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Experts debate optimal strategies for the allocation of antiobesity medications


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4 minutes

High demand for glucagon-like peptide-1 (GLP-1) receptor agonists has led to many providers struggling with supply shortages and reckoning with the task of prioritizing who should receive access to the drugs first. A group of experts at the 84th Scientific Sessions guided attendees through the nuances of these considerations during the debate session Keeping Up with Hollywood—Who Should Be Prioritized for New Antiobesity Medications?  

Deborah Horn, DO, MPH, MFOMA
Deborah Horn, DO, MPH, MFOMA

The session can be viewed on-demand by registered meeting participants on the virtual meeting platform. If you haven’t registered for the 84th Scientific Sessions, register today to access the valuable meeting content through Aug. 26.

Deborah Horn, DO, MPH, MFOMA, Associate Professor and Medical Director at the University of Texas Health Science Center at Houston, asserted that patients who have already shown benefits from receiving the medication should be prioritized first.

“I just want us to focus on what happens in every trial that we run on obesity: We finish the trial, and the population regains their weight,” Dr. Horn said. “And that’s what’s going to happen if you take a successful person who has had a successful treatment on GLP-1 and take it away from them.”

The SURMOUNT-4 trial studied the effect of maintaining GLP-1 regimens after participants reached the maximum tolerated dose at 36 weeks and subsequently randomized the groups to either continue GLP-1 administration or be given a placebo for an additional 52 weeks, she explained. After the full 88 weeks, 89.5 percent of participants who received continuous treatments of tirzepatide maintained at least 80 percent of the weight they lost during the lead-in period compared with 16.6 percent of those who received the placebo at 36 weeks. The overall mean weight reduction from weeks zero to 88 was 25.3 percent for tirzepatide and 9.9 percent for placebo.

Pam R. Taub, MD, FACC, FASPC
Pam R. Taub, MD, FACC, FASPC

“People who are on GLP-1 and have succeeded deserve to continue to say ‘Yes,’” Dr. Horn said.

Pam R. Taub, MD, FACC, FASPC, Professor of Medicine at the University of California San Diego School of Medicine, presented the case for patients who are overweight with cardiovascular disease (CVD) to be prioritized to receive GLP-1 receptor agonists.

“The harsh reality of our clinical practice is that it is dictated by what the payors will cover and what we can get our patients access to,” Dr. Taub explained. “So, we need to play the game to satisfy our payors and get our patients access to the drugs.”

Neda Rasouli, MD
Neda Rasouli, MD

She encouraged clinicians to harness the pleiotropic effect of these medications to treat a wide spectrum of cardiometabolic diseases to get their patients access to GLP-1 receptor agonists, as payors are more likely to sign off on medications to treat conditions like heart attack or stroke than obesity.

“If we really focus on the cardiovascular benefits, payors will see that in the long run, these drugs are going to save them money, and they’re going to give our patients access to these drugs,” Dr. Taub said.

Neda Rasouli, MD, Professor at the University of Colorado School of Medicine, advocated for patients with Class 3 obesity to receive prioritization for GLP-1 receptor agonists. She contended that there are more fair ways to approach resource allocation in health care than the United States’ current first-come, first-served model that can lead to ethnic, racial, and socioeconomic inequalities.

“It should be based on maximizing the benefits and prioritizing those people who will do the worst without this intervention,” Dr. Rasouli said.

William H. Herman, MD, MPH
William H. Herman, MD, MPH

She claimed that the best metric to measure these criteria was potential years of life lost (PYLL). Dr. Rasouli shared data that showed PYLL for those with Class 3 obesity was approximately 6.5–13 years compared to those at a normal weight. Comparatively, PYLL for current smokers versus those who had never smoked was measured at 8.9 years.

“Think about all the resources and efforts made for stopping smoking,” said Dr. Rasouli. “That should be done with the same urgency for obesity.”

Dr. Rasouli also shared data from the SURMOUNT-1 trial showing that participants with Class 3 obesity showed higher percentages of body weight loss with tirzepatide than those that were overweight (20.3 percent versus 15.2 percent). The SELECT trial showed similar trends with semaglutide, she noted. SELECT also found that participants with higher baseline body mass index (BMI) had a lower rate of adverse effects and drug discontinuation.

Dr. Rasouli concluded by saying that if she were to prioritize GLP-1 receptor agonists among a cohort of patients with Class 3 obesity, she would most urgently prioritize those with type 2 diabetes, atherosclerotic CVD, or chronic kidney disease. Next, she would focus on patients younger than 50 years of age, followed by underrepresented minorities.

After the debate, William H. Herman, MD, MPH, the Stefan S. Fajans/GlaxoSmithKline Professor of Diabetes at the University of Michigan, shared insights from a health economics perspective.

“I believe that access to the newer anti-obesity medications should be given to those who are at the highest risk for adverse health outcomes, which includes people with diabetes and/or cardiovascular disease who are most likely to benefit,” Dr. Herman said. “And I do think we need to pay more attention to health equity.”

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There is still time to register for on-demand access to learn about the latest advances in diabetes research, prevention, and care presented at the 84th Scientific Sessions. Select session recordings will be available through Aug. 26.