Listen in as our expert panel walks through today’s full range of obesity treatment options — from older agents like orlistat and phentermine/topiramate to the latest GLP-1 therapies — and how to match the right medication to each patient’s health profile. Plus, you’ll walk away with practical strategies for managing side effects, counseling patients on muscle loss and long-term cost, and switching agents when needed.
This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in September 2026.
🏷️ Use code mt1026b at checkout for 10% off a new or upgraded subscription.
Special guest:
- Elizabeth Van Dril, PharmD, BCPS, BCACP, CDCES
- Clinical Associate Professor, Department of Pharmacy Practice
- Director, PGY2 Ambulatory Care Residency Program
- University of Illinois Chicago Retzky College of Pharmacy
- Clinical Pharmacist, Internal Medicine
- University of Illinois Hospital and Health Sciences System
You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:
- Andrea Darby-Stewart, MD
- Associate Director, HonorHealth Family Medicine Residency Program
- Clinical Professor of Family, Community & Occupational Medicine
- The University of Arizona College of Medicine – Phoenix
- Craig D. Williams, PharmD, FNLA, BCPS
- Clinical Professor of Pharmacy Practice
- Oregon Health and Science University
CE Information:
None of the speakers have anything to disclose.
TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- Chart: Comparison of Weight Loss Products
- Interactive Chart: GLP-1 and GIP/GLP-1 Receptor Agonist Interactive Comparison Chart
- Chart: Comparison of GLP-1 and GIP/GLP-1 Receptor Agonists
- Chart: Guide for Helping Patients Afford Their Medications
- Article: Navigate Questions About the Medicare GLP-1 Bridge
- Article: Point Out Caveats With Direct-to-Consumer Meds
- Article: Be Ready for the New Oral GLP-1 Agonist Orforglipron
- Article: Explain How New ORAL Semaglutide Stacks Up for Weight Loss
- Chart: Comparison of Drugs for Metabolic Liver Disease
- Chart: Diabetes Medications: Cardiovascular and Kidney Impact
Email us: [email protected].
The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
Medication Talk is a production of TRC Healthcare.
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Transcript:
This transcript is automatically generated.
00:00:07 Elizabeth Van Dril
The good news is that patients don’t need to lose a large amount of weight to improve their health.
00:00:12 Elizabeth Van Dril
Even a modest weight loss of about 5% of baseline body weight can lead to meaningful improvements in blood pressure, cholesterol, blood glucose, and overall quality of life.
00:00:22 Elizabeth Van Dril
So for a person weighing 250 pounds, let’s say that translates to about 12 to 13 pounds of weight loss that has meaningful improvements on their health.
00:00:33 Andrea Darby-Stewart
We have had, interestingly enough, two elderly patients on our hospital service with complications from GLP-1s in the last month, both related to essentially what looked like failure to thrive.
00:00:50 Narrator
Welcome to Medication Talk, an official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources.
00:00:59 Narrator
On this episode, listen in as our expert panel walks through today’s full range of obesity treatment options, from older agents like orlistat and phentermine topiramate to the latest GLP-1 therapies, and how to match the right medication to each patient’s health profile.
00:01:15 Narrator
You’ll also walk away with practical strategies, from managing side effects, counseling patients on muscle loss and long-term cost, and switching agents when needed.
00:01:25 Narrator
Our guest today is Dr.
00:01:26 Narrator
Elizabeth Van Dril, a board-certified ambulatory care pharmacist and certified diabetes care and education specialist who manages patients with overweight and obesity as part of an interprofessional cardiovascular kidney metabolic care team at the University of Illinois, Chicago.
00:01:44 Narrator
You’ll also hear practical advice from panelists on TRC’s editorial advisory board, Dr.
00:01:49 Narrator
Andrea Darby-Stewart from the University of Arizona College of Medicine, Phoenix, and Dr.
00:01:54 Narrator
Craig Williams from the Oregon Health and Science University.
00:01:58 Narrator
This podcast is an excerpt from one of TRC’s monthly live CE webinars.
00:02:02 Narrator
Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.
00:02:13 Narrator
And now, the CE information.
00:02:17 Narrator
This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians, and nurses.
00:02:24 Narrator
Please log into your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account, and look for the title of this podcast in the list of available CE courses.
00:02:34 Narrator
None of the speakers have anything to disclose.
00:02:37 Narrator
Now let’s join TRC editor and clinical pharmacist, Dr.
00:02:41 Narrator
Sara Klockars, and start our discussion.
