This content material initially appeared on On a regular basis Well being. Republished with permission.
By Ross Wollen
Medically Reviewed by Adam Gilden, MD, MSCE
Drugmakers are struggling to maintain up with the demand for weight reduction medicine semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound). The restricted provide is forcing docs, public well being consultants, and insurers to confront an disagreeable query: Who “deserves” these life-changing therapies probably the most?
“Proper now, it’s first come, first served,” says Neda Rasouli, MD, an endocrinologist and professor on the College of Colorado in Aurora. “However it needs to be primarily based on maximizing the profit and prioritizing individuals who do worse with out this intervention.”
GLP-1 medicine had been initially developed to deal with kind 2 diabetes and are nonetheless thought of a game-changing remedy within the area. In recent times, they’ve been well known as the simplest weight reduction medicine ever developed, and researchers hold discovering new advantages, too. GLP-1s additionally seem to stop or deal with kidney illness, sleep apnea, and heart problems.
Medical doctors want these medicine had been universally accessible and inexpensive, however shortages proceed as demand rises. As a substitute, well being practitioners are debating how these medicine would ideally be distributed so {that a} restricted provide can have the most important doable well being affect.
GLP-1 Medicine Are Not Distributed Equitably
“In our system, Individuals should buy no matter they’ll afford,” says William Herman, MD, professor of epidemiology on the College of Michigan in Ann Arbor.
“We actually want to consider well being fairness,” says Dr. Herman. “Permitting rich people to buy GLP-1s which are in brief provide denies entry to people who usually tend to profit.”
Excessive costs and unequal insurance coverage entry have triggered disparities in GLP-1 use alongside acquainted racial and socioeconomic fault strains. Amongst adults with kind 2 diabetes, white sufferers in America are considerably extra seemingly to make use of GLP-1 medicine than nonwhite sufferers, together with folks from Black, Asian, Hispanic, and American Indian/Alaskan Native backgrounds.[1] GLP-1 customers even have increased revenue, extra schooling, and usually tend to stay in prosperous city areas.[2] It’s doable that the disparities are even starker for folks with out diabetes, as insurers (together with Medicaid) are much less prone to cowl the usage of GLP-1 medicine for weight reduction.
Dr. Rasouli believes that the state of affairs should be reversed: “I wish to prioritize … underrepresented minorities, as a result of they don’t seem to be getting medicine they usually’re at even increased threat of comorbidities.” A number of nonwhite communities have increased charges of weight problems and diabetes problems, resembling cardiovascular and kidney illness, and would possibly due to this fact reap even larger advantages from GLP-1 medicine.[3]
Herman factors to analysis suggesting that Novo Nordisk might manufacture and distribute a single Ozempic pen for as little as $40, even whereas turning a ten % revenue.[4] And but the sticker worth for Individuals continues to be round $1,000. In the meantime, an evaluation printed in 2023 discovered that in peer nations, a month of semaglutide was priced between $83 (France) and $169 (Japan).[5]
Timothy Garvey, MD, professor of medication on the College of Alabama in Birmingham, calls the state of affairs, with sky-high costs inflicting American insurers to revoke protection, “untenable.”
“These are life-saving medicines,” says Dr. Garvey. “To disclaim them to sufferers who would profit is unacceptable.”
Who Advantages the Most From GLP-1 Medicine?
So as to maximize the general public well being advantages, it’s obligatory to know who responds finest to those medicine. That may be a troublesome query to reply, as a result of totally different folks take GLP-1 medicine for various causes. Whereas one grownup might select Ozempic for kind 2 diabetes to assist management their blood sugar, one other would possibly select Wegovy, basically the identical medicine, to shed pounds and handle coronary heart illness dangers. There’s no straightforward strategy to examine the significance and cost-effectiveness of the advantages throughout circumstances.
