GLP-1s: The Medications Redefining Diabetes and Obesity Treatment

In part one of this three-part Instagram Live discussion, MedPage Today editor-in-chief Jeremy Faust, MD, talks about how GLP-1 receptor agonists are transforming diabetes and obesity care in a discussion with Karl Nadolsky, DO, a clinical endocrinologist and obesity specialist at Holland Hospital in Michigan, and Fatima Cody Stanford, MD, MPH, an associate professor of medicine and pediatrics at Massachusetts General Hospital and Harvard Medical School in Boston.

Following is a partial transcript of the video (note that errors are possible):

Faust: I just want to start, first of all, by thanking the two of you because, I think, maybe 2 years ago when we first did this session, the three of us, that was what really opened my eyes to the literature on this topic and caused me to look at what was there and keep track of what was coming. And I have been blown away — I think we all have been — because it’s not the usual, oh, they’re squeezing out some signal of benefit. The pharma companies are doing sketchy stuff. These are amazing outcomes and thank you both for educating me about this and the Medpage and Inside Medicine audience and welcome back.

Stanford: Thanks for having us.

Nadolsky: Thank you.

Faust: So, I mean people have tons of questions. And I have questions for the both of you. I think I’ll start actually with questions that I got from readers just today. And some of these may be regulatory questions that I don’t know the answer to. I don’t know if you do, but so JL asks whether we will address — I’m going to look at my notes here — whether RFK [Robert F. Kennedy Jr.] or anyone’s plans in the government to withdraw approval or to change the legal status of these medications is a concern. And I’ll ask a kind of correlated question: Right now, does Medicare and Medicaid cover this? Will it? Won’t it? What’s the status?

Stanford: So the Biden administration just last week stated that they have a proposal to actually cover these for Medicare and Medicaid. So that was an announcement that came out last Tuesday, if you guys were paying attention to the news story. Now that was a Biden proposal. We know that that administration will be ending soon. So whether or not that proposal will carry forward with this upcoming administration is a big question mark, particularly because this upcoming administration has been known not to really believe in whether or not these medications are useful.

I think what we’ve heard from the upcoming administration, particularly RFK, is that if you just give everyone 3 mg, we’ll solve obesity, which I think is not quite what we believe. We know that 75% of U.S. adults have overweight and obesity in the United States alone. And so the idea that 3 mg will just solve overweight and obesity seems to be a bit not grounded in what we believe to be the science behind this disease process. And so I think that that would be taking us several steps back if we were to really think that that will just magically solve overweight and obesity for 75% of the country. So that’s the issue.

So that’s a proposal coming forth, like I said, from the Biden administration. Right now, Medicaid and some states [do] cover these medications. So it’s a state-by-state basis in terms of some coverage. For example, here in Massachusetts, we do cover these medications. Of course, that’s based upon what your income status is. Medicare, however, does not cover these medications. If you have obesity, if you have diabetes — since you’re covering the different medications that we’re talking about, Ozempic [semaglutide] for example, Ozempic, Mounjaro [tirzepatide] are used for patients with diabetes, Wegovy [semaglutide], Zepbound [tirzepatide] are used for patients with obesity, those medications for patients with obesity not covered by Medicare. But like I said, that new Biden proposal would be to cover these for patients with obesity specifically.

Nadolsky: Yeah, I think that’s a great point that you stated at the end. I was going to say, it seems like we’ve had these medications around for almost 20 years now. I mean, I was doing endocrine rotations in 2005 when exenatide was available for type 2 diabetes in the form of Byetta twice-a-day shots.

And even back then, I mean one of your talking points that you wanted to talk about was why has this captured so much public and medical interest? And really if you ask those of us who have been in that space — I think for 20 years even though I was a med student at the time — it was a game changer back then. And then it continued to progress. And I think it’s been fun as a student and as a resident and then a fellow and then staff seeing the progression of these therapies from exenatide to liraglutide [Victoza, Saxenda].

And then suddenly we got into the weekly stuff and dulaglutide (Trulicity), which is approved for type 2 diabetes, has been around and does a very, very good job for those with obesity complicated by type 2 diabetes, as she was noting. And Medicare has generally done a pretty good job of covering some of them.

The problem comes in for all the people struggling with obesity, but they don’t have type 2 diabetes criteria per se. But there are a lot who are at really, really, really high risk. And we can talk about risk stratification and we can’t necessarily afford to just give it to half the population necessarily, but there are people who have all the criteria for pre-diabetes. They have established atherosclerotic disease, they have metabolic-associated steatotic liver disease, they have kidney disease. And now we have all these data — heart failure with preserved ejection fraction — all these data showing the benefits of treating the obesity in that population over 65, who should have this covered by Medicare.

Now, yeah, we’re going to have to figure out how to make sure we give it to the right people, those who get the most benefit. So it’s cost effective and all that stuff and get the cost down and everything. But that’s a big deal for those people if we can get it for them.

For more, please watch the video above.