00:02:45 Sara Klockars
And we know there are many different effects of obesity on health, chronic diseases, cancer, and so wondering, Liz, how much weight do patients need to lose to see health benefits for some of these conditions?
00:03:02 Elizabeth Van Dril
Yeah, I think the good news is that patients don’t need to lose a large amount of weight to improve their health.
00:03:07 Elizabeth Van Dril
Even a modest weight loss of about 5% of baseline body weight can lead to meaningful improvements in blood pressure, cholesterol, blood glucose, and overall quality of life.
00:03:17 Elizabeth Van Dril
So for a person weighing 250 pounds, let’s say, that translates to about 12 to 13 pounds of weight loss that has meaningful improvements on their health.
00:03:26 Elizabeth Van Dril
An additional weight loss is associated with greater benefits.
00:03:29 Elizabeth Van Dril
So we know that weight loss of 10% or more can actually improve conditions such as obstructive sleep apnea, metabolic dysfunction associated steatotic liver disease, osteoarthritis symptoms, and type 2 diabetes, and even some patients that achieve remission with extensive weight loss of diabetes.
00:03:46 Elizabeth Van Dril
So setting that target at 5% and reassessing as patients start to achieve their weight loss goals completely appropriate.
00:03:57 Sara Klockars
Andrea, when should meds be considered for treatment of obesity?
00:04:01 Andrea Darby-Stewart
We offer medications for patients who have a BMI more than 30 or if they have a BMI more than 27 with at least one cardiometabolic risk factor like dyslipidemia, hypertension, metabolic associated liver disease, diabetes.
00:04:17 Andrea Darby-Stewart
And basically my discussion is that this is an add-on rather than an instead of for all of the lifestyle modifications that we’ve talked about.
00:04:28 Andrea Darby-Stewart
That nutrition is even more important when starting these medications because of the need for actual healthy nutrition when starting particularly GLP-1s and honestly anything that reduces your appetite.
00:04:42 Andrea Darby-Stewart
And basically, it’s also not a substitute for that, all the exercise, that mindfulness that we may have talked about before.
00:04:50 Andrea Darby-Stewart
And in my practice, right now, what we’re seeing most is people who are requesting the GLP-1s injectables over orals, and sometimes the naltrexone-bupropion combination, but not really looking at any of the other options that are available.
00:05:09 Craig Williams
So yeah, all the rage is certainly GLP-1, but there are some other non-GLP meds that you have listed here that certainly belong in our armamentarium and should be considered.
00:05:19 Craig Williams
And for that patient who’s motivated and willing to take medications to get to a health goal for whom a GLP-1 is not available or they didn’t tolerate it or maybe it didn’t work, they’re going to be a lot more affordable than the GLP-1s.
00:05:33 Craig Williams
But yeah, they’re not getting much traction out there in practice.
00:05:38 Sara Klockars
Thank you.
00:05:40 Sara Klockars
And so, Liz, in your practice, do non-GLP-1 meds still have a role in obesity treatment, and when would you use those?
00:05:49 Elizabeth Van Dril
Although GLP-1 based therapies generally provide the greatest weight loss, non-GLP-1 medications remain important for those patients that can’t access incretin therapies because of costs, insurance restrictions, maybe they have a contraindication, they’ve had side effects in the past, or maybe just personal preference.
00:06:06 Elizabeth Van Dril
In all cases, I generally pick my medication for my patient in collaboration with them, and it should be individualized based on their comorbidities and other considerations I just mentioned.
00:06:19 Sara Klockars
Thank you.
00:06:20 Sara Klockars
And I would like to know just some of the pros and cons, just high-level overview for the different options, starting with orlistat.
00:06:30 Elizabeth Van Dril
I’ve got decades of experience, safety experience with orlistat.
00:06:33 Elizabeth Van Dril
It’s relatively inexpensive, available over the counter and by prescription.
00:06:37 Elizabeth Van Dril
There’s some data out there that it helps reduce the risk of developing type 2 diabetes.
00:06:42 Elizabeth Van Dril
But the downside is it is generally one of the least effective obesity medications and it’s commonly associated with some pretty significant gastrointestinal side effects such as oily stools, fecal incontinence and flatulence.
00:06:54 Elizabeth Van Dril
So definitely not an appealing option for our patients, and it can also decrease absorption of those really important fat-soluble vitamins and certain medications, including levothyroxine.
00:07:05 Elizabeth Van Dril
So maybe not the most optimal choice in the eyes of our patients.
00:07:10 Craig Williams
And for our listeners out there, you know, working in the community spaces, I think the over-the-counter version is still available Alli or Alli, but I haven’t heard much about that for a long time.
