We Have Better Obesity Medications, but Access Is Lagging

Obesity is a complex, chronic disease that currently affects more than 40% of adults in the United States with another 30% estimated to have preobesity (overweight).^1,2 The efficacy of newer obesity medications is greater than that of other medications approved for the treatment of obesity, but access is an issue.³ Less than 3% of patients who are eligible for antiobesity medications filled a prescription for agents including the newest agents glucagon-like peptide-1 (GLP-1) agonists liraglutide and semaglutide as well as orlistat, phentermine-topiramate, naltrexone-bupropion, which are all approved for long-term use.^4-6 The question is: why aren’t more people being treated for obesity with medications that are effective?

One answer is that these medications may not be covered by health insurance policies. Medicare does not cover antiobesity medications. Most Medicaid state programs and some commercial insurers also do not cover these agents, especially the newer incretin-based medications. This speaks to a common bias against using obesity medications, even for people with a clear medical need.

The GLP-1 agonists semaglutide and the investigational dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists tirzepatide are receiving a lot of media attention recently. Semaglutide is approved by the US Food and Drug Administration (FDA) for the management of obesity under the brand name Wegovy with a reported average of 14.9% weight loss.⁷ In late December 2022, the FDA approved semaglutide 2.4 mg for use in adolescents aged 12 years and older with an initial body mass index (BMI) at the 95th percentile or greater for age and sex as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management.⁸ The approval was based on a study that reported 16% weight loss in this age group.⁹ At the 2022 ObesityWeek, several presenters reported weight loss results for tirzepatide (not yet approved for obesity) of greater than 20%.^10,11

These are clinically meaningful outcomes that can influence the risk for obesity-related complications. It is those complications that give us compelling reasons for treating obesity. Clearly, these incretin medications add a new level of effectiveness to the tools for treating obesity. For people living with obesity, this is important.

Eric Topol, MD, director and founder of Scripps Research Translational Institute, described semaglutide and tirzepatide as medical breakthroughs, saying: “These drugs will likely become some of the most prescribed of all medications in the upcoming years. While there are many drawbacks, we shouldn’t miss such an extraordinary advance in medicine—the first real, potent, and safe treatment of obesity.”¹³

One bias against these medications is their cost. Incretins are not cheap. GLP-1 receptor agonists, which are also approved for the treatment of type 2 diabetes, range from $750 to $865 monthly, according to GoodRx [search based on an Arizona zip code]. The price tag for tirzepatide comes in at about $973 monthly for the treatment of type 2 diabetes. Looking at the same molecules for obesity, we find another form of bias. The costs for the GLP-1 receptor agonists liraglutide 3 mg and semaglutide 2.4 mg, the doses used for weight management, are approximately $1350 each, according to GoodRx. One reason for the difference in pricing based on disease is the difference in dosing, which is higher in obesity management, but the cost for GLP-1 receptor agonists for the management of diabetes is the same for the lowest dose vs the highest dose so that argument is not persuasive. The US has some of the highest-priced drugs in the world and these drugs fall in line with that trend. In the United Kingdom, for example, semaglutide for obesity is priced at only $100 per month.¹³

Stigma and Obesity Medications

When we study media and social media coverage of these newer obesity medications we also see the bias against obesity. Many sites asked why people with diabetes were not able to fill their semaglutide (Ozempic) prescriptions (the reason was supply chain issues) and concluded it was because people with obesity were causing the problem and making it difficult for people with diabetes to get the medicine they so clearly need. The implication is that people with obesity should be last in line, as if obesity is a less worthy diagnosis. What the reporting misses is that type 2 diabetes is a complication of obesity. So, in fact, many of these patients have both conditions.

Fatima Cody Stanford, MD, obesity medicine physician, scientist, educator, and policy maker at Massachusetts General Hospital and Harvard Medical School, explained that “This type of story pushes the very wrong idea that people with obesity don’t deserve medical care. Sensational reporting like this is unethical. It harms my patients.”¹³

How Can Clinicians Help Patients Access Obesity Medications?

What can be done to help patients access the medicine they need? This is perhaps the most relevant question for clinicians.

• First, we can support the 2021 Treat and Reduce Obesity Act when it or similar legislation is reintroduced in the next session of Congress. Having Medicare put medicines for obesity on equal footing with other chronic diseases would go a long way. 
• Next, we can help patients understand how to work with their patients’ human resources departments. Resources for clinicians to use for writing letters to patients’ employers and state insurance agencies can be found at STOP Obesity Alliance.

We hope that NPs and PAs will become advocates for their patients, empowering them to help improve the treatment of obesity for themselves and others like them.

