A personal mission to get obese patients on GLP-1 agonists [PODCAST]

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“Obesity is not the consequence of bad behaviors it is a disease that finally has effective, safe, lasting treatments. Patients with obesity have been marginalized long enough. We, especially health care providers, have got to start taking down barriers for these patients — not adding to them.”

Christine Meyer is an internal medicine physician.

She shares her story and discusses her KevinMD article, “A personal mission to get obese patients on GLP-1 agonists.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Christine Meyer. She’s an internal medicine physician, and we’re going to talk about her KevinMD article, “A personal mission to get obese patients on GLP-1 agonists.” Christine, welcome to the show.

Christine Meyer: Hey, Kevin, thanks for having me.

Kevin Pho: So we’ll get into the article a little bit, but first off, briefly share your story and journey to where you are today.

Christine Meyer: Yeah, so I currently practice internal medicine. I own a practice that I started 18 years ago. It was just me back then, and now we have 17 clinicians, two buildings, and thousands of active patients. It’s awesome. It’s big and busy, and I’m just super proud of it.

Kevin Pho: So as you know, we were talking off air about how private practice internal medicine is a little bit of a dying breed now. For those medical students who may be listening to the show, tell me why you love outpatient internal medicine.

Christine Meyer: I practice medicine for the connection with my patients, and it is such a great way to connect with patients on so many levels. In 18 years, I’ve watched my patients kind of grow up with me. We started in the same station of life, with tiny kids and building our careers, and now we’re all in menopause together. It’s just very cool to be able to connect with patients longitudinally, and even on things way deeper than their health. It’s just amazing.

Kevin Pho: And in terms of private practice, that also is a dying breed. You have a lot of these practices being purchased by private equity and being purchased by large hospital systems. So tell me what keeps you going in private practice.

Christine Meyer: Well, honestly, there have been moments where it’s touch and go, because those dollars that they dangle in front of you, especially, like you said, private equity firms, are really hard to look away from sometimes. But this is my fourth child. I feel so devoted to this practice and to my patients, and I know that the care they get, if my practice were in the hands of a private equity firm or even a big hospital system, just wouldn’t be the same. So knowing that the level of quality care that we deliver in my practice would change for the worse if we weren’t private, I just can’t do it.

And honestly, I think that financially, the rewards of owning your own practice and staying independent are fantastic. A lot of people starting out maybe don’t realize that. They see the security in an unquestioned paycheck month to month, or whatever, and might not consider that you could be an entrepreneur and be a physician and have a lot of success, and financial stability too.

Kevin Pho: And how did you learn all those business skills? Because private practice is pretty much owning and running a business. So how did you learn?

Christine Meyer: Honestly, by mistakes. And I’m so glad that I started small, just me, because when you make a mistake and it’s one person and you lose a couple hundred bucks because you paid too much for this or that, it’s OK. And then it just grows by scale. We’re all type A. I heard your last podcast, or one of the most recent ones, about being type A and super competitive and wanting to succeed, and that’s just in my blood. So I think entrepreneurship and medicine just kind of went hand in hand for me.

Kevin Pho: And if you were to redo your medical career all over again, is there anything that you would have done differently?

Christine Meyer: You know, I have personal regrets sometimes, because when you’re an entrepreneur, you give up a lot at home to make your practice and your business succeed. So I missed a lot of things when my kids were little. Maybe devoting a little less time to the practice and a little more time at home, finding that balance. I have it now, but now two of my three kids are out of my house. So I feel like I wish I had kind of had a better balance back in the early days. But then maybe I wouldn’t be where I am today. Who knows?

Kevin Pho: Sure. All right, let’s talk about your KevinMD article. We hear a lot about GLP-1 agonists in the news, and people have very good results on them from a weight loss standpoint. Your article is titled “A personal mission to get obese patients on GLP-1 agonists.” Before we talk a little about that, to make sure everyone’s on the same page, tell me, what is a GLP-1 agonist?

