Prescriptions for GLP-1s are becoming commonplace, and although obesity and diabetes experts all know that weight loss drugs can be an integral part of overall chronic disease management, the murky landscape for drug coverage and access is complicating matters.
In the first part of this series about chronic disease management with diabetes and weight loss drugs, we touched base with providers who shared the best practices for treating patients getting this new class of drugs. GLP-1 medications are an effective part of diabetes, heart disease and obesity treatment, but they need to be complemented by wraparound patient care to support intensive lifestyle change.
Engaging patients around diet and nutrition, physical activity and other lifestyle factors, plus prescribing a GLP-1, is integral to long-term success, most experts agree.
"Because what we know about obesity care is evidence-based, we don't typically approach it that way," said Enrica Basilico, MD, a weight loss specialist with Providence Swedish in Seattle, referencing the around 15% to 20% of body weight GLP-1 users can expect even without any lifestyle intervention.
"We don't just say, 'Hey, take the drugs, see you in a year.'"
Providers will want to engage patients in shared decision-making when prescribing GLP-1 medications and set up a multidisciplinary care team to ensure patients are engaged in all four pillars of obesity care management (lifestyle, nutrition, physical activity and medical interventions).
That care management process usually happens when a patient visits with a physician.
We don't just say, 'Hey, take the drugs, see you in a year.'
Enrica Basilico, MDWeight loss specialist, Providence Swedish in Seattle
But weight loss has been largely stigmatized and commercialized, adding a layer of complexity that can make obesity difficult to treat. That, plus the numerous options for remote prescribing, care management and even drug compounding, have fueled misconceptions and even obscured best practices for obesity care management.
Perils of bypassing holistic care management
Wraparound patient engagement doesn't just put patients on the track to better outcomes; it can prevent them from derailing altogether.
For Barbara Eichorst, MS, RD, CDCES, vice president of health care programs at the American Diabetes Association, strong patient engagement and care management means helping patients mitigate the side effects they might feel when taking a GLP-1.
"It's a medication that has a lot of side effects, especially at the beginning," Eichorst said, citing the nausea, weakness and muscle loss many patients might experience. "That has become a very significant barrier because many people give up that medication because of the side effects at the beginning."
Fundamentally, patients need to keep a close relationship with their prescribing clinician to ensure they can mitigate these side effects. Clinicians are also responsible for titrating the dosage slowly to reduce the intensity of side effects and avoid adverse drug interactions, Eichorst said.
That physician has access to those diabetes care education specialists, the dieticians and the pharmacists.
Barbara Eichorst, MS, RD, CDCESVice president of health care programs, American Diabetes Association
There's another logistical reason why patients need to be engaged in holistic care management: these drugs are simply hard to come by these days.
"These medicines are meant to be used chronically, but there are a lot of challenges in getting the medications and maintaining coverage for the medication," Basilico noted.
According to Novo Nordisk, the maker of Wegovy, U.S. patients use the medication for an average of six months before discontinuing. The drugmaker cited low availability.
"If you haven't engaged in some of the behavior and lifestyle stuff, it's going to be even more challenging if you have a period where you don't have access to the medication," Basilico said.
Healthcare providers might be used to helping patients access their medications, whether by discussing drug costs, filling out prior authorizations or advising patients about pharmacies. But in a dire GLP-1 shortage like the one the U.S. is seeing now, strong patient engagement will be a critical next step in helping to mitigate medication access and adherence woes.
Clinician-led care gold standard for GLP-1 drugs
The experts indicated that holistic obesity care management is lacking when an individual bypasses a clinician to get the medication. Clinician-led care is the gold standard for ensuring patients get the engagement and management they need to achieve optimal outcomes.
According to a May 2024 KFF survey, 10% of GLP-1 users are getting their drugs from medical spas.
"GLP-1s have become designer drugs," says one 2024 Wolters Kluwer article on the topic. "Patients may come across health spas and clinics that advertise availability of GLP-1s, but they are generally not certified to dispense medications and have no pharmacy personnel overseeing this dispensing."
In these settings, it is less likely the GLP-1 user will get the type of holistic, wraparound care that experts assert is necessary for long-term outcomes.
We're used to thinking about weight as a personal failing. For many, many years, a commercial approach was taken. Obesity feels like something I did to myself, so I should go and fix it.
Lydia Alexander, MDPresident, Obesity Medicine Association
Eichorst insisted that patients need to visit with a physician to receive comprehensive care.
"That physician has access to those diabetes care education specialists, the dieticians and the pharmacists," she explained. "A person who is outside the healthcare system is without that support."
In fact, Eichorst argued that comprehensive care management is part of the GLP-1 prescription. It's not just about a needle stick, but rather about the prescription and the support from the care team who can mitigate side effects and risks associated with the medication.
GLP-1 access that lacks clinician-led care might also mean the patient is getting a compounded version of the drug, introducing a new layer of patient safety issues.
Drug and pharmaceutical compounding means a pharmacist mixes a new version of a brand-name drug when a patient wouldn't be able to take it otherwise. Compounding can be effective if a patient is allergic to an ingredient in a brand-name drug. The FDA also allows compounding in certain circumstances of serious drug shortages.
Although compounding serves a key purpose, Basilico stressed that it can be extremely risky. Compounded versions of GLP-1s are not FDA-approved, and there is scant safety data about these medications.
"The bottom line is that these are not FDA-regulated or approved, so they're bootleg versions of these medicines, and therefore we don't have safety data on them," she stressed. "The risk of taking a compound is that you are taking a medication that has not been tested for safety."
Some studies have shown that illegal websites bootlegging compounded GLP-1s contain too much semaglutide, which can have serious patient safety implications. The above mentioned Wolters Kluwer article also indicated that some med spas issue fraudulent, counterfeit or diluted forms of semaglutide.
Patients can avoid safety risks by getting their medications from a healthcare provider, experts suggest. In doing so, they'll likely get the holistic care management that's been proven effective. But it might be common to get a GLP-1 in a med spa or clinic because of the way weight loss has often been portrayed as something that can be bought as opposed to a medical treatment.
According to Lydia Alexander, MD, president of the Obesity Medicine Association, patient engagement might be missing from the mainstream conversation due to the way the U.S. has commercialized obesity. After all, it wasn't until 2013 that the American Medical Association declared obesity a chronic illness.
"We're used to thinking about weight as a personal failing. For many, many years, a commercial approach was taken," Alexander noted. "Obesity feels like something I did to myself, so I should go and fix it."
"We've been treating some obesity in the medical setting and then some obesity in the commercial setting, so part of what we're doing now is making that mental shift that this is actually a condition, a disease," she added.
Still, the path to fully understanding the role of GLP-1s and patient engagement is unclear. For one thing, insurance coverage for the drugs is still largely undecided, leaving some experts to fear income-based disparities in drug access and potentially poor medication adherence.
Meanwhile, the hold that commercialized weight loss programs, like those offered at med spas, have some clinicians leery.
Clinician-led GLP-1 management, even when done with a remote care provider, offers pathways to high-touch patient engagement. But so long as commercial weight loss plans continue to peddle compounded versions of the drug and neglect to include credentialed healthcare providers from the treatment team, patient safety could be at risk.
Sara Heath has covered news related to patient engagement and health equity since 2015.
