How to Handle Noncompliant Patients on GLP-1 RAs for Obesity

Primary care practices are seeing an uptick in patients inquiring about glucagon-like peptide 1 receptor agonist (GLP-1 RA) medications due to both media hype and sizzle-reel stories they see on social media. If your patients start an appointment with their own agenda about wanting a prescription for these medications, there are ways to pause the pressure and pivot to other options first. Here is how to better handle noncompliant patients who may not want to follow your advice.

How to Offer Other Proactive Measures

Understanding the goals of your patients can help alleviate some pushback from the start of an appointment.

“When discussing GLP-1 receptor agonists or any ant-obesity medication, clinicians (should) approach the conversation with a combination of empathy, education, and clear guidance,” said Amy J. Sheer, MD, MPH, associate professor of medicine, Division of General Internal Medicine, University of Florida (UF) College of Medicine and UF Health Shands Hospital in Gainesville, Florida.

To begin, the medical professional should systematically review the patient’s past medical history, medications, weight history, nutrition (24-hour diet recall), physical activity and limitations, and their health goals, she noted.

“But, if a patient appears irritated that you are taking the time to do a thorough history, it is best to explain that knowing their specific goals can help in many ways, including which pharmacotherapy is safe and most effective for them and prescribing the medication most likely to be covered,” Sheer also shared.

Sheer described how she takes the time to discuss the challenges so that patients can get a better grasp of expectations.

“I explain to my patients briefly the pathophysiology around weight loss and why weight loss and maintenance are so difficult — hormonal control, etc.,” she continued. “I tell my patients that all people need to have a healthy diet and be physically active to be healthy. We all need to do this, whether we are on pharmacotherapy for weight loss or not.”

In some cases, patients get very pushy. They said, “Can you get my insurance to cover these?”

To begin with, Sheer said to be honest about the outcome. “Tell the patient, ‘Maybe’ and ‘We will try.’ Have a plan A and plan B, and write it in your notes so you remember,” she advised. Also, suggest that your patient research their own insurance company’s formulary by logging into their insurance portal to see what’s possibly covered.

“I write down the names of the medications of interest, such as Saxenda, Wegovy, or Zepbound. Often, when a patient calls their insurance, they are given incorrect information — they are told their insurance covers Mounjaro and Ozempic and to have their physician prescribe this — but the patient does not have diabetes, so this will not work,” she said. Also, when a patient calls, Sheer said, they will be told to have their physician prescribe an acute otitis media with codes that do not make sense, like hypertension. What they need is to look at their formulary.

Streamlining the Process 

To assist patients who are suitable candidates, here are some strategies:

Stay on indication. Sheer said coverage for GLP-1 RA is complicated and changing rapidly based on the indications. “Clinicians should prescribe the pharmacotherapy best suited for the patient based on their comorbidities. This gives the best chance of coverage. Long gone are the days of getting Ozempic or Mounjaro for weight loss — the patient must have diabetes. It is a waste of time to prescribe a diabetes medication for weight loss because it will not get approved,” she said.

Have an appeal letter ready to submit. “I have an appeal letter for the common GLP-1 RA for weight loss that I will submit for patients who get denials,” said Sheer. “These can work, and templates of these letters can be found online.”

Is there a recommended process? Brintha Vasagar, MD, MPH, a family physician with Progressive Community Health Centers in Milwaukee, reported how GLP-1RAs should be considered in patients with obesity (body mass index [BMI] > 30 or BMI > 27 with one or more weight-related comorbidities) who have not reached their weight loss goals after 3-6 months of lifestyle efforts.

“A review of medications which can contribute to weight gain and bloodwork to evaluate for other causes of weight gain can be helpful,” outlined Vasagar. “Comorbidities can be helpful in deciding which GLP-1 RA would be most beneficial for each specific patient.”

What other tips can medical professionals suggest? Clinicians prescribing these medications must be comfortable advising about healthy nutrition, including goals for protein, fiber, and water intake, recommended Sheer.

“Also, they should feel comfortable giving a weight loss goal range, which I usually tell my patients is 1-2 pounds a week, depending on their BMI, starting weight, comorbidities, nutrition, and physical activity,” she explained. “I tell my patients that when they lose weight, they do not just lose fat — they lose fat, muscle, and bone. We must try to target fat. Exercise and nutrition help target the fat, lose more weight healthily, strengthen bones, and ultimately keep weight off.”

Why a discussion about side effects is vital. It is important to review the most common side effects, which are gastrointestinal and include nausea, constipation, diarrhea, and increased reflux. “Also, you should ask the patient about their personal history of pancreatitis and personal or family history of medullary thyroid cancer,” Sheer reported.

What happens if the patient is truly noncompliant? If after your patient has received the prescribed medication, they are not returning to your practice for check-ins, some physicians are taking a firm approach.

“At Novant Health Bariatric Solutions, we have a 6-month cutoff rule. If the patient is noncompliant with our program, their appointments, or their medication, we will not provide another prescription,” said David Voellinger, MD, bariatric surgeon at Novant Health Bariatric Solutions – Elizabeth in Charlotte, North Carolina.

What else should you be telling your patients? Voellinger told patients that obesity is a chronic, relapsing, multifactorial disease that must be treated in a multimodal fashion in a multidisciplinary program including lifestyle management, medical management, surgical management, or integrative management.

“Every patient requires a different individual approach, and each patient responds differently to treatment,” he stated. “We try to use the lowest effective dosage of medication possible to minimize side effects.”

GLP-1 RAs are great medications to help with weight loss and are particularly effective in decreasing “food noise” and the cravings and desires to eat, Voellinger said. “But they can also be dangerous if not used correctly and used as part of a comprehensive program. They are not a magic bullet or quick fix for weight issues.”