00:07:19 Craig Williams
So I was curious myself.
00:07:21 Craig Williams
So I looked at just some numbers in our health care system.
00:07:22 Craig Williams
And for the other agents, Contrave and Qsymia, we’ve kind of got still a couple 1000 kind of patients at least getting prescribed it over the course of the last several years.
00:07:34 Craig Williams
We had under 200 patients kind of ever prescribed orlistat in the last several years.
00:07:37 Craig Williams
So yeah, the marketplace has certainly spoken for it.
00:07:41 Craig Williams
And yeah, the abdominal side effects really are for most people, just a bit of a game changer for the benefits you get for it.
00:07:47 Craig Williams
So I think sustained therapy with it is particularly bad beyond six months or a year.
00:07:53 Sara Klockars
Thank you.
00:07:54 Sara Klockars
Craig, would you want to comment on the pros and cons of Contrave or naltrexone-bupropion?
00:08:01 Craig Williams
So it’s really about thinking about what the individual agents are.
00:08:05 Craig Williams
So Contrave, naltrexone, and bupropion.
00:08:08 Craig Williams
So bupropion is a stimulant antidepressant.
00:08:10 Craig Williams
So has the suicidal warning that all antidepressants do and some warnings about if you have seizure, epilepsy history.
00:08:19 Craig Williams
Cause it has naltrexone in it.
00:08:20 Craig Williams
People in opioids obviously can’t use it.
00:08:22 Craig Williams
So between the two of them, it’s probably slightly less effective than the other one.
00:08:26 Craig Williams
So Qsymia, this combination of phentermine and topiramate.
00:08:29 Craig Williams
So you got two individual agents that you got to think about.
00:08:32 Craig Williams
What are my precautions and contraindications for those individual components?
00:08:35 Craig Williams
So phentermine is a stimulant.
00:08:38 Craig Williams
Don’t take it at bedtime.
00:08:40 Craig Williams
Some patients may not like the way they feel on phentermine.
00:08:43 Craig Williams
It’s really about thinking about the individual ingredients and where they can and can’t be used.
00:08:48 Craig Williams
Qsymia has, of the several, certainly Qsymia is the one that on average has the most benefit associated with it.
00:08:55 Craig Williams
So it kind of average weight loss in the range of 10% body mass as opposed to kind of 5 to 7% for Contrave.
00:09:04 Craig Williams
So if you have good coverage for it and there’s no individual concerns about topiramate or phentermine, I think it’d be the one to try to reach for first, in terms of the patient having success with losing weight and feeling encouraged to stay on it.
00:09:20 Andrea Darby-Stewart
I’m actually curious, Liz and Craig, these are combination medications, individually available at different doses, but at much less expense.
00:09:31 Andrea Darby-Stewart
Do you ever have patients that are on individual naltrexone and bupropion or individual phentermine and topiramate?
00:09:41 Elizabeth Van Dril
I personally haven’t seen it in practice.
00:09:43 Elizabeth Van Dril
I’ll be honest, I’m mostly in diabetes management and just kind of, you know, segued into weight management with the onset of GLP-1s really creating a lot of noise in that space.
00:09:54 Elizabeth Van Dril
I imagine it would be a reasonable option if patients don’t necessarily have insurance coverage for Contrave or Qsymia, but generally be prescribing the FDA-approved product.
00:10:08 Craig Williams
Yes, I have colleagues at Kaiser who seem to have gotten good at using individual components.
00:10:13 Craig Williams
Kaiser seems to be pretty good at offering things that kind of hold down costs.
00:10:16 Craig Williams
So it definitely can work.
00:10:17 Craig Williams
So for clinicians out there or listeners on the call that are seeing that, that’s definitely not wrong.
00:10:22 Craig Williams
So if you’re dispensing a separate prescription for phentermine and for topiramate and the patient’s doing well on it, that’s certainly perfectly reasonable.
00:10:30 Craig Williams
It’s obviously easier to use the combination product, but it’s just a little hard to operationalize, Andrea, but perfectly reasonable to try clinically.
00:10:41 Andrea Darby-Stewart
Thank you.
00:10:43 Sara Klockars
Any other comments before we move on?
00:10:46 Elizabeth Van Dril
I would just say like also looking at your whole patient and for example, if I had a patient that came in and maybe like GLP-1s weren’t the most ideal option for them, or they had contraindications, side effects previously, and they had a history of migraines, phentermine, topiramate might be my go-to option given topiramate’s established role in migraine prevention for patients that have depression, thinking about something like naltrexone, bupropion, just to kind of, what they say, kill two birds with one stone.
