GLP-1s, like Ozempic and Wegovy, are creating a frenzy in healthcare. In just the last three months of 2022, providers wrote more than 9 million prescriptions for these drugs.
While GLP-1s have shown near-term weight-loss benefits, there are still many questions that remain about their long-term use – which is creating challenges for payers, providers and patients.
We recently spoke with Nicole Bulochnik, senior vice president of drug strategy for Abarca, about what payers need to consider as demand for these drugs remains high. The following interview has been edited for length and clarity.
The rapid growth in prescriptions for GLP-1s has been cause for both celebration and concern. What are the reasons to celebrate?
To properly frame the impact of these medications, it’s important to understand the magnitude of one of the problems GLP-1s are trying to solve. In 2019, the estimated medical cost of obesity was nearly $173 billion, according to the CDC. This condition is also linked to the development of diabetes, hypercholesterolemia, hypertension and its complications such as stroke, heart attack and cardiovascular disease.
With that in mind, GLP-1s are undeniably effective. People taking them are losing 10% to 15% of their body weight, or more in some cases. They are also easy to use, requiring just a once-weekly injection, without required lifestyle changes (for example, diet and exercise).
What are the causes for concern?
As of now, I would say the greatest cause for concern is the unknown, particularly when it comes to long-term side effects. For example, we have seen common gastrointestinal side effects that can be alleviated by slowly tapering up the dose. But we have also seen rare and serious side effects of pancreatitis, thyroid cancer and intestinal blockage that require immediate cessation and follow-up care. Given how recently these drugs have been introduced to treat obesity, there may be other concerns that have not yet been uncovered.
So, I believe it pays to be cautious and prudent.
Other issues being discussed include how to ensure the drug’s effects are sustainable once patients get off the medications and managing costs for payers.
What are other potential challenges for payers that come from GLP-1s?
One of the biggest factors payers must consider is the high discontinuation rate. Recent studies have shown discontinuation rates at one year of 30% plus or 40% plus, and that number could fluctuate as more side effects are discovered. Health plans need to evaluate what additional programs and/or treatments may be required when patients start GLP-1 therapy to help with the side effects and to sustain the weight loss should use of the medications be discontinued.
What reasons are you seeing for the drop-off in adherence?
Primarily the gastrointestinal side effects, such as nausea, diarrhea and constipation. Many patients also have dyspepsia and heartburn.
Another reason is the perceived lack of benefit. Patients sometimes plateau after using these drugs and, for whatever reason, they can’t lose more weight. When that happens, patients may think they don’t need to continue using the drug. Unfortunately, if they do go off their GLP-1, the weight is often gained back.
Does that create a yo-yo effect, like what you might see with fad dieting?
Yes, which is a concern for payers as well as patients. That’s why it’s important to consider a holistic approach and ensure patients make changes in diet and exercise in tandem with the medication. If patients don’t change any of their habits from before they started taking GLP-1s, they will likely regain the weight once they stop treatment.
What other clinical programs or lifestyle initiatives can be implemented in addition to or instead of GLP-1s?
Minor modifications that are sustainable are best, especially ones that are focused on diet. This often comes down to patient-specific factors: What makes sense for an individual and what are they going to be able to maintain? How can they eat better for their lifestyle?
Next would be adding exercise, especially activities that are relatively easy to do but will lead to long-term and sustainable change. However, that’s important with or without GLP-1s.
Additional tools that patients are finding helpful are support groups and related resources.
Are lifestyle and dietary changes easier if patients are making them alongside use of GLP-1s since they might be seeing results more quickly?
In all the studies we’ve looked at, it’s a lot easier to maintain than it is to lose weight. So, when patients see the benefit from losing weight, it’s a big motivator.
On the other side, could lifestyle modifications be a tougher sell if patients think they need only a prescription medication?
Yes. Many people take GLP-1s because they have not been successful with lifestyle changes and are looking for an easier way to lose weight. Particularly for this group, changes to diet and exercise can be difficult to sell, but, if minor changes that are easier to maintain can be adopted during the weight loss phase, patients can see an even greater benefit during and after therapy. And that’s the sweet spot of weight management.
What can payers do to encourage a holistic approach?
We have seen a couple of payers provide some type of additional counseling for drug side effects as well nutritional counseling and diet recommendations. In some instances, they may make that service a condition for accessing the medication, which both helps with compliance and can be an additional value for members.
The healthcare industry is increasingly acknowledging social factors when planning patient treatment. What are the main social factors that affect weight management and how should they be considered?
There are several important factors to take into account in addition to more traditional risk factors for obesity. First, behavior and psychology can help understand and minimize triggers. Affordability is always a very big piece to consider, as it influences the medication patients can afford as well as the food/diet options that they are likely to consume. And social support, such as a coach and group support with others on similar therapy, can significantly improve results. In fact, a recent study found that coaching and peer support were associated with at least 1.7x more weight loss from GLP-1s than GLP-1 therapy alone.
Holistic therapy options should consist of medications, exercise and resources to address social risk factors.
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