Christine Meyer: So a GLP-1 agonist is basically a naturally occurring hormone and neurotransmitter, it turns out, that helps our bodies regulate hunger, satiety, blood sugar levels, and insulin levels.

Kevin Pho: And how long have they been available for?

Christine Meyer: A long time. They’ve been used to treat type 2 diabetes for many years, but only recently came onto the weight loss arena.

Kevin Pho: All right. And how are they being used currently, both in diabetes and in weight loss?

Christine Meyer: So in diabetes, usually not as a first-line treatment for type 2 diabetics, but they probably should be, basically to control hemoglobin A1Cs. They’re add-ons to typical oral regimens like metformin. In weight loss, basically, for an obese person with a BMI over 31, or 27 with any kind of medical condition attributed to their obesity, they can be used to help enhance a reasonable diet and exercise regimen.

Kevin Pho: All right. So tell me why it’s your personal mission to get obese patients on these types of medications.

Christine Meyer: They are amazing, and obesity is killing people at a ridiculous rate. I think for a long time, until very recently, we treated obesity as a personal failure, a consequence of bad behavior: Obese people just didn’t try, or didn’t care, or gave up too fast, or wanted an easy answer. But now we understand that obesity is a diagnosis in and of itself.

I weigh 110 pounds, and I’m five foot two, and I have hypertension. Like, why is that? That’s not my fault. That’s a disease that I have, and I don’t blame myself every time I take my blood pressure pill. But I think in obesity, there’s this tendency to think that people should be able to pull themselves up by their bootstraps and just get it done. But now, seeing how these GLP-1 medications work, it’s pretty clear that there is a missing piece that some people just don’t have.

Kevin Pho: Now, just for some context, what are the current FDA-approved medications that we use to treat obesity?

Christine Meyer: So there are two GLP-1s that are FDA-approved for obesity, Saxenda and Wegovy. And then there’s Contrave, which is a combination of bupropion and naltrexone, and there is phentermine, the long-standing appetite suppressant. Those are pretty much the most common ones.

Kevin Pho: And in terms of the GLP-1 agonists, tell me, what kind of weight loss does one expect after using these medications?

Christine Meyer: So in the most recent trials, probably 15 to 20 percent is not an unreasonable expectation, which, for someone who weighs 200 pounds, could be 40 pounds. It’s pretty remarkable.

Kevin Pho: And over a period of what time?

Christine Meyer: So the studies are ongoing, but people generally continue to lose weight over a 48-week period. So just starting, probably after the first month or two, people start to see one to two pounds of weight loss per week, and it continues. And like I said, the trials are still going on, but 48 or 50 weeks in, people are continuing to lose weight.

Kevin Pho: So take us into your exam room. Give us a typical case study, story, or patient where the conversation about a GLP-1 agonist would come up, and how would you approach that conversation?

Christine Meyer: Sure. So it’s a 48- or 49-year-old perimenopausal woman who has had a pretty much lifelong struggle with her weight. She has been on the up-and-down roller coaster, knows that she should eat better, knows that she needs to exercise, and has, over the course of a lifetime, lost and gained the same 10 or 20 pounds. And she is at a point where now, approaching menopause, her body doesn’t cooperate as much. If joints hurt, it’s harder to do as many things.

And what I see, what always kind of draws me to those patients in my examining room, is this feeling of heaviness and defeat and lack of self-worth that is just clearly tied to their weight. I think it’s in those patients, the ones that have been there, done it, and tried it, and now they’re at a point where it’s bringing them down and stealing their quality of life and joy, that I see an opportunity for these medicines to make a huge difference.

Kevin Pho: And when you bring up the possibility of this medicine in general, what are some of the patient reactions?

Christine Meyer: Honestly, the direct-to-consumer information has been amazing, so it makes my job a little bit easier. Patients almost universally are like, “Yes, let’s go. I’m ready. Let’s do it.” The hesitancy with stimulants and appetite suppressants is always about safety, but as more and more information comes out with these specific drugs, I think patients are much less inhibited. And I think obviously hearing their doctors say, “Hey, you should probably consider this,” goes a long way too.