00:11:17 Sara Klockars
Thank you.
00:11:20 Sara Klockars
And what are clinical considerations for GLP-1 agonists, some differences between the oral and injectable?
00:11:27 Sara Klockars
I know you all mentioned that folks are still requesting the injectable version.
00:11:32 Sara Klockars
So would love your thoughts on that, Liz.
00:11:36 Elizabeth Van Dril
Yeah, absolutely.
00:11:37 Elizabeth Van Dril
They’re really considered first-line pharmacologic treatment for many people with obesity because they provide the greatest weight loss and have demonstrated benefits beyond weight reduction, improvements in cardiovascular risk, obstructive sleep apnea, and metabolic liver disease depending on your specific agent.
00:11:53 Elizabeth Van Dril
So really medication selection should consider the efficacy, comorbidities, tolerability, preferred route of administration, and of course insurance coverage.
00:12:03 Elizabeth Van Dril
I would say the primary difference between oral and injectable formulations is, of course, convenience and efficacy.
00:12:08 Elizabeth Van Dril
So your injectable semaglutide and tirzepatide provide that greatest weight reduction and benefit from weekly dosing, whereas oral semaglutide avoids injections but has those strict administration requirements for proper absorption.
00:12:21 Elizabeth Van Dril
And then we have our newest kid on the block, which is orforglipron, offering the convenience of an oral agent without the food or water restrictions that oral semaglutide have, but that might become an attractive option for people who prefer pills.
00:12:33 Elizabeth Van Dril
However, it doesn’t yet have that evidence for improving heart disease risk like oral semaglutide or evidence for benefit for those other weight-related comorbidities like those injectable GLP-1 based therapies.
00:12:46 Sara Klockars
Craig, when should GLP-1 agonists be avoided and what are some downsides of GLP-1 agonists?
00:12:55 Craig Williams
Unfortunately, the upfront contraindications are pretty clean.
00:12:58 Craig Williams
If you have an allergy, don’t tolerate the agent, you can’t use it.
00:13:02 Craig Williams
But otherwise, it’s really mostly about managing the adverse effects and the efficacy.
00:13:08 Craig Williams
So I think as most everyone in practice knows at this point, the adverse effects are of essentially kind of a drug-induced gastroparesis, nauseousness and vomiting and such an early sense of satiety that it’s just kind of uncomfortable eating.
00:13:22 Craig Williams
So It’s really about the expected adverse effects.
00:13:25 Craig Williams
We have list here a couple of the rare side effects that are in the label.
00:13:29 Craig Williams
That’s really been hard to sort out from the clinical data how real those are.
00:13:33 Craig Williams
These have been used in a lot of different trial settings, in a lot of different patients with different risk factors, a lot of patients with diabetes who are at risk for some of these complications.
00:13:41 Craig Williams
Pancreatitis is probably one of the more common of the potentially rare adverse effects or precautions.
00:13:46 Craig Williams
And we certainly would not let that stop us from trying these agents.
00:13:50 Craig Williams
So, and again, reasons to believe that if it’s partly obesity driven, you may help with that.
00:13:54 Craig Williams
So for any listeners out there seeing that as kind of a hard stop or having that come up in practice, it’s something to be aware of.
00:14:00 Craig Williams
But again, it’s a history of pancreatitis that should not exclude someone from trying a GLP-1 agent in our minds.
00:14:07 Elizabeth Van Dril
I would say gastroparesis is definitely like a real concern.
00:14:10 Elizabeth Van Dril
You know, these work by slowing gastric emptying.
00:14:14 Elizabeth Van Dril
Most patients really only experience mild gastric emptying, slowing, but those with significant pre-existing gastroparesis can definitely have worse symptoms, nausea, vomiting, bloating, early satiety.
00:14:26 Elizabeth Van Dril
That said, a history of gastroparesis doesn’t automatically exclude every patient from using a GLP-1 therapy, so really looking at the severity of symptoms, underlying cause, and treatment goals to really guide your decision-making.
00:14:37 Elizabeth Van Dril
So someone with severe symptomatic gastroparesis are generally poor candidates, while those that have mild or uncertain symptoms may be able to use these medications with careful monitoring and slow titration.
00:14:50 Elizabeth Van Dril
Even things like pancreatitis, if the etiology is well identified in the past and that etiology has been resolved and is no longer present, I have used GLP-1s in those patients because of the net metabolic and cardiovascular benefit from their use.
00:15:06 Sara Klockars
Thank you.
00:15:07 Sara Klockars
What about retinopathy?
