
8. Epilogue
Drug therapy targeting pathways affecting glucose homios-
tasis, satiety and weight would suit management of both
diabetes and obesity. If patients are unable to attain 5% loss in
body weight, adjunct long-term anti-obesity therapy is
indicated. Patients most likely to benefit from anti-obesity
drugs are those with higher than 27 BMI associated with
comorbidities viz. hypertension, diabetes, dyslipidaemia,
obstructive sleep apnoea, etc.47
Choice of medication involves
consideration of individual patients for comorbidities, other
drugs taken and health contexts that would increase benefit/
harm profile of therapy. Many medications used for diabetes,
other chronic morbidities and depression cause gain in weight.
A proposed dictate is ‘‘treat obesity first then treat comorbidi-
ty’’, as obesity is recognized as disease now. There is no ‘‘one
size fits all’’ approach possible. Complexity of pharmacother-
apy is due to variables as age and ethnicity. Varied distribution
of metabolically active adipose tissue in different communi-
ties can affect efficacy of drug classes, and also make drugs
loose efficacy. Drug combinations that target multiple com-
plimentary pathways of energy and calorie control have
potential to promote better weight loss in broader heteroge-
neous population. Newer drug therapies aim at targeting
multiple mechanisms preferably by single molecules (e.g.
tesofensine) but more feasibly through combinations, viz.
qnexa, contrav, empatic and pramlintide + metreleptin. Obe-
sity is chronic disease, while no anti-obesity drug is permitted
for long-term continuation. Advance formulation technologies
are also to be employed towards widening safety margins of
drug therapy. Bariatric surgery is an option available to few
and carries its own risks.
Minimum targeted 3% reduction of bodyweight in morbid
obesity reduces level of triglycerides, risk of development of
diabetes and profile of blood glucose and HbA1c. Greater
weight losses lower raised blood pressure, improve LDL and
HDL cholesterol profile and requirement of medications for
diabetes, hypertension, dyslipidaemia, etc.48
The obesity
pandemic along with metabolic comorbidities seems to be
enormous, with increase of ageing population. It would
constitute essential basic skill therefore, to steward manage-
ment of obesity with diabetes using the right therapeutic
choices, in patients.49,50
Conflicts of interest
The authors have none to declare.
r e f e r e n c e s
1. Wing RR, Lang W, Wadden TA, Safford M, Knowler W, Bertoni
AG. Benefits of modern weight loss in improving
cardiovascular risk factors in overweight and obese individuals
with type 2 diabetes. Diabetes Care. 2011;34:1481–1486.
2. Kershaw EE, Flier JS. Adipose tissue as endocrine organ. J Clin
Endocrinol Metab. 2004;89:2548–2556.
3. Reaven GM. Role of insulin resistance in human disease.
Diabetes. 1988;37:1595–1607.
4. Saxena M, Srivastava N, Banerjee M. Genetic association of
adiponectin gene polymorphisms (+45T/G and +10211T/G)
with type 2 diabetes in North Indians. Diabetes Metab Syndr.
2012;6(2):65–69.
5. Look AHEAD Research Group. Effect of a long-term
behavioural weight loss intervention on nephropathy in
overweight or obese adults with type 2 diabetes: a secondary
analysis of the Look AHEAD randomised clinical trial. Lancet
Diabetes Endocrinol. 2014;2(10):801–809.
6. Wadden TA, Volger S, Sarwer DB, et al. A two-year
randomized trial of obesity treatment in primary care
practice. N Engl J Med. 2011;365(21):1969–1979.
7. Kushner RF, Ryan DH. Assessment and lifestyle
management of patients with obesity: clinical
recommendations from systematic reviews. JAMA. 2014;312
(9):943–952.
8. Colman E. Food and Drug Administration's obesity drug
guidance document: a short history. Circulation. 2012;125
(17):2156–2164.
9. Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ.
Comparison of the Atkins, Ornish, Weight Watchers, and
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x4
APME-316; No. of Pages 6
Please cite this article in press as: Pandit A, Pandey AK. Obesity context of type 2 diabetes and medication perspectives, Apollo Med. (2015),
http://dx.doi.org/10.1016/j.apme.2015.08.001

6. Zone diets for weight loss and heart disease risk reduction: a
randomized trial. JAMA. 2005;293(1):43–53.
10. Leblanc ES, O'Connor E, Whitlock EP, Patnode CD, Kapka T.
Effectiveness of primary care-relevant treatments for obesity
in adults: a systematic evidence review for the U.S. Preventive
Services Task Force. Ann Intern Med. 2011;155(7):434–447.
