Yesterday, the UK Government announced a plan to spend £40 million on a two-year pilot to explore ways to make obesity drugs accessible to patients living with obesity outside of hospital settings. As readers may know, anti-obesity medications including semaglutide have already been approved for prescription in hospital-based obesity clinics in the UK (albeit its use is limited to just two years, which makes little sense for a chronic disease like obesity). As noted in the announcement, however, this limitation to use in hospital-based clinics will only reach about 35,000 people living with obesity, a tiny fraction of the over 12 million people with BMIs >30 kg/m2 in the UK. According to the release, “Obesity costs the NHS around £6.5 billion a year and is the second biggest cause of cancer. There were more than 1 million admissions to NHS hospitals in 2019/2020 where obesity was a factor.” The pilot will explore how approved anti-obesity drugs can be made safely available to more people by expanding specialist weight management services outside of hospital settings. This includes looking at how GPs could safely prescribe these drugs and how the NHS can provide support in the community or digitally. The hope is that wider use of these medications can help cut waiting lists by reducing the number of people who suffer from weight-related illnesses, who tend to need more support from the NHS and could end up needing operations linked to their weight – such as gallstone removal or hip and knee replacements. These activities to improve access to anti-obesity medications, of course, also includes negotiating a secure long-term supply of the products at prices that represent value for money taxpayers. Obviously, this is a step in the right direction, as I have previously noted that to have a discernible impact on population health, anti-obesity medications will ultimately have to be made available and properly managed by GPs, not unlike their management of hypertension, diabetes or other common chronic diseases. It will be interesting to see how this pilot develops and if other countries in Europe and elsewhere will follow suit. DrSharmaBerlin, D Disclaimer: I have received honoraria as an independent medical, research and/or educational consultant from various companies including Aidhere, Allurion, Boehringer Ingelheim, Currax, Eli-Lilly, Johnson & Johnson, Medscape, MDBriefcase, Novo Nordisk, Oviva and Xenobiosciences.
I seldom give a talk on anti-obesity medications (AOMs) where I do not get the question regarding predicting response. Indeed, predicting response appears to be one of those topics that drives much of the enthusiasm around “personalised” medicine (a misnomer, if there ever was one). One must first point out, however, that the desire to predict therapeutic response is by no means unique to obesity. In fact, there is probably no area of medicine, where prediction of response is not something that would be preferred. Unfortunately, with a few rare exceptions, we are far from predicting therapeutic response beyond statistical probabilities. Thus, in most cases, we present a likelihood, i.e. “you have a one in three chance of losing 20% of your weight”. Whether you would see this as a good or poor chance, depends on whether you are of “glass half-empty” or “glass half-full” disposition. Indeed, trying to reliably predict individual responses based on mode of action, pathophysiology or some phenotypical characteristic, has failed miserably (despite all efforts) in most fields of medicine (with cancer perhaps being a notable exception). This has not worked for hypertension, dyslipidemia, diabetes, depression, or most other conditions. Indeed, virtually all guidelines recommend starting with the most “popular” medication (with due consideration of individual indications and contraindications), but then adjusting the dose or adding or switching to another agent based on actual tolerability or response. This “trial and error” or rather “empirical” (which sounds much better) approach to medical management is not uncommon in most fields of medicine. Like it or not, predicting who will tolerate and who will respond to a medication remains largely a guessing game. I see no reason why this should be any different for obesity. The good news is that in medicine we have the luxury of “trying” – something that surgeons don’t have – you cannot try a sleeve gastrectomy – once you have it, there is no going back. It is also good news that with all AOMs, early response remains the best predictor of long-term outcomes – so no one needs to continue on an ineffective medication for all too long. Yes, it does mean some people will have to bear the cost and exposure to a medication that will not work for them, but, in most cases, there is not much harm done. So while, in an ideal world, I would love to be able… Read More »
