This content material initially appeared on On a regular basis Well being. Republished with permission.
By Ross Wollen
Medically Reviewed by Adam Gilden, MD, MSCE
Drugmakers are struggling to maintain up with the demand for weight reduction medicine semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound). The restricted provide is forcing docs, public well being consultants, and insurers to confront an disagreeable query: Who “deserves” these life-changing therapies essentially the most?
“Proper now, it’s first come, first served,” says Neda Rasouli, MD, an endocrinologist and professor on the College of Colorado in Aurora. “Nevertheless it needs to be based mostly on maximizing the profit and prioritizing individuals who do worse with out this intervention.”
GLP-1 medicine had been initially developed to deal with kind 2 diabetes and are nonetheless thought of a game-changing remedy within the discipline. In recent times, they’ve been widely known as the best weight reduction medicine ever developed, and researchers hold discovering new advantages, too. GLP-1s additionally seem to stop or deal with kidney illness, sleep apnea, and heart problems.
Medical doctors want these medicine had been universally accessible and reasonably priced, however shortages proceed as demand rises. As an alternative, well being practitioners are debating how these medicine would ideally be distributed so {that a} restricted provide can have the largest potential well being influence.
GLP-1 Medication Are Not Distributed Equitably
“In our system, People should purchase no matter they’ll afford,” says William Herman, MD, professor of epidemiology on the College of Michigan in Ann Arbor.
“We actually want to consider well being fairness,” says Dr. Herman. “Permitting rich people to buy GLP-1s which are in brief provide denies entry to people who usually tend to profit.”
Excessive costs and unequal insurance coverage entry have induced disparities in GLP-1 use alongside acquainted racial and socioeconomic fault strains. Amongst adults with kind 2 diabetes, white sufferers in America are considerably extra probably to make use of GLP-1 medicine than nonwhite sufferers, together with folks from Black, Asian, Hispanic, and American Indian/Alaskan Native backgrounds.[1] GLP-1 customers even have larger earnings, extra training, and usually tend to stay in prosperous city areas.[2] It’s potential that the disparities are even starker for folks with out diabetes, as insurers (together with Medicaid) are much less prone to cowl the usage of GLP-1 medicine for weight reduction.
Dr. Rasouli believes that the state of affairs must be reversed: “I wish to prioritize … underrepresented minorities, as a result of they don’t seem to be getting treatment they usually’re at even larger danger of comorbidities.” A number of nonwhite communities have larger charges of weight problems and diabetes problems, reminiscent of cardiovascular and kidney illness, and may due to this fact reap even larger advantages from GLP-1 medicine.[3]
Herman factors to analysis suggesting that Novo Nordisk might manufacture and distribute a single Ozempic pen for as little as $40, even whereas turning a ten p.c revenue.[4] And but the sticker worth for People remains to be round $1,000. In the meantime, an evaluation printed in 2023 discovered that in peer nations, a month of semaglutide was priced between $83 (France) and $169 (Japan).[5]
Timothy Garvey, MD, professor of medication on the College of Alabama in Birmingham, calls the state of affairs, with sky-high costs inflicting American insurers to revoke protection, “untenable.”
“These are life-saving drugs,” says Dr. Garvey. “To disclaim them to sufferers who would profit is unacceptable.”
Who Advantages the Most From GLP-1 Medication?
So as to maximize the general public well being advantages, it’s mandatory to grasp who responds finest to those medicine. That could be a tough query to reply, as a result of completely different folks take GLP-1 medicine for various causes. Whereas one grownup could select Ozempic for kind 2 diabetes to assist management their blood sugar, one other may select Wegovy, basically the identical treatment, to drop some weight and handle coronary heart illness dangers. There’s no straightforward strategy to examine the significance and cost-effectiveness of the advantages throughout situations.
