The demand for obesity medications is high, but access, cost, and insurance coverage create significant barriers for clinicians and patients. These challenges complicate the landscape of obesity treatment, making it difficult for many to receive the care they need.
Current Obesity Medication Landscape
The FDA has approved several medications for long-term weight management, including glucagon-like peptide-1 (GLP-1) receptor agonists like liraglutide, semaglutide, and tirzepatide. However, access to these medications is not always straightforward. According to Sandra Christensen, an obesity medicine specialist, many insurance providers have tightened their requirements for GLP-1 receptor agonist prescriptions, often requiring a diagnosis of diabetes. "I had so many people taking off-label GLP-1 RAs and GIP/GLP_1 RAs and their Medicare supplemental plan was paying for them without requiring a prior [authorization]," she said. "Then my patients started receiving letters that [Medicare was] not going to cover them after January 1, 2024, unless they have diabetes."
Disparities in Access
Access to affordable care is a significant issue for patients with obesity. "Access is a big problem," Christensen stated. "There is so much demand for the medications. If you don’t have insurance coverage, it’s really difficult to afford them. People with means can pay out of pocket for them." While privately insured patients and those who can afford out-of-pocket expenses have better access, state Medicaid programs are working to close these gaps. States like California, Michigan, Wisconsin, Minnesota, and Mississippi are increasingly covering obesity medications for Medicaid recipients. Some programs, such as Montana and Washington, now cover semaglutide 2.4 mg (Wegovy) for patients with a history of cardiovascular events and overweight or obesity.
Comprehensive Obesity Management
Christensen emphasizes a comprehensive approach to obesity management, with lifestyle changes as the foundation. Obesity medications and bariatric surgery should be considered adjuncts to nutrition, physical activity, and behavioral counseling. Anticipatory guidance is crucial when initiating obesity medication, particularly GLP-1RAs or GIP/GLP-1 RAs. Patients should be informed about potential side effects and strategies to prevent or lessen their severity. "You want to let them know what the potential side effects are, and then give them strategies that can help prevent them or lessen their severity," Christensen explained. "I counsel patients to eat frequently, eat first thing in the morning, eat small meals, avoid high-fat meals, stop eating when they’re full, and let them know that the side effects will likely be worse with the first couple of doses [of medication] or after a dose increase."
Long-Term Medication Use
Many patients find themselves in a difficult situation when they reduce their weight and no longer meet prior authorization requirements. While insurance providers often continue coverage, issues can arise with pharmacy benefit managers and insurance companies. Christensen advises patients to continue taking obesity medications as long as they experience benefits, including improved health and quality of life. "When I speak on the topic of obesity medications and emphasize that they are part of the treatment plan for managing a chronic disease, [I get] questions from clinicians, [like] ‘How long do you keep people on these meds?’ ‘How do you taper them off?’ It’s like, well, we really don’t. The body is programmed to store energy. And whenever we reduce weight, it fights back with increases in hunger hormones, decreased satiety hormones, and decreased resting metabolic rate. You’re not going to get to this place where everything is just stable without the meds," she said.
Future Directions
As clinical trials continue to demonstrate the efficacy of obesity medications, Christensen anticipates increased insurance coverage and lower costs. "I think with all these trials that are looking at other health outcomes, it’s going to push the needle over to where insurance companies have to cover them," she said. She also hopes that the increasing number of available medications will improve patient access and that combining multiple medications may become a promising strategy for obesity management. "What I’ve known forever, is that when you treat obesity first, other conditions improve, and now we’re getting the evidence to show that," she concluded.
