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GLP-1 End Game: Should Deprescribing be the Goal?
Written by Dr. Tejaswi Kompala, Senior Director, Clinical Strategy, Teladoc Health and Robert Hsu, Director, Clinical Strategy, Teladoc Health
The early stages of any new, clinically impactful drug put pressure on benefit leaders. While research evolves at a pace that keeps health care professionals on their toes, benefit leaders must make precise decisions that have a big impact on the people they cover and their organization.
There’s no historical parallel to the situation benefit leaders currently face with GLP-1s. More than 50% of the U.S. adults meet the FDA’s eligibility criteria to use GLP-1s for chronic weight management, and they’re understandably concerned about the coverage costs for a drug with this level of demand.
That’s a big reason why “deprescribing” often comes up when I meet with benefit leaders. Their belief is that once the combination of GLP-1s and lifestyle changes gets employees to their health goals, then that level of health can be maintained with just lifestyle changes.
Though I understand the goal of cautious GLP-1 use—and associated drug spend—we need to carefully consider the clinical ramifications of encouraging population-level deprescribing. And let’s be clear, programmatic deprescribing at a population level is different than intentional, individual-level deprescribing. Though it may seem like semantics, it’s important we distinguish between the two.
- Clinically grounded deprescribing is the intentional choice of a provider because medication is no longer clinically appropriate for an individual patient. The decision is informed by evidence, clinical guidelines, and individual response, such as when a patient isn’t sufficiently responding, experiences intolerable side effects or has a serious adverse event.
- Programmatic deprescribing is the pre-planned step by a care program to stop an effective medication, for most or all users, once a target weight loss goal has been achieved, largely to minimize pharmacy costs.
With GLP-1s, providers must always be prepared for patients being forced to stop a medication due to factors beyond the provider. We define this as discontinuation, and it commonly occurs for GLP-1s because of things like supply issues and coverage.
When something causes discontinuation, it’s the provider’s role to help patients safely navigate through medication changes and set expectations. Benefit leaders may inadvertently contribute to this challenge by supporting vendors who claim successful “deprescribing” in large populations.
Programmatic deprescribing interferes with the patient-provider relationship. Removing a medication that works for an entire population isn’t an accepted approach for other cardiometabolic conditions like diabetes or hypertension, and obesity shouldn’t be any different.
For broad deprescribing to be appropriate once health goals are met on any medications, a few things must be true:
- If taken off the medication, the patient can reasonably maintain their level of health.
- There is data that can reliably predict which patients can safely be taken off medication.
- The underlying cause of the patient’s disease is cured, so there’s no need for medication.
- Taking the patient off medication won’t cause unnecessary harm.
Evidence from GLP-1 and obesity research doesn’t support the above. What we know from the research is that most patients who stop taking a GLP-1 regain weight and lose the cardiometabolic health benefits. Studies show the role of sustained lifestyle changes in preventing weight regain differs from person to person depending on numerous factors. That has to do with the complexity of weight regulation physiology, and the brain’s goal of getting us back to a higher weight.
So, what strategies can be used to address cost-driven pressures for GLP-1s? At Teladoc Health, we recognize five clinically appropriate options.
The first two focus on appropriate patient selection for long term GLP-1 therapy. Employers and health plans can balance GLP-1 access with costs by:
- Stratifying eligibility requirements to focus access on those with higher clinical risk. This prevents some who could benefit from a GLP-1 from accessing it, but it allows the organization to maximize the value on their investment while still offering ongoing coverage.
- Increasing self-selection among populations by emphasizing upfront treatment education and engagement via lifestyle modification programs. Obesity itself and patient preferences are diverse, so GLP-1s won’t be appropriate for and won’t be desired by everyone. Upfront engagement helps ensure only the most prepared people start treatment and avoids spending on short-term users who won’t see the benefits.
Three additional options are up to each individual patient’s provider. In the context of current cost and resource constraints, these are reasonable, clinically grounded alternatives that still acknowledge that obesity is a chronic disease. Instead of removing all medications after a patient reaches their health goals on a GLP-1, providers can choose to:
- Switch to an alternative anti-obesity medication to support weight loss maintenance, assuming the patient can tolerate it safely.
- Reduce dose levels of the GLP-1 to continue some level of appetite suppression.
- Alter dosing patterns to extend the time between medication. The effectiveness of this approach is still being evaluated but is something Teladoc Health is keeping a close eye on.
Benefit leaders are under a lot of pressure to find a strategy that balances GLP-1 coverage and cost implications.
Programmatic deprescribing across a broad population may seem like an easy answer. But important clinical decisions like this should remain with a qualified provider, who can decide how to tailor the use of lifestyle modification, mental health support and anti-obesity medications to best address each individual patient’s obesity.
Benefits leaders can instead focus on finding clinically appropriate ways of supporting the right individuals. They can do this by ensuring these individuals have access to GLP-1 therapies and encouraging care from safe, knowledgeable care teams with a comprehensive approach to treating obesity.
** This content was originally published on Forbes.