We do know a couple of issues about common GLP-1 responses. Researchers have discovered that ladies are likely to lose extra weight than males, for instance, and folks with a decrease baseline A1C are likely to lose extra weight than these with the next baseline A1C.[6]
Rasouli wish to see GLP-1 medicine made obtainable first to sufferers with class 3 (“extreme”) weight problems — the heaviest classification of weight problems, similar to a physique mass index (BMI) of 40 kilograms per sq. meter (kg/m2) or larger.[7] “We use to name this morbid weight problems,” Rasouli says, explaining that the situation is related to a excessive danger of illness and early demise.
Medical trials have proven that individuals with class 3 weight problems reply particularly effectively to GLP-1 medicine.[8] “Individuals with the next BMI lose the next share of their physique weight. Extra apparently, the speed of uncomfortable side effects resulting in drug discontinuation is decrease in folks with class 3 weight problems,” says Rasouli. “These folks tolerate the treatment higher, they usually have a greater response.”
Against this, folks with diabetes are likely to lose much less weight.[9] However that actually doesn’t imply the treatment is any much less impactful. Up to now, insurers have been way more prone to cowl the price of GLP-1 medicine for folks with diabetes, as a result of the medicine virtually actually cut back the incidence of the illness’s harmful (and costly) long-term problems.
Revoking GLP-1 Entry
Deborah Horn, DO, medical director on the College of Texas’ Middle of Weight problems Drugs and Metabolic Efficiency in Bellaire, is very involved with the plight of people that lose entry to their medicine. In 2023, the College of Texas introduced that it will cease overlaying weight reduction medicine for its a number of hundred thousand staff, lots of them Dr. Horn’s sufferers: “I’m serving to handle all these sufferers who had nice success, however then had to determine one other strategy to handle their illness.” She has loads of expertise seeing what occurs when sufferers cease taking Ozempic — the burden normally comes again whereas the opposite metabolic advantages disappear.
Different insurers and employers throughout the nation, confronted with staggering drug prices, have additionally begun to tighten restrictions on entry and reimbursements.[10] Generally this implies discontinuing protection after a affected person’s BMI falls beneath U.S. Meals and Drug Administration (FDA) cutoffs, a observe which appears to battle with established requirements for the usage of medication to deal with and stop power illness.
“We might by no means do that with diabetes drugs!” says Horn.
Pam Taub, MD, a heart specialist at UC San Diego Well being, agrees: “No payer would ever inform you to cease a statin after your LDL [cholesterol] met your aim.”
Prioritizing Coronary heart Illness
Dr. Taub has a unique perspective. She believes that clinicians can’t be guided by an educational idea of most public well being profit. As an alternative, they should have interaction with the fact of the insurance coverage trade that largely decides which People get to make use of which medicine. And she or he believes that it might be the GLP-1 household’s impact on cardiovascular well being that permits them to grow to be broadly accessible.
In March 2024, semaglutide was authorized to stop coronary heart assaults and strokes. The FDA’s determination got here on the heels of a three-year examine exhibiting the utmost dose of semaglutide lowered the danger of heart problems and demise by 20 p.c.[11] “We see unimaginable profit from throughout the cardiovascular spectrum,” Taub says. A equally giant and rigorous cardiovascular end result trial is underway for tirzepatide now, with analyses of earlier knowledge suggesting that tirzepatide may boast comparable advantages.[12]
Taub believes these cardiovascular advantages are the important thing to persuading insurers, employers, and governments to pay for these notoriously costly medicine. “The tough actuality of our medical observe is that it’s dictated by what payers will cowl and what we are able to get our sufferers entry to,” she says. Emphasizing the cardiovascular advantages of GLP-1 medicine might be the easiest way of accelerating entry — and of permitting sufferers to benefit from the full vary of cardiometabolic advantages, together with weight reduction, blood sugar discount, and kidney safety.
Prioritizing Total Cardiometabolic Well being
In actuality, the situations that GLP-1 medicine deal with are inextricably linked. Whereas there are actually folks with weight problems who would not have diabetes, and vice versa, the situations share causes and danger components. Coronary heart illness, kidney illness, and sleep apnea are all comorbidities of weight problems and sort 2 diabetes, as are different situations reminiscent of metabolic dysfunction related steatotic (fatty) liver illness.[13]
“All of our organs are intricately linked,” says Taub. “The dysfunction of 1 results in the dysfunction of one other.”