11. Price DW, Ma Y, Rubin RR, et al. Diabetes Prevention
Program Research Group Depression as a predictor of weight
regain among successful weight losers in the diabetes
prevention program. Diabetes Care. 2013;36(2):216–221.
12. Apovian CM, Aronne LJ, Bessesen DH, et al. Endocrine
Society Pharmacological management of obesity: an
endocrine Society clinical practice guideline. J Clin Endocrinol
Metab. 2015;100(2):342–362.
13. Wolfenbuttel BHR, Landgraf RA. One year multicentre
randomized double blind comparison of repaglinide and
glyburide for the treatment of type 2 diabetes. Diabetes Care.
1999;22:463–467.
14. Marbury T, Huang W, Strange P, Lebovitz H. Repaglinide
versus glyburide: a one year comparison trial. Diabetes Res
Clin Pract. 1992;15:755–772.
15. Aronoff S, Rosenblatt S, Egan JW, Mathisen AL, Schneider RL.
Pioglitazone hydrochloride monotherapy improves
glycaemic control in the treatment of patients with type 2
diabetes: a 6 month randomized controlled dose response
study. Diabetes Care. 2000;23:1605–1611.
16. Lebovitz HE, Dole JF, Patwardhan R, Rappaport EB, Freed MI.
Rossiglitazone monotherapy is effective in patients with
type 2 diabetes. J Clin Endocrinol Metab. 2001;86:280–288.
17. Dailey G, Admane K, Mercier F, Owens D. Relationship of
insulin dose, HbA1c lowering and weight in type 2 diabetes:
comparing insulin Glargine and insulin Detemir. Diabetes
Technol Ther. 2010;12:1019–1027.
18. American Diabetes Association. Standards of medical care
in diabetes 2014 (Position Statement). Diabetes Care. 2014;37
(suppl 1):S14–S80.
19. Nauck M, Stockmann F, Ebert R, Creutzfeldt W. Reduced
incretin effect in type 2 diabetes. Diabetologia. 1986;29:46–52.
20. Demuth HU, McIntosch CH, Pederson RA. Type 2 diabetes
therapy with dipeptidyl dipeptidase 4 inhibitors. Biochim
Biophys Acta. 2005;1751:33–44.
21. Astrup A, Rössner S, Van Gaal L, et al. Effects of liraglutide in
the treatment of obesity: a randomised, double-blind,
placebo-controlled study. Lancet. 2009;374(9701):1606–1616.
22. Singh-Franco D, Perez A, Harrington C. The effect of
pramlintide acetate on glycaemic control and weight in
patients with type 2 diabetes mellitus and obese patients
without diabetes: a systematic review and meta analysis.
Diabetes Obes Metab. 2011;13:169–180.
23. Bailey CJ, Gross JL, Pieters A, Bastien A, List JF. Effect of
dapagliflozin in patients with type 2 diabetes who have
inadequate glycaemic control with metformin: a
randomized double blind placebo controlled trial. Lancet.
2010;375:2223–2233.
24. Li C, Hung Y, Qamruddin K, Aziz MFA, Stein H, Schmidt B.
International non-interventional study of acarbose
treatment in patients with type 2 diabetes mellitus. Diabetes
Res Clin Pract. 2011;92:57–64.
25. Bays HE, Goldberg RB, Truitt KE, Jones MR. Colesevelam
hydrochloride therapy in patients with type 2 diabetes
mellitus treated with metformin. Arch Intern Med.
2008;168:1975–1983.
26. Cincotta AH, Meier AH, Cincotta Jr M. Bromocriptine
improves glycaemic control and serum lipid profile in obese
type 2 diabetic subjects: a new approach in the treatment of
diabetes. Expert Opin Investig Drugs. 1999;8:1683–1707.
27. Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. Xenical
in the prevention of diabetes in obese subjects (xendos)
study. Diabetes Care. 2004;27:155–161.
28. Miles JM, Leiter L, Hollander P, et al. Effect of orlistat in
overweight and obese patients with type 2 diabetics treated
with metformin. Diabetes Care. 2002;25:1123–1128.
29. Rössner S, Sjöström L, Noack R, Meinders AE, Noseda G.
Weight loss, weight maintenance, and improved
cardiovascular risk factors after 2 years treatment with
orlistat for obesity. European Orlistat Obesity Study Group.
Obes Res. 2000;8(1):49–61.
30. Chon S, Park C, Koh G, et al. The effect of orlistat in obese
patients with type 2 diabetes: benefit on observed obesity and
glycaemic control. J Korean Soc Study Obes. 2004;13:281–292.
31. Shin JH, Gadde KM. Clinical utility of phentermine/
topiramate (QsymiaTM
) combination for the treatment of
obesity. Diabetes Metab Syndr Obes. 2013;6:131–139.