Kevin Pho: So I believe these medications are injected subcutaneously. Is that correct?

Christine Meyer: Almost all of them are. There’s one available orally, Rybelsus, that you can take in pill form every day, but the rest are injections.

Kevin Pho: Yes. And when you bring that up to patients, do they have any reservations?

Christine Meyer: Very few. And usually what I’ll do for those that are hesitant is I will give them their first dose as a sample in my office and just show them how easy it is. I show them the size of the needle. It’s microscopic. My old eyes can’t even see the needle unless I put readers on. And in my experience, I have hundreds of patients on these medicines, and no one ever stops because of the needle. The injection is just a non-issue.

Kevin Pho: And then, of course, the elephant in the room is cost. You have a lot of mainstream media articles that talk about GLP-1 agonists and obesity, and how insurers and Medicare don’t cover them for obesity, but they do cover them for diabetes. So talk about the cost of these medications.

Christine Meyer: They’re prohibitive for anyone. It could be $1,600 a month if you’re a cash-paying patient without insurance coverage. I mean, you could spend that on a mortgage. It’s crazy.

Kevin Pho: Do you have any success in getting it covered for obesity?

Christine Meyer: Very little. So in our area, Independence Blue Cross is our main insurer, and most of their plans just don’t cover it for obesity. Sometimes we can get them approved, because they don’t ask what the medication is being covered for, and in those cases we kind of get lucky. But for the most part, we use a lot of manufacturer coupons. Some of our patients get the prescriptions from Canada. Really, by any means possible. We use samples, whatever we can do.

Kevin Pho: And when these patients get prescriptions from Canada, do you know how much it costs from Canada?

Christine Meyer: Yeah, so just as an example, Ozempic, which is one of the most commonly prescribed ones in our area here, like I said, is about $1,600 a month. If you get your prescription from Canada, you can get a three-month supply for about $800. So it’s still not cheap, $200 to $300 a month, but just a fraction of the cost here.

Kevin Pho: Are there any types of patients that should be wary about GLP-1 agonists? What are some of the downsides?

Christine Meyer: Sure. So the biggest warnings are about pancreatitis. It doesn’t seem like, if you have a history of pancreatitis, you’re more likely to get pancreatitis on these medications, but that’s one. And obviously, pancreatitis can be a life-threatening condition, so it’s very important to talk about. And the other is medullary carcinoma of the thyroid. Apparently, in some of the animal trials, it appeared to be a rare but possible adverse effect of using GLP-1s, but it really hasn’t translated into the human trials. So I always mention those two things.

I think the bigger issues really are the very common day-to-day side effects, which are nausea, and almost everybody gets nauseous just in the beginning, and then over time that tends to get better, and then constipation, which never gets better. So pretty much when you sign up for these GLP-1s, you’re also signing up to have some sort of bowel regimen on board. But that’s another one of those things that people just accept.

Kevin Pho: So the majority of the patients who are prescribed GLP-1 agonists, they’re primarily paying either out of pocket, $1,600 a month, or getting it from Canada at $800 for three months?

Christine Meyer: Or using a manufacturer’s coupon. That’s honestly the most likely scenario. The most recent GLP-1 to hit the market, Mounjaro, which is manufactured by Lilly, has an amazing manufacturer coupon, which will get the monthly cost down to $25 a month for commercially insured patients, and they can use that coupon for a year. And because Mounjaro just applied to the FDA to get a fast-track approval for weight loss, we expect that at the end of 2024. So basically, patients can use this coupon and buy their time for a year. Hopefully by then, that medication will get weight loss FDA approval, and then the tide should start to turn, I’m hoping, and access should just be a little bit easier for most patients.

Kevin Pho: Now, what about when you talk to your other primary care colleagues? Are they prescribing GLP-1 agonists relatively frequently for obesity?

