Today we are joined by Dr. Anthony Auriemma. He discusses the popularity and efficacy of GLP-1 therapy, but notes that while these medications have shown promising results, there’s a lot of misinformation about them. He also expresses hope for future treatments including new medications and potential price reductions.

Dr. Auriemma: So, hello, my name is Dr. Anthony Auriemma. I’m the medical director at Ascension Weight Loss Solutions in Chicago area. I have been the medical director here for 12 years practicing exclusively obesity medicine. Prior to my practice of obesity medicine, I had a combined practice of family medicine and obesity medicine going all the way back to 2006. So I’ve been in this field for quite a while. Way before it was popular on TikTok and with all the movie stars in Hollywood. And it is an exciting time to be in this field. It is exciting to have new therapies available. It’s exciting to have a lot of attention given to the disease of obesity because for way too long, even way before I began practice in 2006, obesity and overweight was seen as a character flaw, was seen as a lack of education, as being slothful and lazy, and it was really not understood like the disease that it is.

I often relate it to kind of the way we used to think about alcoholism 30 or 40 years ago when we thought it was a character flaw and we didn’t understand the disease process. And so the nice thing about what I’m doing in the last five plus years is we have many new therapies that are becoming more and more ineffective, and these therapies are actually providing a better understanding of the disease of obesity and able to help patients way more than ever before. Prior to the last five years or so, I mean the only really, really effective therapy we had was bariatric, metabolic, and bariatric surgery. Medications could be helpful, but we’d often be just excited about 5% weight loss, maybe 10% weight loss. Now with newer therapies, we’re seeing even more and more weight loss with all this excitement around obesity care and treatment.

We’ve heard a lot about the GLP-1 therapy—the injectables. So that’s the first thing I hear now when patients come through the door is they’re asking for some type of injectable medication because they saw it on Facebook, heard about it on TikTok, or their hairdresser is selling it in their salon. And so it’s good and bad. So, these new injectable medications do have some great efficacy and some great data around them, but it’s also so a lot of misinformation about these type of medications. And so I think we need to be open and honest about what patients can expect with these newer therapies. And forget that I was practicing obesity medicine since 2006. We have therapies that work and are effective even going back that far. So the concern with these newer medications is it’s not a one size fits all. Just like anything in medicine, you don’t go to a physician and they just tell you whatever your disease is.

There’s one cure for it, one medication, and that’s it. I mean, it’s the art of medicine. It’s the individual and personal approach to each person who has their own differences. And we need to appreciate that, evaluate that, and find the best therapy for each patient. And so GLP-1 therapy, these injectables might be helpful for many, many patients, but it’s not for everyone. So what kind of concerns do we have about these newer GLP-1 therapies? Well, there are some contraindications to them. So patients do need to undergo a medical evaluation and they should not be seeking care through non-healthcare relationships. Unfortunately, there are compounded forms of these medications out there which are not FDA approved for use, and not all of them are being used correctly in the right population. We’re not even sure what some of these compounded medications are when you are getting the right therapy though.

A couple of things you have to remember is any medication that we give does have a side effect profile. So there needs to be full awareness of that. And for some patients, these side effects can prevent them from being able to tolerate the medication. In my clinical practice, I probably see it about one in 10 to two out of 10 don’t tolerate the medication well or can’t take the full dose of the medication, have the full benefit. The other caveat with these medications, and not just to pick on GLP ones, but any type of therapy that we use for treatment of obesity, including bariatric surgery, there are a fair amount of non-responders. This is a disease process that’s very complex and even if we have a very powerful medication and therapy, not everyone responds equally to it. So for medication A, I may have some patients that have greater than 20% weight loss, maybe even approaching levels of what we could see with surgery.

And some other patients with that same exact medication, same dose, may have no weight loss or even weight gain. And you can see that even in the clinical trials, even in the newest, latest, greatest, most expensive medications, they’re still a good one out of 10 that don’t respond at all. And response rate is considered 5% and there’s still a good 20 to 25% that don’t even attain 10% weight loss. And that’s really the number we’re looking for nowadays is trying to get at least 10% weight loss because realistic for most of our patients. So what does that mean? So that means there’s a role for other therapies and using medications that we’ve used since 2006. So there are older medications that are effective, and a few of those medications that we use going back to the fifties and sixties, there was the generic medications like phentermine.

And then the newer iterations is we have a combined phentermine topiramate medication called Kesimpta, which is an oral medication. And another medication is a combination of Naltrexone and Bupropion called contrave—that’s an oral medication. And then after those two, most of the other ones that have come along have all been the injectable, the GLP-1 class medications, which are either a daily injection, which we see with Liraglutide, which is a name brand Saxenda, or there’s a weekly injectable which is Wegovy or a weekly injectable, which is called Zepbound—that’s the latest medication that’s come out. And so I think for a full appreciation for treatment of obesity, you have to have familiarity and comfort with use of these medications and use all the tools in the toolbox. The other thing that we see, and this is really the future of obesity medicine, I don’t think people talk about it enough, is that we’re looking at more and more combination therapy.

It hasn’t been studied well in clinical trials, but just like we treat other types of diseases like hypertension or hyperlipidemia or type two diabetes, we often use combination therapy if we have medications that work by different pathways to kind of treat the same disease. So I think that’s what we’re going to see growing over the coming years. In terms of the difficulty in treating patients with obesity, the biggest barrier I have each day I got done seeing patients a few minutes ago is getting coverage for medications. Whether it’s even the older ones or the newer medications, the newer injectables, there is a wide lack of coverage and primarily Medicare doesn’t cover any medication for treatment of obesity. And most commercial payers, at least in the Chicago area, still do not cover anti-obesity medication. And so one of the concerns with the newer medications is that cost barrier with list price being over a thousand, there are coupon programs that bring it down to $500 or $600 a month. It sounds like a bargain, but that’s still too expensive for many of my patients.

The real concern here is with these medications from all our understanding to date is these medications need to be used and if we’re going to use them, they need to be cost effective. For patients paying $500 or $600 a month indefinitely or maybe even more for many of my patients, that’s a no-go. So we need insurance coverage. The older oral medications, like I mentioned, Kesimpta and contrave both have coupons down to as little as $100 a month. So that’s much more palatable for my patients. Many more of my patients can afford those medications. And then even the older first-generation medications, like just straight phentermine from the 50 and 60’s, you can get down to those little as $20 a month. But those medications are only indicated for a short-term use.

There was an outside group that did an evaluation of anti-obesity medications in 2022—It’s called the ICER report. It stands for the Institute for Clinical and Economic Review. They did a white paper looking at the effectiveness of these medications and looking at the cost effectiveness. So they measure the impact of the medication and treating obesity, and then they compare that to the cost of it. The more impact it has on obesity, perhaps the more cost you can absorb, the less impact it has, the less cost you can absorb. It’s kind of a way to measure the value of these therapies in treating obesity, and they looked at four medications. They looked at semaglutide, which is Wegovy injectable liraglutide, which is Saxenda, injectable phentermine, topiramate combination, which is Kesimpta, and then Naltrexone Bupropion combination, which is contrave. And they looked at those four medications and even though they showed a good efficacy of the injectables of semaglutide and liraglutide, they only found that Kesimpta was cost effective at the prices in 2022, which essentially haven’t changed much since then.

For future treatment and what I’m excited about is there are newer players coming out since that report in 2022. There’s more coming down the road and hopefully we’ll see a reduction in pricing and hopefully more access to these medications.