Ted Kyle, RPh, MBA, is founder of ConscienHealth, chair of The Obesity Society’s Advocacy Committee, and serves on the Steering Committee for the STOP Obesity Alliance and the Board of Directors for the Obesity Action Coalition; Angela Golden, DNP, FNP-C, FAANP, FOMA, is the owner of NP Obesity Treatment Clinic and NP from Home, LLC, in Flagstaff, Arizona, as well as past president of the American Association of Nurse Practitioners (AANP).

Disclosures

Ted Kyle, RPh, MBA, has received consulting fees from Emerald Lake Safety, Novo Nordisk, Gelesis, Johnson & Johnson, and Nutrisystem.

Angela Golden, DNP, FNP-C, FAANP, FOMA, has served on the advisory board and as a promotional speaker for Novo Nordisk, Acella Pharmaceuticals, and Currax Pharmaceuticals. She has also served on the advisory board of Gelesis, Eli Lilly and Company, WeightWatchers, and SetPoint.

References

1. Stierman B, Afful J, Margaret C, et al. National Health and Nutrition Examination Survey 2017–March 2020 prepandemic data files development of files and prevalence estimates for selected health outcomes. National Center for Health Statistics; June 14, 2021: NHSR No. 158. https://stacks.cdc.gov/view/cdc/106273
2. Fryar CD, Carroll MD, Afful J. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960–1962 through 2017–2018. NCHS Health E-Stats, Centers for Disease Control and Prevention; December 2020. Updated January 29, 2021. Accessed January 30, 2023. https://www.cdc.gov/nchs/data/hestat/obesity-adult-17-18/overweight-obesity-adults-H.pdf
3. O’Neil PM, Birkenfeld AL, McGowan B, et al. Efficacy and safety of semaglutide compared with liraglutide and placebo for weight loss in patients with obesity: a randomised, double-blind, placebo and active controlled, dose-ranging, phase 2 trial. Lancet. 2018;392(10148):637-649. doi:10.1016/S0140-6736(18)31773-2
4. Saxon DR, Iwamoto SJ, Mettenbrink CJ, et al. Antiobesity medication use in 2.2 million adults across eight large health care organizations: 2009-2015. Obesity (Silver Spring). 2019;27(12):1975-1981. doi:10.1002/oby.22581
5. MacEwan J, Kan H, Chiu K, Poon JL, Shinde S, Ahmad NN. Antiobesity medication use among overweight and obese adults in the United States: 2015-2018. Endocr Pract. 2021;27(11):1139-1148. doi:10.1016/j.eprac.2021.07.004
6. Claridy MD, Czepiel KS, Bajaj SS, Stanford FC. Treatment of obesity: pharmacotherapy trends of office-based visits in the United States from 2011 to 2016. Mayo Clin Proc. 2021;96(12):2991-3000. doi:10.1016/j.mayocp.2021.07.021
7. Wilding JPH, Batterham RL, Calanna S, et al; STEP 1 Study Group. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989-1002. doi:10.1056/NEJMoa2032183
8. FDA approves once-weekly Wegovy® injection for the treatment of obesity in teens aged 12 years and older. News release. Novo Nordisk. December 23, 2022. Accessed January 30, 2023. https://www.novonordisk-us.com/content/nncorp/us/en_us/media/news-archive/news-details.html?id=151389
9. Weghuber D, Barrett T, Barrientos-Pérez M, et al; STEP TEENS Investigators. Once-weekly semaglutide in adolescents with obesity. N Engl J Med. 2022;387(24):2245-2257. doi:10.1056/NEJMoa2208601
10. Kushner R, Aronne L, Stefansku A, et al. Tirzepatide-induced weight loss is associated with body composition improvements across age groups. Obesity. November 21, 2022. Oral abstract 109. https://doi.org/10.1002/oby.23625
11. Aronne L, Jastreboff A, Le Roux C, et al. Tirzepatide reduces body weight across BMI categories: a SURMOUNT-1 pre-specified analysis. Obesity. November 21, 2022. Oral abstract 110. https://doi.org/10.1002/oby.23625
12. Topol E. The New Obesity Breakthrough Drugs. Ground Truths. December 10, 2022. Accessed January 30, 2023. https://erictopol.substack.com/p/the-new-obesity-breakthrough-drugs
13. Kansteiner F. Novo Nordisk’s Wegovy passes NICE checkpoint on course to blockbusterland. Fierce Pharma. February 8, 2022. Accessed January 30, 2023. https://www.fiercepharma.com/pharma/novo-nordisk-s-wegovy-passes-nice-checkpoint-course-to-blockbuster-land
14. Throwing people with obesity under the bus. ConscienHealth. December 30, 2022. Accessed January 30, 2023. https://conscienhealth.org/2022/12/throwing-people-with-obesity-under-the-bus/

This article originally appeared on Clinical Advisor