Maintain a Patient-Centered Approach When Developing Clinical Recommendations for Weight Management Medications

Pharmacy Times spoke with Jennifer Clements, PharmD, FCCP, FADCES, BCPS, CDCES, BCACP, BC-ADM, clinical professor and Director of Pharmacy Education at the University of South Carolina College of Pharmacy, about her presentation at the 2024 American Pharmacists Association (APhA) Meeting and Exposition. Clements discussed the evolving landscape of weight management medications, clinical considerations, and obstacles to use.

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Pharmacy Times: How has the landscape of weight management medications changed in recent years?

Jennifer Clements: Yeah. So since, like, 2013, we hadn't had anything for a while and then all of a sudden Qsymia came out, and then Belviq, which has now left the market. So, you had 2 drugs immediately come out, and then Contrave kind of floated after that, and then it was easy to switch Victoza to Saxenda for that indication. Since then it's kind of been a drought, I would say for a couple of years or even 5 years. And now I think because people see the benefit and also more potent agents, it's pushing that needle closer to bariatric surgery to investigate combinations, triple agonists, you know, to see. I don't think we'll have a drought for a while. It may seem like a drought of maybe 2 years, but I think then things are going to keep rolling with some of these investigational agents. So, yeah, I would say over the past 11 years we've had quite a few drugs, but I think that was also to address some of the safety concerns with older ones because of cardiovascular considerations.

Pharmacy Times: What are the current medication classes for weight management and are there any specific drugs that you'd like to highlight?

Jennifer Clements: I think probably the ones that we feel very comfortable with and we use a lot are the GLP-1 receptor agonists. Liraglutide (Saxenda) has kind of fallen by the wayside; it's still available but it's just not being actively advertised. But we see a lot of Wegovy, which is semaglutide. And then the new Zepbound, or tirzepatide. So, these are obviously I think the 2 newer as well as the 2 most popular, because the weight loss has been more than what we've seen with other agents. So that's why they're very popular and everybody wants them. Everybody's asking about them, and it's led to some issues, particularly with those indicated for type 2 diabetes and [individuals] trying to maybe use them off label and things like that. But those are the most popular ones I would highlight because we know that based on their mechanism, they're very potent agents for weight loss.

Pharmacy Times: What considerations should pharmacists keep in mind when they're developing a clinical recommendation?

Jennifer Clements: I think, number one, they always need to think about developing that trusting relationship with the individual. There are even things you could consider changing in your practice to make [patients] feel comfortable because it's not easy for everybody to talk about their weight. It also may not be easy for the provider to start that discussion, so I think that's very important before you even start asking questions and doing a thorough interview and trying to collect your information to then assess them. But obviously once we get to the point of developing the plan, I think we would do it just like we do any other disease state. We're going to think about what tools do we have in our toolkit? What's going to fit best for that patient? So, it's going to be based on their medical history, current medications, what their weight is now. So, we're really overall looking at the drug-specific and person-specific factors to then figure out what is the best recommendation to offer to that individual. I always like to think of more than one option because you should give the person choices and discuss even what the cost would be, because we know that if people can't afford it, if we don't have that discussion about cost, then they're not going to pick up the prescription. We need to be proactive when we talk about certain things with them. So, it's shared decision making. We give them the options and let them choose what's best.

Pharmacy Times: Supply chain issues have been a major problem. Do you see any resolution coming and how can pharmacist help navigate this?

Jennifer Clements: I like to think resolution is coming. You know, I think though, it just goes back to help. People want these medications because they want to lose weight. Unfortunately, that may have led to some outsourced and compounded products so that they get it somehow, some way. And obviously, people can go to the Obesity Medicine Association for their statement on compounded products and what to do, but I think eventually things will be caught up. However, I wonder with newer drugs in the pipeline, you know, we always think have to think about shortages moving forward. But again, as pharmacists, we have to think about what are the other options? Can I do something else? Is something going to go generic or is something already generic that's going to lower the costs? We may see changes in these copay cards over time, but some of them may seem still pretty steep if the copay gets reduced maybe to $550. But if we see new indications with the medications beyond weight loss, then does that change coverage? Does it allow somebody to opt in to cover those medications for an individual for their plans? So, I think there could be changes in that sense to resolve some of the drug shortages and so that we don't get into these situations. And then obviously, I think a piece we have to factor in is samples. You know, not all of them have samples that you can give out, and you may have to think about how you're going to regulate that and control that in your clinical practice if it does become available, because you can't just give it out. But obviously, that hasn't been a concern yet because people are wanting to give the drug out right now rather than focus on that patient and giving the sample. But I'd like to think there's resolution. I just think, you know, it may take some time.