00:15:10 Elizabeth Van Dril
Yeah, retinopathy, specifically diabetic retinopathy, isn’t necessarily a contraindication to GLP-1 therapy.
00:15:16 Elizabeth Van Dril
The concern really stems from large studies of semaglutide, I think it was SUSTAIN 6, if I remember correctly, in which some patients with pre-existing diabetic retinopathy experience worsening eye disease, particularly when blood sugar levels improved rapidly.
00:15:33 Elizabeth Van Dril
So in clinical practice, most patients with retinopathy can safely use these agents.
00:15:38 Elizabeth Van Dril
I generally recommend ensuring, you know, patients should be getting regular eye exams anyway as for all of us, but making sure that we’re assessing for reported changes in vision after initiation and any dose changes and counseling them to report any new visual symptoms.
00:15:52 Elizabeth Van Dril
Of course, seen more in the diabetes population than the overweight obesity population, but still something to regularly monitor.
00:16:01 Elizabeth Van Dril
And I feel like, again, just the overall metabolic and cardiovascular benefits really outweigh the potential risks, especially when those vision symptoms are being monitored and eye health is being monitored regularly.
00:16:12 Sara Klockars
Thank you.
00:16:13 Sara Klockars
Have any of you seen hair loss or alopecia with GLP-1 use in practice?
00:16:19 Andrea Darby-Stewart
I’ve had a couple of patients, rapid weight loss experience, some alopecia, and it prompted a discussion both about med changes, telogen effluvium, and also appropriate nutrition as well.
00:16:33 Andrea Darby-Stewart
But it’s not something that I particularly list as a disclosure of what might happen to you should you start taking these medications.
00:16:43 Andrea Darby-Stewart
We have had, interestingly enough, 2 elderly patients on our hospital service, with complications from GLP-1s in the last month, both related to essentially what looked like failure to thrive, just having such suppressed appetite that they didn’t, they basically were hypoglycemic and they had not been eating appropriately, resulting in a fall and then some altered mentations.
00:17:08 Andrea Darby-Stewart
So it’s something that we’re looking at pretty closely.
00:17:12 Andrea Darby-Stewart
One was a patient from our practice and another was a patient from another practice.
00:17:15 Andrea Darby-Stewart
And so I think that’s something that we should probably be aware of in many of our patients, particularly our elderly patients.
00:17:24 Elizabeth Van Dril
And I can just add, like I’ve seen a few cases of alopecia and just to echo Andrea, it’s very much related to, again, that rapid weight loss, maybe inadequate protein intake, inadequate nutrition overall.
00:17:39 Elizabeth Van Dril
So generally, something that we counsel on to make sure that patients are getting adequate nutrition when they’re using these agents and certainly try and identify those effects if they’re not receiving adequate nutrition.
00:17:54 Sara Klockars
Thank you.
00:17:54 Sara Klockars
And that brings me to the next audience question.
00:17:58 Sara Klockars
What should I tell patients about muscle loss?
00:18:00 Sara Klockars
How much muscle loss should patients expect and can using a lower dose limit that?
00:18:07 Elizabeth Van Dril
I think it’s important to educate patients that some loss of lean mass or muscle occurs with almost any successful weight loss intervention, and that includes lifestyle changes, bariatric surgery, and pharmacotherapy.
00:18:21 Elizabeth Van Dril
Currently, data suggests that approximately 20 to 30% of weight loss with GLP-1s can come from lean mass, while the majority comes from fat mass.
00:18:30 Elizabeth Van Dril
So I think that leads you to the conclusion that body composition generally improves because patients are losing substantially more fat than muscle.
00:18:38 Elizabeth Van Dril
I personally find that the best strategies for preserving muscle mass are making sure that those patients are getting that adequate protein intake.
00:18:46 Elizabeth Van Dril
Literature varies, but targeting anywhere from 1 to 1.5 grams of protein per kilogram per day, and then making sure that they get regular physical activity, particularly resistance or strength training, definitely in our older adults.
00:18:59 Elizabeth Van Dril
And then for patients with overweight or obesity that also have chronic kidney disease, and we see a lot of this in our practice, and especially those that are at risk for progression, it’s also important to emphasize that protein intake should not exceed 1.3 grams per kilogram per day because we know that higher intake can also accelerate kidney damage.
00:19:16 Elizabeth Van Dril
So kind of finding that sweet spot between 1 and 1.3 grams per kilogram per day.
00:19:21 Elizabeth Van Dril
And really at this time, I don’t think there’s a lot of solid evidence that intentionally lowering that GLP-1 dose prevents muscle or bone loss.
