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Glucagon-like peptide 1 (GLP-1) receptor agonists are the latest blockbuster drugs thanks to their powerful ability to help patients lose weight. But shortages are expected to last until the end of this year, and combined with increased demand, raises ethical questions about who is eligible to get the drug.
Semaglutide (Wegovy) for weight loss is available in eight countries: Denmark, Germany, Iceland, Norway, United Arab Emirates, UK, US, Switzerland, and was launched in Japan in February. Semaglutide (Ozempic) for type 2 diabetes is approved in 82 countries and is often prescribed off-label to treat obesity.
Tirzepatide, a dual glucose-dependent insulinotropic polypeptide/GLP-1 agonist (sold as “Mounjaro” for type 2 diabetes), began rolling out in 2022. It is approved for chronic weight management in the European Union and the United Kingdom, the weight loss drug Zepbound in the United States, and is currently under review in China.
Continued shortages have led some governments to urge clinicians not to prescribe the drug for obese patients and instead reserve it for patients with type 2 diabetes. However, there are limits to how the government can enforce this requirement, and some providers disagree with this guidance. Here’s a look at different countries’ approaches to dealing with these blockbuster drugs.
Sweden
Dr Ylva Troll Lagelos says it is common for the Swedish Medicines Agency to post guidance on medicines on its website, and that when a medicine is recalled or new side effects are discovered, the Agency sends a letter to doctors. He says he sometimes sends them. In December, Lagelos, along with doctors from across Sweden, decided to introduce GLP-1 receptor agonists to people whose only goal was weight loss, over concerns that they were not available for people with type 2 diabetes. I received a letter at home asking me not to prescribe agonist drugs. .
Given the shortage, Lagelos, an obesity medicine expert and associate professor at the Karolinska Institute in Stockholm, Sweden, said she was hoping for guidance, but that was reinforced by a letter mailed to doctors’ homes. Ta.
Dr Lagelos, who is also a senior physician at the Stockholm Obesity Center, Sweden’s largest obesity clinic, said: “Off-label use is not prohibited. It is our right as doctors, but we are clearly told not to do it.” ” he said. .
Healthcare providers are being forced to prioritize some patients over others, she added.
“Yes, GLP-1 [agonists] “It’s good for people with type 2 diabetes, but given this global shortage, I think those with the most severe disease should be prioritized,” she said. You should have diabetes. ”
Dr. Lagelos does not prescribe Ozempic, the only injectable GLP-1 currently available in Sweden, off-label because he works closely with the government on national obesity guidelines and feels unable to do so. But he said he understands why some of his colleagues at other clinics prescribe it. .
Lagelos said some companies import and sell Wegovy, which is not normally available in Sweden, at various price points. She said at least three of her telemedicine apps are operational in Sweden, where patients are prescribed semaglutide for weight loss without seeing a doctor.
“If you prescribe it to treat diabetes, the patient doesn’t have to pay, but if you prescribe it to treat obesity, the patient has to pay a lot of money, which creates an even bigger ethical issue,” Lageros said. Stated.
England
Last summer, British health authorities took a similar approach to Sweden. urge the provider Stop prescribing appetite suppressants to diabetics for weight loss due to deficiency. The notice asked health care providers to refrain from writing new prescriptions for GLP-1 agonists and Trulicity for patients with type 2 diabetes.
In the UK, Wegovy, Mounjaro, and Saxenda, an oral semaglutide, are approved for weight loss. covered According to the national medical system. To qualify for Wegovy, a person must have a body mass index (BMI) of 30 or higher and have one weight-related condition, or have a BMI of at least 35. Ozempic is only approved as a treatment for type 2 diabetes and is used off-label, but it is not specifically indicated for weight loss, so doctors typically use the same treatment as his Wegovy when prescribing it off-label. Use parameters.
Dr Naresh Kanumiri, a general practitioner and diabetologist at Northenden Group Practice in Manchester, UK, said he did not think GLP-1 agonists should be used off-label for weight loss.
“Many drugs were directed at obesity when they should be directed at diabetes, which has probably exacerbated the global shortage,” he said.
Mr Kanumiri, who is also director of diabetes at the National Health Service England Clinical Network, said he hoped more doctors in the UK would offer patients another medication for weight loss before using Wegoby. Stated.