Shortages in supply of semaglutide, approved in various countries (including the US, Canada, UK, and the European Union) for the treatment of type 2 diabetes and obesity, have led to calls to restrict its use to patients with type 2 diabetes (T2DM). Indeed, there has been much ado about people using (and misusing) semaglutide “simply” for weight loss, apparently depriving people living with T2DM of this “essential” medication. While it makes no sense to pit one disease against another, one could well argue that it is the people living with T2DM who are in fact depriving the folks living with obesity of this “essential” medication. For one, there are plenty of treatments available for managing T2DM. Although semaglutide may well be a safe and effective medication for T2DM, there are plenty of other GLP-1 analogues around, not to mention the many other classes of medications approved for T2DM. Thus, were semaglutide to disappear from the market, most people living with T2DM would do just fine with the many alternatives that already exist.. This, however, is not the case for obesity! People living with obesity requiring obesity treatment have no alternative that is even remotely as effective as semaglutide, which, for a significant proportion of patients, can result in weight loss comparable only to what can be achieved with bariatric surgery. Thus, while there is no discernable unmet need for people with T2DM, the unmet need for those living with obesity is indisputable. Reserving the limited supplies of semaglutide for them should be a priority. Obviously, most people living with T2DM are also living with obesity (which highlights the absurdity of pitting one disease against the other), but emphasising the need for people with T2DM while ignoring the much greater need for those living with obesity, to me, reeks of weight bias and discrimination. Hopefully, the supply of semaglutide will eventually increase to meet the demand, but perhaps in the meantime those living with T2DM who are not in desperate need of losing weight should help conserve the limited supplies of semaglutide in favour of those living with obesity, who do not have the luxury of switching to an alternative but equally effective treatment. DrSharmaBerlin, D Disclaimer: I have received honoraria as an independent medical, research and/or educational consultant from various companies including Aidhere, Allurion, Boehringer Ingelheim, Currax, Eli-Lilly, Johnson & Johnson, Medscape, MDBriefcase, Novo Nordisk, Oviva and Xenobiosciences.
With the recent introduction of the new class of highly-effective incretin-based anti-obesity medications, we have seen a lot of hand-wringing about the prohibitive costs that would incur, if even a fraction of those who may stand to benefit, were treated. These assessments are of course based on current costs, which for Semaglutide 2.4 mg (Wegovy) in the US, can run up to $16,000 per year (albeit it is likely to be far less expensive in other countries). Current costs, however, are not the final word in pricing – rather, I can foresee several factors that will eventually drive prices down (despite apparently limitless demand). For one, we can expect that competition will have its effect (although this may not be immediately apparent). Over time, patents will expire and less expensive generic versions will appear – for e.g. liraglutide goes off patent this year. Oral forms of these medications will further reduce the logistical cost and hassles of cool-chains and devices. Small-molecules, that are easier to mass-produce than biologics, will further decrease cost. Given their potency, not everyone is going to need to be on the highest dose of these meds. Negotiations with payers (rebates) will likely land on more reasonable prices. Finally, as with all chronic diseases, only a fraction of eligible individuals will ever be on these medications for very long (even if they probably should be). Thus it is probably only a matter of time (probably a few years), before the cost of medically treating obesity falls to that of managing other chronic diseases like diabetes or hypertension. If we also factor in the potential healthcare savings from effectively treating obesity and reducing related complications (including heart disease and cancer), the economic picture certainly appears a lot less bleak than presented in most current projections. DrSharmaBerlin, D Disclaimer: I have received honoraria as an independent medical, research and/or educational consultant from various companies including Aidhere, Allurion, Boehringer Ingelheim, Currax, Eli-Lilly, Johnson & Johnson, Medscape, MDBriefcase, Novo Nordisk, Oviva and Xenobiosciences.