32. Allison DB, Gadde KM, Garvey WT, et al. Controlled-release
phentermine/topiramate in severely obese adults: a
randomized controlled trial (EQUIP). Obesity (Silver Spring).
2012;20(February (2)):330–342.
33. Gadde KM, Allison DB, Ryan DH, et al. Effects of low-dose,
controlled-release, phentermine plus topiramate combination
on weight and associated comorbidities in overweight and
obese adults (CONQUER): a randomised, placebo-controlled,
phase 3 trial. Lancet. 2011;377(9774):1341–1352.
34. Garvey WT, Ryan DH, Look M, et al. Two-year sustained
weight loss and metabolic benefits with controlled-release
phentermine/topiramate in obese and overweight adults
(SEQUEL): a randomized, placebo-controlled, phase 3
extension study. Am J Clin Nutr. 2012;95(2):297–308.
35. O'Neil PM, Smith SR, Weissman NJ, et al. Randomized
placebo-controlled clinical trial of lorcaserin for weight loss
in type 2 diabetes mellitus: the BLOOM-DM study. Obesity
(Silver Spring). 2012;20(7):1426–1436.
36. Greenway FL, Fujioka K, Plodkowski RA, et al. Effect of
naltrexone plus bupropion on weight loss in overweight and
obese adults (COR-I): a multicentre, randomised, double-
blind, placebo-controlled, phase 3 trial. Lancet. 2010;376
(9741):595–605.
37. Apovian CM, Aronne L, Rubino D, et al. A randomized, phase
3 trial of naltrexone SR/bupropion SR on weight and obesity-
related risk factors (COR-II). Obesity (Silver Spring). 2013;21
(5):935–943.
38. Hollander P, Gupta AK, Plodkowski R, et al. Effects of
naltrexone sustained-release/bupropion sustained-release
combination therapy on body weight and glycemic
parameters in overweight and obese patients with type 2
diabetes. Diabetes Care. 2013;36(12):4022–4029.
39. Makowski CT, Gwinn KM, Hurren KM. Naltrexone/
bupropion: an investigational combination for weight loss
and maintenance. Obes Facts. 2011;4(6):489–494.
40. Garber A, Henry R, Ratner R, et al. Liraglutide versus
glimepiride monotherapy for type 2 diabetes (LEAD-3 Mono):
a randomised, 52-week, phase III, double-blind, parallel-
treatment trial. Lancet. 2009;373(9662):473–481.
41. Jeon WS, Park CY. Antiobesity pharmacotherapy for patients
with type 2 diabetes: focus on long-term management.
Endocrinol Metab (Seoul). 2014;29(4):410–417.
42. Sharma MK, Murumkar PR, Kanhed AM, Giridhar R, Yadav
MR. Prospective therapeutic agents for obesity: molecular
modification approaches of centrally and peripherally acting
selective cannabinoid 1 receptor antagonists. Eur J Med
Chem. 2014;79:298–339.
43. Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and
prevention of type 2 diabetes in Swedish obese subjects. N
Engl J Med. 2012;367(8):695–704.
44. Kral JG, Näslund E. Surgical treatment of obesity. Nat Clin
Pract Endocrinol Metab. 2007;3(8):574–583.
45. Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric
surgery on mortality in Swedish obese subjects. N Engl J Med.
2007;357(8):741–752.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 5
APME-316; No. of Pages 6
Please cite this article in press as: Pandit A, Pandey AK. Obesity context of type 2 diabetes and medication perspectives, Apollo Med. (2015),
http://dx.doi.org/10.1016/j.apme.2015.08.001

7. 46. Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus
non-surgical treatment for obesity: a systematic review and
meta-analysis of randomised controlled trials. BMJ.
2013;347:f5934.
47. Pagotto U, Vanuzzo D, Vicennati V, Pasquali R.
Pharmacological therapy of obesity. G Ital Cardiol (Rome).
2008;9(4 suppl 1):83S–93S [Italian].
48. Millen BE, Wolongevicz DM, Nonas CA, Lichtenstein AH.
2013 American Heart Association/American College of
Cardiology/the Obesity Society Guideline for the
Management of Overweight and Obesity in Adults:
implications and new opportunities for registered dietitian
nutritionists. J Acad Nutr Diet. 2014;114(11):1730–1735.
49. Pandey AK, Pandey G, Pandey SS, Pandey BL. Human biology
of diet and lifestyle linked chronic inflammatory non-
communicable disease epidemic – a review. Human Biol Rev.
2014;3:25–42.
50. Pandey G, Pandey AK. Nutrition research perspectives in
immune mediated inflammatory disorders. Indian J
Rheumatol. 2013;8:30–36.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x6
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