The Ever-Changing Pharmacologic Landscape for Obesity Management
In this Q&A, Laura Davisson, MD, MPH, FACP, professor of medicine, West Virginia University, discusses the rapidly evolving pharmacologic landscape for obesity management, including practical strategies for handling medication access, managing GLP-1s in primary care, and navigating ongoing knowledge gaps and future developments. Dr Davisson presented her session, "The Changing World of Obesity Management" at the American College of Physicians Internal Medicine Meeting in New Orleans, LA.
Additional Resource: https://annualmeeting.acponline.org/educational-program/scientific-program/scientific-sessions.
Consultant360: Can you discuss the key themes of your presentation at the ACP conference?
Laura Davisson, MD, MPH, FACP: My talk is about the pharmacologic treatment of obesity. Obesity treatment is quite broad; it incorporates diet, physical activity, behavior change, and of course, pharmacologic and surgical treatment. Although my talk is very much focused on the pharmacologic approach to obesity treatment, I wouldn't want anyone to think that that is the only thing that we use to treat obesity. But that is what I was asked to speak about.
Consultant360: And why do you think the pharmacological aspect of obesity is particularly relevant right now?
Dr Davisson: Well, it's interesting. The talk was titled “Changing World of Obesity Management.” And that title is so relevant because how we manage these obesity medications is changing very rapidly. And in fact, since my slides were due, which was I think February 17th, I've had to send two updates because things have changed even since then. Things like shortages, prices, laws, those are the kinds of things that are changing in the field of obesity at a rapid pace.
Consultant360: As a follow-up, what specifically did you need to change in your presentation?
Dr Davisson: The objective or aim of my talk was to consider three main questions. The first question asked about the pharmacologic treatments that have the most benefit. The second question asked about the complications associated with pharmacologic treatment and the approaches to managing those complications. And the third question focused on the ways to manage medication shortages and inconsistent insurance coverage for these obesity medications. I added that question to the original ones assigned for my talk because I think this is something that people are facing every day, and this is something that I wanted to make sure my talk addressed so that when people left, they would have strategies on how to manage it.
Right after I turned in some of my slides, there were announcements by two of the manufacturers about price changes for people who are paying cash for the GLP-1 medications because, as we know, there are a lot of issues with GLP-1 medications not being covered by insurance. Now, of course, to be clear, there are other medications that we use for treatment of obesity, and that is something I also cover in my talk. But the GLP-1s come up quite a bit with my patients and they get a lot of attention. When you talk about the GL-1s, insurance coverage is poor. So, patients have asked us about paying cash for these medications.
The two companies started announcing lowered cash pay options. This was what recently came out. One of the first things I had to do to update my slides was change that part because it significantly changed the options. For the first time, patients might be able to pay cash for these medications. Now they're still very expensive, but for a while, it was prohibitively expensive--we're talking about $1300 a month. But when these announcements came out, suddenly it came to a point where people might consider paying out of pocket. The prices went down to a starting dose of around $350 a month to $500 a month. And, depending on doses, and if you could maybe space the doses out a little bit, sometimes people can consider paying that amount. So that’s a major change. We need to plan on managing those conversations with patients as they will continue to occur.
Consultant360: What are the most important takeaways for clinicians in practice? Do those takeaways tie into the questions you detailed in your presentation?
Dr Davisson: The first takeaway is that pharmacologic treatments are an adjunct to lifestyle treatment of obesity. This is crucial because I think in the past, people relied on lifestyle changes alone for treating obesity. And when you look at the evidence and the research, people just were not getting the results that they needed with lifestyle alone. And so, to ignore the fact that we have these available and effective treatments that can give people results that are better than lifestyle alone would be inappropriate. And so we need to, as scientists and as clinicians, offer these treatments to our patients. So that's number one.
And then number two, if you are going to use pharmacologic treatments, there are more than just GLP-1s. Like I said, we talk a lot about GLP-1s, but there's more than that in our toolbox. If people don't have access to these GLP-1s because of costs or because of insurance coverage issues or because of side effects or contraindications, we have other tools in our toolbox and we need to be mindful that there are other things we can offer our patients. And so, my talk does review some of the oral medication options or even non-medical options--there are other things to consider. There are still surgical options, there are still lifestyle options. And so, you need to really have a full spectrum of treatment options that you offer patients just like with other diseases.
And then I think the final point is if you are using these GLP-1s in primary care, you must be able to manage them appropriately. And so, I have this phrase: “It's not appropriate to just start ’em and forget about ’em.” These GLP-1s need to be managed appropriately. You need to start these medicines and see the patient again pretty frequently because these medicines need to be titrated up. You start low. But to get the results you're looking for, these doses need to be titrated up to the effective doses where the patients are going to get the results they're looking for. If they just stay on the lowest dose, they probably won't lose the weight and they're going to be on these expensive medications without the results they're looking for. Plus, there are side effects, and if you're not seeing the patient frequently, you may not be able to manage or prevent those side effects and give the appropriate counseling to go with the medicines to minimize the side effects.
There's dietary counseling that goes along with these medications too, and that's going to help them get the best results in terms of weight loss but also prevent some of these side effects. So, if you're going to prescribe these medications for obesity, which is great, and I encourage it in primary care, you should have your practice set up to be able to see the patients again on consistent basis and do all those things appropriately. And if you can't do that in your primary care practice, I get it. I know it's hard. I did primary care for many years. So, if that’s the case, maybe that would be a time when you would want to refer to a specialist practice to prescribe the GLP-1s for obesity treatment. But if you want to prescribe them in your primary care practice, I suggest developing a process in your office so that you can get those things done. It doesn't necessarily have to be done by the primary care clinician themselves. It can be maybe done by having a nurse help you out or having a pharmacist help you with some of those touch points for dose titration and side effect management. Access to a dietitian for dietary counseling is also great if it is available.
Consultant360: That's great advice. And that kind of leads into my next question about any gaps in our knowledge that remain and areas of future research that your presentation touches on. With all these changes, obviously, there's going to be gaps involved that we just haven't gotten to yet and that we're still finding out, correct?
Dr Davisson: Well, I think since my talk focuses on pharmacologic treatment of obesity, I think one of the main things that I do touch on is that there are a lot of pipeline drugs up and coming. So, I do touch on those, and I think you're going to be seeing more soon. There's a whole list of ones that we're going to be expecting to see. And so, I think this field is going to be continuing to evolve. Right now, we just have two main drugs in terms of the GLP-1s. And there's soon going to be more. Just like we have five or six or more different hypertension drugs, we're going to see a whole variety of different GLP-1s and similar types of medications that we can use to treat obesity.
And then we're going to be able to really choose the right one for our patient based on different characteristics. And so, it's going to be a whole new world when we have all these different drugs that are in the pipeline that are available. That's another thing to be looking out for in the future. We're probably going to see expanded indications to use obesity medications to treat fatty liver disease, arthritis, and more.