We do know a number of issues about common GLP-1 responses. Researchers have discovered that girls are inclined to lose extra weight than males, for instance, and other people with a decrease baseline A1C are inclined to lose extra weight than these with a better baseline A1C.[6]
Rasouli want to see GLP-1 medicine made out there first to sufferers with class 3 (“extreme”) weight problems — the heaviest classification of weight problems, akin to a physique mass index (BMI) of 40 kilograms per sq. meter (kg/m2) or increased.[7] “We use to name this morbid weight problems,” Rasouli says, explaining that the situation is related to a excessive threat of illness and early demise.
Scientific trials have proven that folks with class 3 weight problems reply particularly effectively to GLP-1 medicine.[8] “Individuals with a better BMI lose a better proportion of their physique weight. Extra apparently, the speed of unwanted side effects resulting in drug discontinuation is decrease in folks with class 3 weight problems,” says Rasouli. “These folks tolerate the medicine higher, they usually have a greater response.”
Against this, folks with diabetes are inclined to lose much less weight.[9] However that definitely doesn’t imply the medicine is any much less impactful. To this point, insurers have been much more prone to cowl the price of GLP-1 medicine for folks with diabetes, as a result of the medicine virtually definitely cut back the incidence of the illness’s harmful (and costly) long-term problems.
Revoking GLP-1 Entry
Deborah Horn, DO, medical director on the College of Texas’ Middle of Weight problems Drugs and Metabolic Efficiency in Bellaire, is very involved with the plight of people that lose entry to their medicine. In 2023, the College of Texas introduced that it will cease masking weight reduction medicine for its a number of hundred thousand staff, a lot of them Dr. Horn’s sufferers: “I’m serving to handle all these sufferers who had nice success, however then had to determine one other strategy to handle their illness.” She has loads of expertise seeing what occurs when sufferers cease taking Ozempic — the burden normally comes again whereas the opposite metabolic advantages disappear.
Different insurers and employers throughout the nation, confronted with staggering drug prices, have additionally begun to tighten restrictions on entry and reimbursements.[10] Generally this implies discontinuing protection after a affected person’s BMI falls under U.S. Meals and Drug Administration (FDA) cutoffs, a apply which appears to battle with established requirements for the usage of medication to deal with and forestall power illness.
“We’d by no means do that with diabetes medicines!” says Horn.
Pam Taub, MD, a heart specialist at UC San Diego Well being, agrees: “No payer would ever inform you to cease a statin after your LDL [cholesterol] met your objective.”
Prioritizing Coronary heart Illness
Dr. Taub has a distinct perspective. She believes that clinicians can’t be guided by an instructional idea of most public well being profit. As a substitute, they should interact with the fact of the insurance coverage business that largely decides which Individuals get to make use of which medicine. And she or he believes that it may very well be the GLP-1 household’s impact on cardiovascular well being that enables them to turn into extensively accessible.
In March 2024, semaglutide was authorised to stop coronary heart assaults and strokes. The FDA’s choice got here on the heels of a three-year research exhibiting the utmost dose of semaglutide lowered the danger of heart problems and demise by 20 %.[11] “We see unimaginable profit from throughout the cardiovascular spectrum,” Taub says. A equally giant and rigorous cardiovascular final result trial is underway for tirzepatide now, with analyses of earlier information suggesting that tirzepatide would possibly boast comparable advantages.[12]
Taub believes these cardiovascular advantages are the important thing to persuading insurers, employers, and governments to pay for these notoriously costly medicine. “The tough actuality of our medical apply is that it’s dictated by what payers will cowl and what we will get our sufferers entry to,” she says. Emphasizing the cardiovascular advantages of GLP-1 medicine may very well be the easiest way of accelerating entry — and of permitting sufferers to benefit from the full vary of cardiometabolic advantages, together with weight reduction, blood sugar discount, and kidney safety.
Prioritizing General Cardiometabolic Well being
In actuality, the circumstances that GLP-1 medicine deal with are inextricably related. Whereas there are definitely folks with weight problems who don’t have diabetes, and vice versa, the circumstances share causes and threat components. Coronary heart illness, kidney illness, and sleep apnea are all comorbidities of weight problems and sort 2 diabetes, as are different circumstances resembling metabolic dysfunction related steatotic (fatty) liver illness.[13]
“All of our organs are intricately linked,” says Taub. “The dysfunction of 1 results in the dysfunction of one other.”