Christine Meyer: Not as much. I mean, endocrinologists definitely are, I think because they have a comfort level using them in diabetes. I think some primary care doctors are starting to, but we’re rule followers, right? We don’t want to prescribe something that we are not supposed to. And this idea that Ozempic, for example, which is semaglutide, doesn’t have FDA approval and therefore should not be prescribed for weight loss is nonsense, because Wegovy is also semaglutide. It’s the exact same drug in a different color box, but we’re not supposed to prescribe the one that’s available. Wegovy is literally not available because they can’t make it fast enough. So I think we all need to step outside of our being do-gooders and try to do good by kind of bending the rules a little bit.

Kevin Pho: And just going back, in terms of the formulations, you mentioned there was one oral formulation of the GLP-1 agonist. Is that as effective as the injectable forms?

Christine Meyer: Yeah, so Rybelsus is also semaglutide, so there are three versions of that. The problem with Rybelsus is that it’s hard to take. You have to take it first thing in the morning, and you have to wait an hour before eating or drinking anything. And in people who do eat within that hour, or even have coffee, we’ve seen the medication be less effective. And I think the side effects are a little bit harder with Rybelsus too, because you have to take it every single day, versus its counterpart, which is a weekly injection, which just makes it a little bit easier to deal with the side effects.

Kevin Pho: We’re talking to Christine Meyer. She’s an internal medicine physician, and we’re talking about her KevinMD article, “A personal mission to get obese patients on GLP-1 agonists.” So, Christine, what do you see as the path forward? Do you see insurers ever beginning to cover this class of medications?

Christine Meyer: Absolutely. I think that we’re all trying to improve health care outcomes and reduce costs, right? Obesity is at the root of so many of the highest-cost medical conditions that we’re trying to manage in this country that if we just got that one right, imagine not just the benefit to patients and their health and their lives, but to our health care dollars. It’s tremendous. I think insurance companies just need to look past this short-term investment in these costly drugs and down the line at what will be saved when we’re not doing knee replacements and giving people insulin and treating heart disease and all those other things.

Kevin Pho: All right. What kind of advice do you have for other clinicians who may be thinking about prescribing these medications?

Christine Meyer: I would say just read about them and understand them. I think fear and hesitancy come predominantly from a lack of understanding. And it’s time. None of us has a lot of time to devote to learning about things. We’re trying to keep our heads above water. But invest the time, read about them, and then try them in a couple of patients. I think the most rewarding thing is just seeing the success. It is just amazing. My patients will come to me and cry, because for the first time in their life of trying to lose weight, they’re actually seeing success. And then once you see that, it’s really hard not to keep prescribing it to appropriate patients.

Kevin Pho: And after they make that initial weight loss, after whatever, 48 weeks, do they have to be on this indefinitely?

Christine Meyer: Yeah, so that is the ongoing question. I tell people to consider this a long-term, lifelong investment. It looks like people who stop using the GLP-1s do gain their weight back, at least in some form. So what I tell my patients is what I tell myself: OK, so now my hypertension is very well managed with my little pill that I take every day, but what will happen if I stop my pill? My blood pressure is going to go up again. So I have just accepted that to manage my blood pressure, I take medicine every day.

I think people need to see their obesity as a disease that will need to be managed for the long term, and if it means taking or using a medication in some shape or form for the long term, so be it. It’s definitely one of those mental blocks that people have to get past, and I have that conversation before the first prescription is written, because I think you really need to go into this with the idea that this is a long-term investment in your health.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Christine Meyer: For anybody who has an obese patient that’s really struggled, look past the idea of them not trying. Consider the possibility that there’s more to it. And even for doctors who are not obesity specialists, who have not prescribed weight loss medications in the past, this is different. This is a new era. The results and the safety are just unprecedented. So look outside your comfort zone, because we can make a huge impact for patients. And if we advocate for them and speak loudly, I think insurance companies will start to see the value, and we can get more patients down to their ideal body weight and living their best life.

Kevin Pho: Christine, thank you so much for sharing your time and insight. Thanks again for being on the show.

Christine Meyer: Thank you so much, Kevin. Such a pleasure. Great to talk to you.

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