00:19:30 Elizabeth Van Dril
So treatment decisions should really be based on primarily that efficacy and tolerability and focusing on those lifestyle nutrition and exercise counseling points.
00:19:41 Craig Williams
Yeah, I’ll say that we are kind of very reassuring this front because the scientific literature really is very reassuring, even down to like biopsies of muscle showing some of what you’re losing is kind of fat striation within that muscle.
00:19:52 Craig Williams
There’s some evidence that muscle may actually be healthier, even those have less mass.
00:19:56 Craig Williams
So again, the science just seems to tell us this is safe and it’s going to be a consequence of losing enough body mass, period.
00:20:06 Sara Klockars
Would love to discuss tips for navigating access to GLP-1 agonists and wondering if any of you have any successes or challenges with the Medicare GLP-1 bridge program.
00:20:21 Sara Klockars
Liz would love your thoughts on this.
00:20:24 Elizabeth Van Dril
I mean, I think access remains one of the biggest barriers to obesity treatment, of course, across all age ranges, thorough documentation of obesity-related comorbidities, those indications that are going to get it approved, any kind of prior weight loss attempts, documenting that they have or have not lost 5% of their body weight over 6 to 12 months.
00:20:45 Elizabeth Van Dril
So that is supporting that they have implemented those lifestyle modifications and making sure that medical necessity is documented to improve prior authorization success is so imperative.
00:20:56 Elizabeth Van Dril
Patients generally have or may have better coverage when those medications are prescribed for FDA-approved indications, especially under Medicare and some Medicaid programs as well — beyond weight loss, do they have a history of cardiovascular disease?
00:21:12 Elizabeth Van Dril
Do they have obstructive sleep apnea, metabolic dysfunction associated liver disease?
00:21:16 Elizabeth Van Dril
Having those clearly documented in the chart can help support very clear FDA-approved indications for use that even if their plan does not cover medications for obesity, they would cover those medications for cardiovascular risk reduction, sleep apnea, and liver disease.
00:21:35 Elizabeth Van Dril
And for me, I think the Medicare GLP-1 bridge program has really significantly expanded access for our older adults with overweight or obesity, but it’s also created some notable workflow challenges for pharmacists.
00:21:46 Elizabeth Van Dril
So affordability, rapid prior authorization turnaround, and clear eligibility criteria are major wins, but pharmacists kind of continue to face that inconsistent pharmacy awareness, some billing confusion regarding like it must be rejected from Part D before it kind of be is submitted to the bridge program.
00:22:07 Elizabeth Van Dril
So definitely some administrative burden there.
00:22:10 Elizabeth Van Dril
And then of course, our pharmacists, both within the clinics, in the community pharmacy, the increasing demand for counseling needs, making sure that we’re setting clear expectations around side effects, consistency of medication taking, and then these pressures are kind of further compounded by the uncertainty about what’s gonna happen with this program once the bridge program sunsets in 2027.
00:22:33 Elizabeth Van Dril
So hopefully some long-term plan as well.
00:22:40 Craig Williams
The only other thing I mentioned, we do have some patients who are in the range where the cash pay option directly from the companies is something they can manage.
00:22:48 Craig Williams
So semaglutide, you’re kind of in the range of $200 a month, potentially depending on dose to get it directly and bypass insurance.
00:22:55 Craig Williams
So that companies are savvy about this, they’ve lowered those prices and that is increasingly an option for some of our patients.
00:23:04 Andrea Darby-Stewart
I think it’s really important to talk to our patients when they start these medications that this is much like their medications for diabetes, hypertension, dyslipidemia, most likely a medication that they’re going to be taking for a very long period of time.
00:23:21 Andrea Darby-Stewart
And having a frank conversation with them about that, because we honestly don’t know what the coverage will be related to weight, related to I’m hopeful that they will continue to cover for the metabolic associated complications, but as the cost of healthcare increases, we see people starting to make it harder and harder for our patients to receive coverage for these medications under their traditional insurance plans.
00:23:49 Andrea Darby-Stewart
And so having that conversation with them about the long-term cost of this medication or this type of medication, I think is really important and we do them a disservice if we don’t talk about that.
00:24:02 Sara Klockars
Craig, why do some patients not lose weight on meds and when should a med be switched or stopped for lack of efficacy?
00:24:10 Craig Williams
Talking about the non-GLP agents, the FDA is generally wanted to see a 5% in average weight loss at roughly the 12 to 16 week period to give a drug the nod for the approval for weight loss.
00:24:23 Craig Williams
And there’s of course a bell curve around that.