“Let’s concentrate on total cardiometabolic well being,” Taub says. “We should be promoting these as extra than simply weight reduction medicine. … By simply specializing in weight problems, we’re doing this area a disservice.”
Herman means that the individuals who will profit probably the most from GLP-1 medicine are those that have been identified with a number of cardiometabolic circumstances: “I believe the worth might be best in folks with kind 2 diabetes, weight problems, and heart problems … and for folks with kind 2 diabetes and problems.”
Rasouli provides that the medicine could also be particularly invaluable “in youthful folks.” The youthful a affected person develops weight problems or diabetes, the extra extreme their problems are prone to be.[14][15] Youthful folks, due to this fact, might have extra to achieve from GLP-1 drug use; prioritizing youthful sufferers might maximize the variety of wholesome years saved.
Is Hollywood Actually Hogging GLP-1s?
Many individuals, each docs and sufferers alike, assume that the extreme demand for GLP-1 medicine has been considerably pushed by individuals who wish to slim down however who don’t have a critical medical must shed pounds.
Rasouli says, “When we’ve got scarce assets, and if Hollywood folks or individuals who don’t really want it get it first, it implies that we’re denying entry to individuals who would possibly want it extra.”
“I believe the least cost-effective method is within the remedy of … people who find themselves chubby or have gentle weight problems who wish to match into that fabulous robe by dropping a number of kilos,” says Herman. “That is what we’re actually seeing in Hollywood, and sadly that is what we’re seeing pretty extensively.”
However Leah Wigham, PhD, a professor of public well being with the College of Texas in Houston, questions this narrative: “There are these tales of film stars [using Ozempic], that’s, what, a pair dozen anecdotes? Do we’ve got information that that’s really contributing in a major strategy to the availability chain points?” A July 2024 research of actual world prescribing information discovered that solely a tiny fraction of customers, 0.37 %, aren’t medically certified to make use of GLP-1 medicine.[16]
Nikhil Dhurandhar, PhD, a professor of dietary sciences at Texas Tech College in Lubbock, says that he “desires to place in a great phrase for many who wish to shed pounds to suit right into a costume.” Dr. Dhurandhar says that so long as customers are medically indicated to make use of a GLP-1 drug, “motivation shouldn’t matter … your advantages are going to be the identical no matter what made you shed pounds.”
Dr. Wigham worries that vilifying some GLP-1 customers solely contributes to the disapproval and discrimination skilled by people who find themselves chubby.
“These sorts of feedback in regards to the costume simply perpetuate this stigma that folks don’t deserve the medicine until they’re making an attempt actually onerous to shed pounds on their very own,” says Wigham. “We don’t try this for different ailments and we have to cease utilizing that language for weight problems.”
Shortages Could Persist
Semaglutide and tirzepatide shortages are projected to final by 2024, however realistically there’s no telling when producers will be capable to catch up. There are seemingly effectively over a billion folks worldwide who’re medically eligible to take a GLP-1 receptor agonist, based on FDA standards.[17] The potential demand is nearly unimaginably giant.
Many various companies try to satisfy the demand. Main drugmakers are racing to develop their manufacturing capability and to develop extra GLP-1 therapies. Generics might quickly be authorised in India and China, and in america, compounding pharmacies working in a authorized grey space supply inexpensive unbranded equivalents.
In an ideal world, everybody who stands to learn from these blockbuster medicine would be capable to entry them. For the time being, that chance appears very distant.
The Takeaway
Demand for GLP-1 medicine like Ozempic has outstripped provide, sparking debates over honest entry. Some well being consultants recommend prioritizing these medicines for many who would possibly profit most, particularly sufferers with a number of cardiometabolic circumstances, together with kind 2 diabetes and extreme weight problems.