Pharmacy Times: Speaking of compounded options, what should pharmacists know about the ongoing discussions around compounded weight management medications?

Jennifer Clements: I think the key things to know is obviously that what people were using was not what was studied in the clinical trials. So, as pharmacists, we always focus on what is the safe and effective option for that person before we tell them to take it, and we [know] that we don't know the evidence with the so-called compounded product that they're taking. However, there are people using it. But I think this is where you can rely on the Obesity Medicine Association's guidance and, obviously, they emphasize that it's not what was studied. But I think if you go to a source that is an accredited compounder that goes through regulatory conditions or regulatory requirements, that may be okay, because you know where you're getting it and that there are qualified compounders going through the steps. As far as good practice, that may be a way to think about narrowing it down. I think people get nervous if they hear that all they're doing is adding B12 to it and they're buying a bottle and pumping out all these injections, because then it seems more that they're making trying to make profit from it and that doesn't technically sound like they may be an accredited compounder that goes through good practices for their regulation. So, again, I don't want to say like yes or no, I think we have to be cautious. That's not what was studied. People could benefit, but I think it depends on where you get it. I think in the cases where we've seen some new evidence of impurities or even cases of severe hypoglycemia with compounded products, I would suppose that those did not come from potentially one source or from somebody that's accredited.

Pharmacy Times: Cost can also be a major hurdle. How can pharmacists help navigate this?

Jennifer Clements: Sure, I think there are several ways. One is being proactive, because when a new drug comes out, you don't know who's going to cover it; you rely on your drug representatives to kind of guide you. But then you’ve kind of got to write the prescriptions for people to know what's covered. Allow the patient to be proactive in their own decisions. They can always call their insurance and have those questions as well, but I think you can start running documents as far as what's covered, because it may change over time and things get added. Be aware of what requires a prior authorization and already have that clear documentation to justify why that medication may be needed. But in some cases, there's the savings card, which can take off some. For example, if you have to use the savings card with Zepbound, it gets the price down to about $550, which is still a lot but there are patients that are willing to pay for it. And I think too, you’ve got to kind of think about the billing. So, it may require a little work with billing to see what the appropriate codes are, and that may help get [the price] pushed down a little bit further. Once a drug does get approved, it may require prior authorization 6 months down the road because they wanted to look at it over a period of time. So, obviously there's strategies. Let's say some can't afford it; you may have to go to a generic option or emphasize lifestyle modifications. I think it's just really dependent on that person and how much they can budget out for their medications as a whole with everything else they have to pay for. But you can always think outside the box for those scenarios.

Pharmacy Times: Where do you see the future of weight management medications going?

Jennifer Clements: I think the way it will go is we'll see new drugs that are probably very impactful and get closer to bariatric surgery. I suspect they could surpass percentages that we see with gastric sleeve. And with that, I think there'll be new drugs, obviously, because you're going to see dual agonist like amylin and GLP-1, the triple agonists, you know, and things like that. I think it'll be a matter of how these drugs are dosed and how are they formulated for ease of use, those little practical things we need to think about to make somebody successful. But I do think even with existing agents, we're going to see how high they can go. I suspect that oral semaglutide could be at 25% to 50%; tirzepatide could be at higher as well. Can you go past 2.4 milligrams of semaglutide? So, I think even with existing drugs there could be some data, some small studies, small number of patients to see how far you can go up to get benefit, while considering gastrointestinal effects once you get to a certain point. Beyond what's already in the pipeline, who knows? You know, it could be just different formulations, continuation of different molecules, different drugs that come out, but I think the next 3 to 5 years will be very exciting to watch what gets the indications, and then we can add it to our toolkit.

Pharmacy Times: Do you have any closing thoughts?

Jennifer Clements: I think my only closing thought is I think when I look back on my career, I was not taught obesity or weight management when I went through pharmacy school, and most schools probably have it in their curriculum now. So, I think we need to be educating learners about it—students and residents—but I think this is where as pharmacists, we can really think about what our role is. And even if we're doing something around it, consider publishing the data because we just don't have enough out there regarding what is truly the role of the pharmacist and their impact on certain outcomes. And that's where people have got to be doing things, and I think this would be a good time for them to look at what they're doing and consider some type of publication to get the word out there so that we all can learn from each other.