Most readers will be quite familiar with my 5As of Obesity Management (Ask, Assess, Advise, Agree, and Assist). Until now, we have emphasized that any conversation about weight with someone in your practice should begin with a polite and non-judgmental request for permission to bring up the topic. However, given the recent surge in popular interest in new medications for obesity, we now suddenly have patients lining up to request weight-loss prescriptions from their doctors. So, while previously, both doctors and patients have been hesitant to bring up the topic of weight, this is now often the exact reason why people are making appointments to see their doctors. This, of course, changes the nature of the Ask. No longer, is it about the doctor initiating the conversation by asking for permission to discuss weight. Rather it is now the patient who brings up the topic outright by asking for a prescription for an anti-obesity medication. This obviously changes the Ask – a more appropriate response would now be, “Why do you think you need this?” and “Where did you hear and what do you know about it?” This opens a whole new conversation. So, yes, we still start with an Ask, but it’s a different Ask. Obviously, we still need to then proceed with the other steps of Assessment, Advising, and Agreeing, before (if appropriate) we then Assist our patients in their treatment journey. An interesting twist to the story is now, that we are left with figuring out how to deal with individuals seeking prescriptions, for whom anti-obesity medication may neither be indicated nor suitable. @DrSharmaBerlin, D
Last week at the 8th Canadian Obesity Summit in Whistler, BC, I was honoured to receive the innaugural Obesity Canada Founder Award for my services to the organisation. In preparation for this event, just for kicks, I asked Bing’s Chatbot to write me an acceptance speech. The following is verbatim what Bing came up with (in under 20 seconds!) – scary! @DrSharma,,Berlin, D p.s. I did not use any of it, but I probably could have without anyone noticing. Prompt: write an acceptance speech for Dr. Arya Sharma as recipient of the Obesity Canada Founders Award Bing Chatbot: Here is a possible thank you address for Dr. Arya Sharma: Ladies and gentlemen, it is my great honor and pleasure to receive the inaugural founder award from Obesity Canada, the leading obesity charity in this country. I would like to thank the board of directors, the staff, the members, and the supporters of Obesity Canada for this recognition and for their dedication to advancing obesity research, education, and advocacy. When I founded Obesity Canada in 2006, I had a vision of creating a network of obesity stakeholders who would work together to improve the lives of Canadians living with obesity. I wanted to challenge the stigma and discrimination that people with obesity face every day. I wanted to promote obesity as a chronic disease that requires evidence-based prevention and management. I wanted to foster collaboration and innovation among researchers, health professionals, policy makers, and people with lived experience. Fifteen years later, I am proud to say that Obesity Canada has achieved many of these goals and more. Obesity Canada has grown to become a network of over 10,000 members across Canada and beyond¹. Obesity Canada has produced the first Canadian clinical practice guidelines for obesity in adults² and children³ [sic], which have been widely adopted and endorsed by various organizations. Obesity Canada has organized six [sic] biennial Canadian Obesity Summits, which have brought together hundreds of experts and stakeholders to share knowledge and best practices. Obesity Canada has advocated for policy changes that support obesity prevention and care, such as the inclusion of obesity in the Canadian Disability Tax Credit and the recognition of obesity as a chronic disease by several provinces. Obesity Canada has also empowered people living with obesity to share their stories and voices through initiatives such as the Public Engagement Committee, the Weight of Living project, and… Read More »
Now that we have medications for managing obesity that are safer and more effective than ever before, the issue of how to get patients to actually take them deserves more attention. Generally speaking, most people do not like taking medications, which is why the issue of adherence is not unique to patients with obesity. In fact, most people don’t take medications exactly how or for how long their doctor has prescribed them (I certainly used to belong to that club). Thus in many ways, adherence to anti-obesity medications (AOMs) is not far worse than to medications in general, which may come as a bit of a surprise, given that the long-term use of AOMs may face more hurdles than other medications. Thus, one of the most common reasons suggested for why people don’t stick with their AOMs is cost. While this may sound obvious, we should remember that many patients don’t stick with their prescription meds even when these are fully covered by their health plans (e.g. statins or anti-hypertensives). Another argument often brought up in this regard, is that patients don’t look at obesity as a chronic disease requiring long-term treatment. Again, while this is certainly true, as noted above, adherence to medications for other (well-established) chronic diseases is not much better (often no more than three to six months). It is also suggested that patients discontinue their AOMs because they are not meeting their (often unrealistic) weight loss goals. However, given that these medications take months before patients achieve their maximum weight-loss (never mind the time it takes to up-titrate to the recommended dose), this does not explain why most patients stop their meds only a couple of weeks into the treatment, i.e. long before they can expect to see the maximum effect or reach their weight-loss plateau. In fact, most patients never seek or fill a second prescription. I also often hear the notion that patients come off their AOMs because weight is easily monitored and patients can directly see the effect (or lack of it), which is certainly different for statins or ASS. Again, we don’t see much better adherence in patients with other conditions where patients can directly experience the effect of their medications (e.g. medications for chronic pain). The fact is that non-adherence is not unique to AOMs but of course as relevant to their use as for any other medications for chronic conditions. … Read More »
There is no doubt that we are currently experiencing the dawn of a revolution in our ability to better treat and manage obesity. Under these circumstances, predicting the future of obesity medicine is perhaps even more difficult than when things were plodding along at a steady pace. Nevertheless, here are some of the trends we should watch for in 2023: With my best wishes for a Happy New Year!@DrSharmaBerlin, D