00:24:24 Craig Williams
But yeah, for the GLP-1s, which clearly are our most effective agent, we’ve known from before these drugs even got marketed that some patients just don’t get the benefit.
00:24:32 Craig Williams
And if you dig into that, it’s around 10%, you can pretty solidly call a non-responder in terms of, they gain a couple pounds on the medicine or they lose less than 2% of their body weight.
00:24:44 Craig Williams
And a lot of those earlier trials, you look at the kind of the response curves, it’s always kind of around 9 out of 10, get what we would define as a meaningful clinical response in that kind of 5 plus percent range, but at least one in 10 that don’t.
00:24:58 Craig Williams
It’s not just intolerance.
00:24:59 Craig Williams
These are patients who can take it.
00:25:00 Craig Williams
So if you broaden it to who doesn’t tolerate it as well, it certainly goes up from there.
00:25:04 Craig Williams
But these are patients who successfully take the medicine that just don’t get the expected weight response.
00:25:10 Craig Williams
And yet in those patients, so I think 5% is still a reasonable number.
00:25:15 Sara Klockars
Liz, do you do anything different in your practice?
00:25:19 Elizabeth Van Dril
I would say probably a similar number of around maybe like 5% of non-responders that don’t necessarily experience that 5% or greater weight loss.
00:25:29 Elizabeth Van Dril
Again, most of my patients are also using these for diabetes, so am I going to stop them?
00:25:34 Elizabeth Van Dril
No, but it is incredibly frustrating for those patients that have heard all these wonderful benefits of these agents.
00:25:40 Elizabeth Van Dril
Some of their friends and family members are using them for strictly weight loss, and they’re seeing those patients or those friends and family members lose the weight, but they plateau and they plateau early for some reason.
00:25:54 Elizabeth Van Dril
I really don’t have an answer for them right now, there’s things in the pipeline that maybe offering more weight loss.
00:26:01 Elizabeth Van Dril
So we’ll have to see, but definitely keeping our A1C in the upper fives, low sixes, and we continue on that front for optimal diabetes management.
00:26:12 Craig Williams
Yeah, let’s add to that, you know, it’s worth pausing with those patients because they could kind of feel like a failure on it because everyone else is responding, is that their, you know, friends are responding, it’s all over the internet people are responding.
00:26:22 Craig Williams
And yeah, it’s a good thing just to tell them that, you know, this is not you’re not that much of an outlier and it’s uncommon, but you’re not an outlier, not a personal failure.
00:26:30 Craig Williams
It’s just we don’t fully understand what drives obesity in every patient and it’s just not a pathway that appears to be effective for you.
00:26:38 Elizabeth Van Dril
Absolutely, especially when they’re making all the other changes to support that weight loss change as well and encouraging them to continue those healthy changes for long-term benefit.
00:26:50 Sara Klockars
Thank you.
00:26:51 Sara Klockars
And we often need to switch agents.
00:26:55 Sara Klockars
So would love your thoughts, Liz, on how do you switch between GLP-1 agonists?
00:27:00 Sara Klockars
Do you need to retitrate from the starting dose?
00:27:04 Sara Klockars
Can you just do a direct switch?
00:27:07 Sara Klockars
How do you do that in your practice?
00:27:10 Elizabeth Van Dril
I feel like this is a daily consult question.
00:27:13 Elizabeth Van Dril
So there’s like really no universal strategy when switching GLP-1s.
00:27:16 Elizabeth Van Dril
There’s a great review article out there, especially in clinical diabetes related to like switching diabetes related GLP-1s, diabetes indicated GLP-1s.
00:27:25 Elizabeth Van Dril
But I really feel like comparative doses can be used as a guide for when you’re switching agents.
00:27:30 Elizabeth Van Dril
In general, like product specific guidance should be reviewed when available.
00:27:33 Elizabeth Van Dril
And clinicians should always look at like the prior dose.
00:27:36 Elizabeth Van Dril
Where are they switching from?
00:27:38 Elizabeth Van Dril
What’s their gastrointestinal tolerability history?
00:27:41 Elizabeth Van Dril
Did they have a lot of nausea, vomiting when they first started?
00:27:44 Elizabeth Van Dril
Like how severe was that?
00:27:46 Elizabeth Van Dril
And if applicable, like looking at how long have they been interrupted in treatment, because that of course would make you go to that starting dose if it’s been a sufficient amount of time.
00:27:56 Elizabeth Van Dril
I would say patients don’t always need to restart from the lowest dose, especially if they’re transitioning directly from another GLP-1 that’s at the therapeutic dose.
