Discussion over glucagon-like peptide analogs (GLPs) has become a medical hot-topic, extending beyond clinical discussion and becoming a cultural phenomenon. Marketed as a weight-loss wonder drug with the clinical and anecdotal evidence to support that claim, the drug dominates celebrity headlines and social media posts. However, GLPs are not a novel class of medication. They were first approved by the FDA in 20021 for the treatment of type II diabetes, and for many years, their primary use was blood glucose control. Liraglutide gained approval for weight loss in 20142, followed by semaglutide in 2017 under the brand name Ozempic for diabetes, and later in 2021 under the higher-dose Wegovy for weight loss3.
GLPs function by binding to and activating the GLP-1 receptor, which enhances insulin secretion through the incretin effect and slows gastric emptying. The GLP-1 receptor is present in various organs, including the brain, and its activation in the hypothalamus is thought to reduce hunger4. This dual action makes GLPs effective for both managing diabetes and aiding in weight loss. However, as their popularity has surged, so have issues related to availability and demand. This raises a crucial question: how do we, as a society, decide who should have access to these medications, and how do we define disease?
Navigating the complexities of insurance coverage and access to GLPs is a daunting task. Diabetic patients often bear the brunt of medication shortages, and uncontrolled blood glucose can lead to serious health complications, including renal disease, infections, eye problems, and cardiovascular issues. On the other hand, individuals with elevated BMI who do not meet the HbA1c threshold of 6.5% for a diabetes diagnosis often find themselves ineligible for insurance coverage. Furthermore, while there are numerous diabetic therapies available, weight loss options are limited. Diet and exercise often fall short, and gastric surgery is a serious procedure with lifelong consequences.
In clinical practice, I’ve seen once well-controlled diabetic patients with HbA1c levels at 10% due to prolonged lack of access to their medications. I’ve also encountered individuals diligently working to lose weight, doing everything right, but still denied access to these drugs simply because their lab results don’t yet indicate severe enough disease. Prescribing these medications cannot be based solely on a single diagnostic criterion. These challenges underscore the complexity of determining access to GLPs, which extends beyond simplistic categorizations of who “deserves” treatment.
While it may seem straightforward to prioritize those with diabetes, the reality is far more nuanced. I’ve observed cases where individuals with an initial diabetes diagnosis continue to receive GLPs even after their blood glucose levels have normalized, simply because their insurance continues to cover the medication and they want to maintain a certain appearance. This situation highlights the arbitrary nature of insurance policies that sometimes overlook true medical necessity. There’s no single metric that can resolve these issues, but we urgently need a standardized approach to prescribing these medications—one that prompts a deeper conversation beyond mere diagnostic codes.
This brings us to a broader, more philosophical question about healthcare: obesity plays a critical role in metabolic syndrome. Should it be treated as a disease in its own right or as a risk factor for future disease? This question touches on broader issues in medicine, including the balance between treatment and prevention, and the challenge of distinguishing between what is necessary and what is desired. Although there is no clear or definitive answer, there must be a consistent approach for patients and physicians alike. In healthcare, deciding who should receive limited resources is never easy, but it’s imperative to have these conversations now to establish guidelines for prescribing GLPs.
The financial disparities in healthcare are particularly evident with GLPs. Individuals who can afford to pay out-of-pocket, regardless of medical need, are often depleting a limited resource—hence the wave of celebrities experiencing significant weight loss on these medications. Stricter guidelines should aim to minimize solely cosmetic use of GLPs until supply can adequately meet the needs of those with legitimate medical conditions. While Wegovy may be trendy, it symbolizes a new era in medicine where advanced pharmaceutical interventions are increasingly common and desired—a trend that shows no signs of fading.
References
- Biochempeg. (n.d.). The mechanism of GLP-1 and its role in diabetes treatment. Biochempeg. https://www.biochempeg.com/article/299.html
- UT Southwestern Medical Center. (n.d.). Obesity medication: An important tool in weight loss programs. UT Southwestern Medical Center. https://utswmed.org/medblog/obesity-medication-weight-program/
- U.S. Food and Drug Administration. (2021, June 4). FDA approves new drug treatment for chronic weight management, first since 2014. https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014
- Kalra, S., Jena, B. N. (2022). Glucagon-like peptide-1 receptor agonists. In M. J. Blaha (Ed.), StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551568/
Nicole Varda is a medical student at the University of Arizona College of Medicine-Phoenix. She’s particularly interested in bioethics and narrative medicine. She also enjoys reading, exploring new coffee shops and breweries, and spending time with family and friends. Please feel free to reach out at nvarda@arizona.edu.