The Pharmacy Is Closed - Managing Weight With An Empty Toolkit

by Kristina Lewis, MD

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The next time you take your car in for a major service - just for fun, ask the mechanic to try doing the whole thing without using any of the tools at his disposal. When you do, I suspect you’ll get an incredulous look and probably a shake of the head; maybe even a comment like:
“I have about 20 tire rotations to do today, and there is no way that is happening without my tools!” 

For doctors, treating patients with obesity sometimes feels a lot like this scenario. Day in and day out, we’re asked to help patients lose weight, and yet most of us don’t have access to an entire category of tools for weight management – prescription medications.

In the past two-and-a-half years, the FDA has approved four new prescription medications for weight loss. The first was lorcaserin (Belviq), a serotonin (5HTc2) agonist that acts in the brain to diminish appetite. Lorcaserin has a clinically significant impact on weight (~5% weight loss with diet and exercise) and boasts a side effect profile that is very favorable. Next came Phentermine / Topiramate ER (Qsymia), a combination of a stimulant (phentermine) which has previously been approved for short-term use in weight management, and an anti-epileptic (topiramate) with appetite-suppressing properties. In clinical trials, this medication, along with diet and exercise, resulted in an about 6-8% weight loss compared to behavior change and placebo. In 2014, Naloxone/Buproprion (Contrave) was approved, another medicine that repurposes two existing compounds for a new indication – weight loss.  Finally, just last month, the FDA approved the use of liraglutide (Saxenda), a Glucagon-like-Peptide-1 agonist typically used in the management of diabetes, for weight loss. These latter two drugs have similar weight loss effects as lorcaserin.

Compared to an intervention like bariatric surgery, the weight loss achieved by any of these medications seems modest. However, even this modest amount is likely to impact a patient’s risk of chronic diseases such as diabetes, and it may provide a necessary boost when diet and exercise alone aren’t cutting it. Unfortunately, insurers are not required to cover the cost of these drugs, leading to prohibitive out-of-pocket costs for many patients. Unlike when treating other chronic conditions, such as diabetes and hypertension, doctors are quite limited in terms of the pharmaceutical tools at their disposal when addressing obesity.

So, what will payers cover when it comes to treating obesity? Perhaps the best coverage comes from the Centers for Medicare and Medicaid Services (CMS) (responsible for paying for Medicare and Medicaid). Beginning in early 2012, CMS agreed to cover weight management counseling services (basically lifestyle change advice) from primary care physicians. While the coverage was a step in the right direction, it was viewed by many as an odd choice, given the lack of evidence on physician-driven counseling for obesity. In contrast, CMS has not agreed to pay for any of the new FDA-approved weight loss medications, a choice that may have downstream impacts on the coverage decisions of many private insurers.

Payers may be justified in their hesitancy to provide widespread coverage for weight loss medications. Historically, many such drugs have proven more harmful than helpful. There is a valid concern that, with broad coverage of prescription meds for weight management, the floodgates would open and the drugs might be used inappropriately. However, these medications are important tools for weight loss, and they should be available for physicians trained in obesity medicine to use with some patients. Moving forward, it is imperative that payers shift away from viewing obesity as a cosmetic issue and toward viewing it as a chronic condition that deserves evidence-based treatment just like any other. Medications included.