Are we at a ‘watershed moment’ for weight-loss drugs?

There have been few healthcare phenomena quite like the surging popularity of weight-loss medications in recent years.
 
With ongoing shortages and even fake importations, the huge public interest shows no sign of abating, with the impact clearly being felt in general practices around the country.
 
In a newsGP poll running this week looking into the frequency of patient weight-loss medication queries, 49% of respondents so far report inquiries from patients at least daily, with 14% of those saying they are receiving multiple inquiries every day.
 
With the world’s interest piqued, new international studies are published weekly citing new uses for the medications, including semaglutide and tirzepatide, or examining their pros and cons.
 
One Monash University expert, gastroenterologist Associate Professor Suong Le, says Australia is at a  ‘watershed moment in obesity management’.
 
She says the medications are ‘transforming the way we view obesity as a condition’ and is calling for more research into specific uses where the medications ‘can make a meaningful difference in clinical practice’.
 
Associate Professor Le was among the authors of ‘The role of GLP‐1 receptor agonists in the management of obesity: risks and opportunities for the Australian healthcare system,’ published in The Medical Journal of Australia.
 
‘The Australian health system is an important test bed for how to strike a balance between addressing obesity‐related health concerns, while maintaining the financial sustainability of healthcare systems given the uncertain health economics of GLP‐1 RAs for obesity,’ its authors wrote.
 
Asked if she also views the current environment as a ‘watershed moment’, Chair of RACGP Specific Interests Obesity Management Dr Terri-Lynne South recognises both the challenges and the potential of the emerging medications.
 
‘In the most holistic terms of that, I would agree,’ she told newsGP.
 
‘There is great opportunity to use a promising evidence-based adjunct as part of holistic care.
 
‘We still need better information about long-term sustainability, both from a cost point of view, but long-term effectiveness in driving down the health-associated costs of obesity management.’
 
In Australia, semaglutide’s growth has been exponential.
 
In 2022–23, 1,255,063 semaglutide prescriptions on the PBS cost the Government $146 million. A year on, there were 2,397,521 prescriptions, more than doubling annual costs to $284.6 million.
 
This was the highest leap of any drug in the most recent financial year by some margin, according to the PBS reports.
 
Off-label prescriptions have also skyrocketed, albeit without the public data to keep track.
 
With that background, it is no wonder that Health and Ageing Minister Mark Butler has clearly acknowledged the tension between systemic sustainability and access for the drugs.
 
‘There’s the cost, there is the number of people who are going to be taking them, whether they’re on the PBS or not,’ he told ABC’s Q&A last year.
 
‘This is going to be a very, very big challenge for us.’
 
It may only just be the beginning of that challenge, with a recent Morgan Stanley analysis estimating GLP-1 RAs usage in the United States, currently the world’s biggest market, at 8 million people – and the potential to grow to 30 million in a decade’s time.
 
In this country, according to the Australian Institute of Health and Welfare, 32% of people were living with obesity in 2022, including 13% of the population living with severe obesity (defined as having a BMI of 35 or more).
 
‘The deployment of GLP‐1 RAs for treatment of obesity has the potential to impact one‐third of Australians,’ the MJA authors wrote.
 
‘This warrants due consideration and planning for future funding models, systems and models of care to ensure equitable access.’
 
For Dr South, this access is a particular concern.
 
‘I feel that the patients that can afford it are the only ones really accessing it at the moment, and we know that there’s a socioeconomic disadvantage for people living with obesity,’ she said.
 
‘The people who need it most are the ones who can least afford it.
 
‘So right at the moment, I’m glad that we’ve got more options theoretically, but I think it is actually worsening the health inequity of people living with obesity.’
 
Despite several attempts by pharmaceutical companies to have the drugs subsidised for obesity management in Australia, there is no sign that is likely to change in the short-term.
 
A complicated patents system may also lengthen the wait for generic drugs – but there have already been attempts to push for greater equity.
 
‘When we’re talking about numbers and costs, we need to not just look at the direct costs of obesity, we need to look at the indirect costs as well,’ Dr South said.
 
‘When you put those two numbers together, that’s when you go, “Gosh, this is much greater impact on our mortality, morbidity, quality of life, but also productivity”.’
 
Dr South emphasises the need for careful monitoring of prescriptions and brings the conversation back to well-rounded healthcare.
 
‘The medications definitely need regular reviews, and not just in the initial phases to get the best benefit,’ she said.
 
‘It’s not just about providing a script. It needs that holistic care, and the GP should be at the centre of coordinating and providing some of that.
 
‘Just sending a patient off with a script is not going to be the best way to utilise these medications.
 
‘It’s one part of also talking about nutrition and eating behaviours and exercise.
 
‘Without doing those other things, we might find that there are longer term side-effects that haven’t been accounted for.’
 
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