A new generation of weight-loss drugs promises — but at a price

Excitement is building over a new generation of drugs that boast the ability to help overweight adults shed more pounds than older drugs on the market.

Some patients, obesity medicine experts say, are seeing lower blood pressure, better-managed diabetes, less joint pain and better sleep as a result of the new treatment.

The new drugs, which are repurposed diabetes drugs, “are showing weight loss unlike any other drug we’ve had in the past,” says David Creel, a psychologist and registered dietitian at the Cleveland Clinic’s Bariatric and Metabolic Institute.

Yet for him and other experts, the thrill is murky.

That’s because no single drug is a magic solution by itself, and it’s possible that many patients will need long-term medication to maintain results. After all, new treatments are often very expensive and often not covered by insurance.

The new drug’s five-figure annual cost is raising concerns about patient access and what widespread use could mean for the country’s overall health care tab.

Evaluating the trade-off — the cost of better health and fewer complications of obesity down the road versus the cost of potential drugs — will increasingly be useful as insurers, employers, government programs and others who pay health care bills consider which treatments to cover.

“If you pay too much for a drug, everyone’s health insurance goes up. Then people stop having health insurance because they can’t afford it,” so the drug delivery system can cause more damage, said Dr. David Rind, chief medical officer of the Institute for Clinical and Economic Review, or ICER, a nonprofit group that Reviews medical evidence to evaluate treatments for effectiveness and cost.

Many commercial insurers limit coverage to certain drugs currently available, or require patients to meet certain thresholds for coverage — often pegged to a controversial measure called “body mass index,” which is the ratio of height to weight. Medicare specifically prohibits coverage of obesity drugs or drugs for “anorexia, weight loss or weight gain,” although it does pay for bariatric surgery. Coverage in other government programs varies. Legislation that would have allowed drug coverage in Medicare — the Obesity Treatment and Reduction Act — has not progressed despite resuming each congressional session since 2012.

As insurers view treatment costs with concern, manufacturers see a potential financial benefit. Morgan Stanley analysts recently said “obesity is the new hypertension” and predicted that industry revenue from US obesity drug sales could grow from its current $1.6 billion to $31.5 billion by 2030.

It’s easy to see how they could predict those staggering numbers based on potential demand. In the United States, 42% of adults are considered obese, up from 33% a decade ago. Sometimes weight-related health problems such as diabetes and joint problems also increase.

Even losing 5% of body weight can provide health benefits, experts say. Some new drugs, which can help suppress appetite, help some patients go beyond that marker.

Wegovi, a higher dose of the self-injectable diabetes drug Ozempic, helped patients lose an average of 15% of their body weight over 68 weeks during clinical trials that led to its FDA approval last year. After stopping the drug, many patients gained weight following an extension of the trial, which is not unusual with almost any diet drug. Wegovy spent most of the year in short supply due to production problems. It can cost around $1,300 a month.

Another injectable drug, still in final clinical trials but fast-tracked for FDA approval, can induce even greater weight loss in the 20% range, according to its manufacturer Eli Lilly. Both drugs mimic a hormone called glucagon-like peptide 1, which can signal the brain in ways that make people feel full.

Average weight loss from both, however, puts the drugs within striking distance of results seen after surgical procedures, offering another option for patients and physicians.

But will the range of old and new prescription medical products — with more in the development pipeline — be the answer to America’s weight problem?

One could be bigger, experts say. For one thing, drugs and devices don’t work for everyone and vary in effectiveness.

A prime example of perfection. With a price tag of $98 per month, it is considered a device by the FDA and requires a prescription. During clinical trials, about 40% of people who tried it failed to lose weight. But in the other 60%, the average weight loss at 24 weeks when combined with diet and exercise was 6.4% of body weight.

This average puts it in line with other, older, prescription weight loss drugs, which often show 5% to 10% weight loss when taken over a year.

While it’s true that weight-loss drugs — both old and new generations — don’t work for everyone, there’s enough variation between individuals that “even the older drugs work really well for some people,” says Rind at ICER.

But it’s too early — especially for new drugs — to know how long the results might last and what patients will weigh in five or 10 years, he said.

Still, advocates argue that insurers should cover treatments for weight problems just as they cover them for chronic conditions like cancer or high blood pressure. Paying for such treatments can be good for both patients and insurers’ bottom lines, they argue. Over time, insurers may pay less for people who lose weight and then avoid other health complications, but it may take years or even decades for such financial gains to accrue to the health system.

Financial benefits for drugmakers have so far been mixed. Novo Nordisk, the maker of Wegovy and Ozempic, saw sales of obesity care grow 110% in the first half of the year, but its stock price was flat and even declined in September. But Lilly, which has received approval for a new diabetes drug, Mounjaro, which may soon also get the green light for weight loss, saw its September stock price 34% higher than last September.

Some employers and insurers who pay health care bills are also asking whether drug prices are fair.

ICER recently compared four weight loss drugs. Two, Wegovi and Saxenda are new-generation treatments, both developed by Novo based on an existing injectable diabetes drug. The other two — phentermine/topiramate, sold as Qsymia by Vivas, and bupropion/naltrexone, sold as Contrav by Curax Pharmaceuticals — are older therapies based on pill combinations.

The results were mixed, according to a report published in August, which will soon be finalized after evaluating and incorporating public comments.

Wegovi showed greater weight loss than other treatments. But Qsymia helps patients lose substantial amounts of weight, Rind said. The net cost of that older drug combination, after the manufacturer’s rebate, was about $1,465 annually in the second year of use, compared with Wegovi, which had a net cost of $13,618 in the second year, the report said. Many patients may be prescribed weight loss medications for years.

With such numbers, Wegovy did not meet the group’s cost-effectiveness threshold.

“It’s a great drug, but it’s about twice as expensive as it should be” when its health benefits are weighed against its cost and the potential to drive up overall treatment costs and health premiums, Rind said.

Don’t expect costs to drop anytime soon, though, as other new drugs continue to hit the market.

Lilly, for example, has yet to disclose what Mounjaro will cost if it clears clinical trials for use as a weight-loss drug. But a hint comes from the diabetes treatment’s $974-a-month price tag — about the same as rival diabetes drug Ozempic, Wegovi’s forerunner.

Novo charges more for Wegovi than Ozempic, even though the weight loss version contains more of the active ingredient. It’s possible that Lilly will take a page from that playbook and charge more for a weight-loss version of Mounjaro.

University of Alabama-Birmingham professor of nutrition science. W. Timothy Garvey predicts that insurance coverage will improve over time

“It’s undeniable that if you’re on medication, you can lose substantial weight — and reduce the complications of obesity,” says Garvey. “It will be difficult for health insurers and providers to deny.”

One thing the new focus on drug treatment can promote, most experts say, is tempering the bias and stigma that has long attached to patients who are overweight or obese.

“The group with the highest level of weight bias is the physician,” says Dr. Fatima Stanford, an obesity medicine specialist and director of equity in the department of endocrinology at Massachusetts General Hospital. “Imagine how you would feel if you had a doctor who told you that your worth is based on your weight.”

Rind sees new, more effective therapies as another way to help dispel the perception that patients are “not working hard enough.”

“It’s become more clear over the years that obesity is a medical problem, not a lifestyle choice,” Rind said. “We have been waiting for a drug like this for a long time.”

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