The soaring costs of prescription medications are a major factor contributing to what most experts report will be a significant rise in health care costs in 2024. According to a recent PwC study, pharmaceutical pricing is expected to experience increases in the high single or double digits from this year to the next. As health plans and employers scramble to find ways to improve health outcomes while remaining cost-conscious, GLP-1 agonist medications for weight management have become a focal point in this ongoing global health conversation.
GLP-1 agonists are a class of medications historically used to treat type 2 diabetes. Mostly administered via subcutaneous injections, these medications lower blood sugar and aid in weight loss. While most of these medications are FDA-approved only for the treatment of type 2 diabetes, a small subset has recently also been approved for treating people with obesity and overweight individuals with comorbid conditions.
Major media coverage has also helped put GLP-1 agonist medications in the spotlight. News stories, celebrity recommendations, and social promotions have driven drugs like Wegovy and Ozempic onto the world stage in a relatively short amount of time.
All this hype has not managed to obscure, and has brought to light, some major concerns with these drugs when it comes to their use in weight loss. For example, serious side effects concerning both physical and mental health can occur. Also, most people regain the weight lost after discontinuing use, particularly concerning since about only a third of those who started a GLP-1 agonist for weight loss remain on the medication after one year. In addition to the high costs of GLP-1 agonists, many health plans, employers, and industry experts are emphasizing a need for more education and better expectation-setting around the best use of these medications.
“GLP-1 agonists and other weight loss medications can be incredibly effective when prescribed at the right time, for the right person, and with the right expectations. As is the case when treating other chronic conditions, however, several parameters must be in place before, during, and after a medication is introduced. Without a comprehensive, whole-person approach, these drugs are not a long-term solution.” — Leslie Helou, PharmD, Vice President of Medication Strategies at MOBE.
— Leslie Helou, PharmD, Vice President of Medication Strategies at MOBEAs is the case when treating other chronic conditions, however, several parameters must be in place before, during and after a medication is introduced.
Obesity has long been identified as a major public health concern in the United States and throughout the world. Since 2012, U.S. medical associations have firmly designated obesity as a chronic condition with dramatic and often deadly impacts on the body and mind. Given these factors, along with the significant stigma faced by people with obesity, it’s not surprising that consumers and clinicians have rushed to embrace GLP-1 agonist medications.
Yet, to achieve long-term results, including weight management, most obesity experts recommend that medication for weight loss be considered only in the context of a multi-faceted approach. The 2016 American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) guidelines state that pharmacotherapy should be considered for people with a BMI of 27 or higher, in addition to lifestyle therapy, depending on additional clinical considerations for the individual.
In addition to the AACE and ACE guidelines, MOBE Pharmacists recommend the following steps before turning to the use of GLP-1 agonists (or other medications for obesity and weight management):
1. Establish lifelong sustainable self-management behaviors, coping mechanisms, and healthy lifestyle choices.
2. Support an adequate trial of lifestyle modification before considering pharmacotherapy and an understanding of the continued commitment required during and after medication use.
3. Determine when and what type of medication treatment is appropriate for an individual should lifestyle modifications fail or not produce adequate results.
4. Manage expectations for weight loss results and communicate potential side effects and risks for GLP-1 agonists and other medication options under consideration.
5. Help people navigate their personal drug coverage and a potential lack of supply of GLP-1 agonists.
Obesity is a tremendously complex condition. Genetic factors play a significant role in metabolic rates and fat storage. Hormonal imbalances often come into play from conditions like polycystic ovary syndrome (PCOS), thyroid disorders, and other situational or chronic conditions. Dietary and physical activity habits are often a primary cause of weight gain, but other factors have also come to the forefront as contributors to obesity rates. Impacts from social determinants of health (SDoH)—including a lack of access to healthy food and psychological factors such as stress, depression, and trauma—can all contribute to challenges when it comes to weight management.
GLP-1 agonists are not the first, nor are they the only, medications shown to be effective for weight loss. In the 1990s, orlistat became the first of a new wave of obesity medications that work by blocking the absorption of dietary fats. Other advances in obesity pharmacotherapy have focused on the body's hunger and satiety signals. Medications such as liraglutide, bupropion-naltrexone, and phentermine-topiramate have shown efficacy in promoting weight loss by targeting various central nervous and metabolic pathways.
Along with orlistat, phentermine, and bupropion, seven medications are currently FDA-approved for weight loss. Among them are Imcivree (setmelanotide), a melanocortin receptor agonist; Wegovy (semaglutide), a weekly injection approved by the FDA since 2021 for long-term weight management; and Saxenda (liraglutide). Other drugs with brand names Ozempic, Trulicity, Mounjaru, Zepbound, and Bydureon BCise are currently approved for diabetes-related conditions only but are prescribed off-label for obesity.
Medications effective for weight loss vary significantly in cost and tolerability for long-term use. In addition to side effects such as nausea, gastrointestinal problems, headache, and heartburn, these drugs can, in some cases, interfere with prior behavioral modifications or a person’s mental health. As of October of 2023, the FDA has received over 250 reports of suicidal thoughts or behavior among patients taking GLP-1 receptor agonists.
GLP-1 agonists are the most effective pharmacotherapy choice for some people and have helped many individuals achieve and maintain clinically significant weight loss. However, GLP-1 agonist medications are not the right choice for everyone eligible to use pharmacotherapy for weight management. Once started, these injectable medications must be continued indefinitely. Once discontinued, research shows that weight is typically gained back, often quite rapidly.
According to the NIH, the universal definition of whole health is physical, behavioral, spiritual, and socioeconomic well-being as defined by individuals, families, and communities. Striving for whole health requires an integrated health care approach that addresses physical, behavioral, and social drivers of health. When determining the best approach for treating obesity, whole health is a major consideration. Comorbidities, the environment, behavioral or mental health factors, and medication side effects (which can worsen the condition) can all play a role in achieving weight objectives.
For most people, medications for weight management should generally be used only when lifestyle therapy has failed to achieve the individual’s goals. In addition, since pharmacotherapy alone will not sustain weight loss results once any medication is stopped, sustainable lifestyle therapy is crucial for enduring weight loss and lowering the risks associated with obesity.
MOBE Guides and Pharmacists collaborate closely with individuals to determine the lifestyle modifications they have tried in the past and discuss how they have approached these modifications. From there, the MOBE team works to help each person effectively apply and sustain lifestyle and behavioral modification before considering pharmacotherapy. If needed, MOBE experts can help with the challenging task of determining when lifestyle modification isn’t enough.
Even at the point when weight loss medications are considered, many people do not have insurance coverage for GLP-1 agonists. In addition, some manufacturers are failing to meet demand, while others are slowing production—as is the case with liraglutide. When GLP-1 agonists are the right choice, the good news is that, over time, there should be greater availability and lower costs for GLP-1 agonists, with the availability of a generic option expected in the summer of 2024.
A whole-health approach that combines a unique combination of lifestyle and medication programming is the best way to help people manage excess weight, obesity, and experience long-term, sustainable weight loss. This may include medications, but only after lifestyle modification trials that consider diet, exercise, environment, sleep, stress management, and as many controllable contributing factors as possible.