He said doctors in the UK were allowing patients to move from a metformin-only regimen to a combination of GLP-1 and metformin without trying an intermediate group of drugs called sodium and glucose transport protein 2 inhibitors. It is said that there is “We would like to emphasize that these drugs should be tried before GLP-1 agonists.” [for obesity treatment],” He said.
America
Despite widespread shortages, the U.S. government is not requiring clinicians to reserve GLP-1 agonists for patients with type 2 diabetes, but patients face additional restrictions related to cost and insurance coverage. facing.
This type of drug is already in use in the United States costs more Compared to other countries, private insurance companies rarely cover obesity drugs. Medicare is prohibited from covering weight loss drugs of any kind, but law Maybe we can change that.
according to August 2023 data According to KFF (formerly the Kaiser Family Foundation), a one-month supply of Wegovy in either a 1.7 mg or 2.4 mg dose costs an average of $1,349 in the United States, which is considerably more expensive than in other countries. In Germany, the same supplies sell for about $328. In the Netherlands it costs $296. His month’s worth of Libersus or Ozempic costs about four times as much in the United States as it does in the Netherlands.List price for 1 month of Mounjaro by Eli Lilly $1069.08 in the US According to the report, it is equivalent to about $319 in Japan.
In rare cases, private insurance companies in the United States will cover GLP-1 agonists prescribed for weight loss. Approximately 27% of insurance companies Implemented in 2023 – May need to prove that other interventions, including lifestyle changes, have not produced results.
Dr. Beverly Chan, assistant professor of clinical medicine at the Weill Comprehensive Weight Management Center in New York, said she takes a patient-specific approach when considering prescribing these drugs.
Wegovy’s BMI threshold in the United States is 27 if you have at least one weight-related comorbidity and 30 if you do not. Chan said that while these rules are strict, there are exceptions for ethnic groups such as South Asian and East Asian descent, where a BMI of 25 applies because they have lower thresholds for overweight and obesity.
If Tchang feels that significant weight loss would benefit the patient, he is comfortable prescribing weight loss drugs to patients who do not have type 2 diabetes.
“Most people I meet would benefit from a weight loss threshold of 10% to 15% or higher, so I often reach for tirzepatide and semaglutide,” she said.
For patients who need to lose close to 5% of their body weight to manage or prevent comorbidities, Chan said they are likely to try a different drug that doesn’t produce extreme results.
Canada
The Canadian government does not instruct clinicians to reserve GLP-1 agonists for specific patients. Rather, access is limited by cost, said Dr. Ehud Ur, a professor of medicine at the University of British Columbia and a consultant endocrinologist at St. Paul’s Hospital in Vancouver, British Columbia, Canada.
According to , approximately 67% of Canadians have private insurance. commonwealth fund. Most private insurance companies cover GLP-1 agonists for weight loss, but Canada’s public healthcare system only covers drugs for type 2 diabetes, not weight loss alone.
He agreed that patients with type 2 diabetes should not be prioritized over obese patients in prescribing GLP-1 agonists. Instead, he said, doctors should focus on what is the best treatment for each patient. For some obese patients, these drugs can cause the same weight loss as surgery, which is currently not possible with other drugs.
Ull said some Canadian clinicians are prescribing GLP-1 agonists to people who don’t need significant weight loss, but the drugs are also taken by people who need to lose weight. That’s what it means.
“The motivation for seeking this drug is primarily due to its effectiveness,” he says. “There are doctors who have more confidence in this drug than in any other anti-obesity drug, so there is a lot of willingness to prescribe it.”
What are the alternatives?
Faced with shortages, doctors including Lagelos, Chan and Ull are turning to other drugs as needed to get patients the treatment they need.
“We’ve been involved in treating obesity for decades,” Chan said. “Before GLP-1 was invented.”
Dr. Lageroth believes that not all patients need GLP-1 agonists, but he hopes to make them more widely available for patients who binge eat because they can’t control their appetite. These people are prime candidates for the drug, she said.
“I tell my patients, ‘Yes, we don’t have semaglutide right now, but we have to hang in there and make do with what we have,'” she said.
