SmartBrief editor Tom Parks reported on presentations at the American Association of Nurse Practitioners National Conference that focused on weight loss, obesity and new GLP-1 medications. This story covers those topics and also has a follow-up: Food noise and how to turn down the volume
The conversation around obesity treatment has moved from asking whether pharmacotherapy is the right choice to which incretin therapy is the best fit in terms of mechanism and access, for weight management and GLP-1 receptor agonists
“They really have changed the conversation because they are successful,” said DNP Melissa Glassford, an assistant professor at the Vanderbilt University School of Nursing. “… We’re seeing big results across the majority of people who take the medication.”
Glassforddiscussed the changing role of GLP-1 receptor agonists and other obesity medications. Real-world factors such as access, cost and continuity of treatment all matter, as does titration and monitoring to limit side effects
Setting expectations early can be important, too. For example, a middle-age patient may think they need to take a GLP-1 receptor only as long as it takes to lose weight. But that’s not so
In a separate presentation at the conference on treating obesity in primary care, Sandra Christensen, MSN, said obesity is a chronic disease whose management is a lifelong process that requires patient involvement and team care. The first thing to know is that obesity medications are long-term treatments for chronic conditions, much like drugs for diabetes or high blood pressure. Just like you wouldn’t expect to stop treatment for hypertension and do well, that same may be true for obesity medications.
The second thing for patients to understand, Glassford said, is that while weight loss is significant with incretin therapy, it is not unlimited. If the average weight loss with a drug is 15%, for example, that means a significant portion of patients lose less than 15%. Patients may need to be told that they are not going to get to the same weight they had at age 20. Moreover, they don’t need to, Glassford added
Some patients who feel frustrated at having reached a plateau may need to be reassured that they have achieved clinically meaningful results. For clinicians, future research and guidance are needed on how to optimize the long-term trajectory of weight loss and health outcomes for patients as more data on use of GLP-1s become available, speakers said
Best obesity treatment? The one you can get
When it comes to access, both insurance coverage and secondary indications matter. Clinical factors can be useful in guiding selections, but in the end, access is king. “The best GLP-1 is the one you can get your hands on. It’s the one you can get and stay on,” Glassford said.
Glassford shared some considerations for prescribing decisions that may affect coverage and outcomes:
- Tirzepatide has an indication for treating obstructive sleep apnea for patients with obesity, which may make it easier for some patients to gain insurance coverage.
- Oral semaglutide may be a good fit for patients who want an oral regimen and for whom fasting rules are realistic. Orforglipron may be a better choice for patients who want a pill but cannot fast.
- When cardiovascular disease and noncirrhotic metabolic dysfunction-associatedSteatohepatitis are present, semaglutide injection moves up the list because of its indications.
Glassford acknowledged the difficulty of figuring out what’s in a patient’s formulary during a 15-minute visit. It’s helpful when patients call insurers ahead of time, but not everyone can do that. Some patients do come in with all the data. But even then, they may arrive with incorrect information because navigating coverage is confusing and frustrating
Only about a third of insurers cover weight-loss meds. While that figure is small, it still represents millions of people who may be able to access treatment, Glassford said
Part of the reason to set realistic expectations about weight loss early is that patients may be frustrated when their progress slows or stops
People with a high body mass index may be able to reach 20% weight loss on Wegovy, for example. When they want more, clinicians can tell them that they have achieved more than the average weight loss, and that’s good and clinically meaningful, Glassford said
Obesity medication pipeline is robust
The pipeline for new obesity medications is large, and some investigative treatments have been found to result in 20% or more weight loss, Christensen said.
At the same time, research is lacking on whether adding other weight-loss drugs to incretin therapy can help patients who hit a plateau and could benefit from additional weight loss. Future studies may help guide treatment
The 4 pillars of obesity treatment
Medical management is only one aspect of obesity treatment in primary care, Christensen said.Nutrition, activity and behavioral therapy matter, too. Treatment plans should be individualized and developed through collaborative goal-setting with a stepwise approach
“We have to build,” Christensen said. “What’s the next thing you want to focus on, we ask patients.” Because clinicians are likely to lose patients when they hit them with everything at once. That said,Christensen acknowledged that it’s so much easier for patients to stick to their eating plans while on incretin therapy.
Medication management doesn’t end with weight-loss drugs. Patients’ medications also need to reviewed to see if they are taking a therapy that promotes weight gain, such as beta blockers. Christensen said she learned early that you can’t treat obesity at the same time you’re prescribing obesity.
What’s causing this case of obesity?
In another presentation, DNP Christy Davis said there is a need to explore the causes of obesity, particularly when lifestyle alone doesn’t fit what clinicians are seeing with a patient. Hormonal, pharmaceutical, genetic and environmental factors could be at play
Conditions that can affect weight include hypothyroidism, Cushing syndrome, hypogonadism and polyendocrine metabolic ovarian syndrome. Going directly from identifying adiposity to prescribing treatment may mean missing conditions that also need treatment
It’s not always possible to drop or replace a drug that could be contributing to overweight or obesity. “Even if you don’t change a med, it can be helpful for patients who don’t know why they’ve been gaining weight,” Davis said “Sometimes it’s helpful to give them an answer.”
Davis said she’s been asked which to treat first, hypothyroidism or obesity. “Both,” she said. “The answer is you treat both.”