“Let’s concentrate on total cardiometabolic well being,” Taub says. “We have to be promoting these as extra than simply weight reduction medicine. … By simply specializing in weight problems, we’re doing this discipline a disservice.”
Herman means that the individuals who will profit essentially the most from GLP-1 medicine are those that have been recognized with a number of cardiometabolic situations: “I believe the worth might be best in folks with kind 2 diabetes, weight problems, and heart problems … and for folks with kind 2 diabetes and problems.”
Rasouli provides that the medicine could also be particularly helpful “in youthful folks.” The youthful a affected person develops weight problems or diabetes, the extra extreme their problems are prone to be.[14][15] Youthful folks, due to this fact, could have extra to achieve from GLP-1 drug use; prioritizing youthful sufferers might maximize the variety of wholesome years saved.
Is Hollywood Actually Hogging GLP-1s?
Many individuals, each docs and sufferers alike, assume that the extraordinary demand for GLP-1 medicine has been considerably pushed by individuals who wish to slim down however who would not have a severe medical have to drop some weight.
Rasouli says, “When we’ve scarce assets, and if Hollywood folks or individuals who don’t actually need it get it first, it signifies that we’re denying entry to individuals who may want it extra.”
“I believe the least cost-effective strategy is within the remedy of … people who find themselves chubby or have delicate weight problems who wish to match into that fabulous robe by shedding a couple of kilos,” says Herman. “That is what we’re actually seeing in Hollywood, and sadly that is what we’re seeing pretty broadly.”
However Leah Wigham, PhD, a professor of public well being with the College of Texas in Houston, questions this narrative: “There are these tales of film stars [using Ozempic], that’s, what, a pair dozen anecdotes? Do we’ve knowledge that that’s truly contributing in a major strategy to the availability chain points?” A July 2024 examine of actual world prescribing knowledge discovered that solely a tiny fraction of customers, 0.37 p.c, will not be medically certified to make use of GLP-1 medicine.[16]
Nikhil Dhurandhar, PhD, a professor of dietary sciences at Texas Tech College in Lubbock, says that he “needs to place in phrase for many who wish to drop some weight to suit right into a gown.” Dr. Dhurandhar says that so long as customers are medically indicated to make use of a GLP-1 drug, “motivation mustn’t matter … your advantages are going to be the identical no matter what made you drop some weight.”
Dr. Wigham worries that vilifying some GLP-1 customers solely contributes to the disapproval and discrimination skilled by people who find themselves chubby.
“These sorts of feedback concerning the gown simply perpetuate this stigma that individuals don’t deserve the treatment except they’re making an attempt actually laborious to drop some weight on their very own,” says Wigham. “We don’t try this for different ailments and we have to cease utilizing that language for weight problems.”
Shortages Could Persist
Semaglutide and tirzepatide shortages are projected to final via 2024, however realistically there’s no telling when producers will be capable to catch up. There are probably effectively over a billion folks worldwide who’re medically eligible to take a GLP-1 receptor agonist, based on FDA standards.[17] The potential demand is nearly unimaginably giant.
Many alternative companies try to satisfy the demand. Main drugmakers are racing to increase their manufacturing capability and to develop further GLP-1 therapies. Generics could quickly be authorized in India and China, and in the US, compounding pharmacies working in a authorized grey space supply cheaper unbranded equivalents.
In an ideal world, everybody who stands to profit from these blockbuster medicine would be capable to entry them. In the meanwhile, that chance appears very far-off.
The Takeaway
Demand for GLP-1 medicine like Ozempic has outstripped provide, sparking debates over honest entry. Some well being consultants recommend prioritizing these drugs for many who may profit most, particularly sufferers with a number of cardiometabolic situations, together with kind 2 diabetes and extreme weight problems.