00:28:04 Elizabeth Van Dril
So if they’re stopping semaglutide 2 milligrams, last week, last Sunday, and they’re starting tirzepatide 7.5 if I’m going up in intensity, maybe 5 if I’m going straight over in intensity.
00:28:19 Elizabeth Van Dril
However, definitely thinking about partial retitration being a reasonable strategy if gastrointestinal side effects have been really problematic in the past, or if you’re switching to a more potent agent.
00:28:31 Craig Williams
These are great guides you have here, sir.
00:28:32 Craig Williams
And I just re-emphasize it, as I said, you do not need to start over for these.
00:28:36 Craig Williams
So if the patient’s doing well and tolerating it, in fact, I advocate don’t start over at the lower dose if a patient has, you know, achieved a dose that’s working for them.
00:28:45 Craig Williams
So I don’t know of any guideline that says you have to start over with a new agent.
00:28:51 Sara Klockars
Thank you.
00:28:52 Sara Klockars
Liz, what meds are in the pipeline for obesity treatment?
00:28:56 Sara Klockars
And what about new uses for GLP-1 agonists or new indications?
00:29:02 Elizabeth Van Dril
Yeah, so I think the obesity pipeline remains extremely active.
00:29:06 Elizabeth Van Dril
Some of the agents like highlighted here, I think you have retatrutide, that triple GIP GLP-1 glucagon receptor agonists.
00:29:14 Elizabeth Van Dril
You’ve got CagriSema, which is cagrilintide and semaglutide, survodutide, and MariTide.
00:29:21 Elizabeth Van Dril
So a lot of new exciting agents in the pipeline, and each of them are, of course, aiming to achieve greater weight loss than the last and may provide additional cardiometabolic benefit, kind of waiting on some of the outcome data there.
00:29:36 Elizabeth Van Dril
So we know that researchers are obviously evaluating GLP-1-based therapies for a growing set of potential indications beyond diabetes, obesity, and current cardiometabolic uses.
00:29:47 Elizabeth Van Dril
So there’s several ongoing trials for these newer agents for cardiovascular and kidney disease.
00:29:54 Elizabeth Van Dril
Heart failure preserved ejection fraction, we’ve got a little bit of data with existing agents and some ongoing studies as well.
00:30:00 Elizabeth Van Dril
And then metabolic liver disease.
00:30:02 Elizabeth Van Dril
There’s also some several phase two in a large phase three program that are investigating GLP-1 agonists for alcohol use disorder.
00:30:11 Elizabeth Van Dril
So really reflecting that rapid momentum in that addiction medicine space.
00:30:16 Elizabeth Van Dril
And then there’s some additional exploratory work looking at their role in inflammatory and immune-related conditions.
00:30:22 Elizabeth Van Dril
So dermatologic applications like psoriasis are still very early in their stages of investigation, but are definitely on the horizon.
00:30:32 Elizabeth Van Dril
And I think overall, this pipeline really shows a clear shift towards leveraging GLP-1’s more broad physiologic effects across multiple organ systems.
00:30:43 Sara Klockars
Thank you.
00:30:43 Sara Klockars
And some of the injectables you can use down to age 12.
00:30:48 Sara Klockars
Is that the lower limit that we’ve seen in practice or do we ever see these used at a younger age?
00:30:55 Elizabeth Van Dril
Yeah, great question.
00:30:56 Elizabeth Van Dril
I think there’s some exciting new data that’s recently published.
00:31:00 Elizabeth Van Dril
But the lower age limit for those anti-obesity medications vary definitely by product.
00:31:05 Elizabeth Van Dril
And like you said, currently liraglutide, injectable semaglutide, and then also extended release phentermine and topiramate are approved for adolescents age 12 and older.
00:31:14 Elizabeth Van Dril
And all other available oral and injectable therapies are limited to adults 18 and older.
00:31:20 Elizabeth Van Dril
There are ongoing clinical trials for tirzepatide and orforglipron, assessing their safety and efficacy in adolescents 12 and up with obesity.
00:31:29 Elizabeth Van Dril
So that should expand future treatment options.
00:31:33 Elizabeth Van Dril
And there’s also some limited data for liraglutide and brand new data for injectable semaglutide in younger populations, specifically those 6 to 12 year olds.
00:31:42 Elizabeth Van Dril
But they’re currently not approved for this age group and any kind of use would be considered off label.
00:31:48 Andrea Darby-Stewart
And I would also counsel that use in youth is really something that probably shouldn’t be done at a general practice level and probably needs to be done in a more comprehensive program, reflecting again back to the fact that we’re talking about a lifelong medication and the implications of that in this population.
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