GLP-1s and Older Medications: The Evolving Landscape of Weight Loss Treatment
The surge in popularity of glucagon-like peptide 1 (GLP-1) receptor agonists for weight loss has prompted many patients to seek medication for obesity. However, the high costs and insurance coverage issues associated with GLP-1s are leading some to explore older, more affordable alternatives.
Dr. Sriram Machineni, director of the Fleischer Institute Medical Weight Center at Montefiore Medical Center and Einstein College of Medicine in New York City, discusses how patients often request GLP-1s but are willing to try alternate drugs when insurance coverage is an issue.
“Patients come through the door asking for a GLP-1, and when they’re told they wouldn’t be eligible with their insurance, they’re open to other therapies,” Machineni explains. With GLP-1s’ less accessible and more expensive counterparts, interest is rising in older medications for weight loss.
Older Medications for Weight Loss
Non-GLP-1 medications, such as various combinations of phentermine, bupropion-naltrexone, topiramate, and metformin, are showing promise. While these drugs may not lead to as rapid weight loss as GLP-1s, they can still be effective. Phentermine can be prescribed alone or in combination with topiramate (commonly sold as Qsymia), whereas bupropion and naltrexone can be prescribed separately or as the combined medication Contrave.
Metformin, often used for type 2 diabetes, also has a modest weight loss effect for some patients. Each of these drugs offers unique mechanisms, making them valuable in diverse patient populations.
According to Dr. Sarah Ro, medical director of the University of North Carolina Physicians Network Weight Management Program, GLP-1s are not applicable for everyone. She emphasizes the importance of utilizing oral agents effectively.
“A GLP-1 isn’t the answer for everybody,” Ro notes. “We need to incorporate effective use of these older medications first.”
Real-World Applications and Benefits
Many patients pursue GLP-1s but face insurance issues that make these drugs inaccessible. As a result, older medications continue to play a significant role in treating obesity.
Dr. Jamie Kane, an internal medicine physician and chief of the Section of Obesity Medicine at Northwell Health and chief medical officer at Luro Health, acknowledges the importance of these therapies.
Kane adds, “Sometimes the patient gets disappointed and thinks, ‘Well, that’s it. I give up.’ The reality is there’s intensive behavioral therapy and older generations of medications that still function well.”
Combining these older drugs with intensive behavioral therapy can yield significant weight loss results. Kane reports that patients often achieve a loss of around 10% of their body weight, with even greater losses possible through diligent behavioral changes.
Primary Care Gaps and Solutions
Despite the growing interest in obesity management, primary care providers often feel inadequate in prescribing these older agents. Kane stresses the importance of closing gaps in obesity treatment within primary care.
“There aren’t enough obesity specialists to take care of the public health failure surrounding obesity, so primary care doctors need to get more comfortable managing this as a complex and chronic disease,” he emphasizes.
Several short courses are available for primary care physicians to enhance their knowledge in obesity medicine, covering drug combinations, pathophysiology of obesity, and behavioral interventions.
Machineni notes, “All of these agents are medications that primary care providers use for other conditions anyway, apart from phentermine. These are medications that have been around for a long time.”
The primary difference lies in the off-label use of these older therapies. Machineni argues, “But off-label therapy is very common in other disease states, so there’s no reason why obesity should be different.”
Effectiveness and Individualization
Kane treats about 25% of his patients without any medications for obesity, with the remaining split between GLP-1s and older medications. Occasionally, patients are prescribed both.
Metformin is effective for some patients, resulting in modest weight loss and often complementing other drugs. “It tends to be about matching the potential side effects with the beneficial effects and other comorbid conditions they have or other medications they’re already on,” Kane states.
Side effects must be considered when prescribing these medications. For example, phentermine and bupropion-naltrexone can lead to activation but may not be suitable for those with arrhythmia, anxiety, or insomnia.
Kane frequently uses phentermine alone, phentermine with topiramate, or phentermine with metformin due to their complementary effects on appetite and metabolism.
Machineni takes a similar approach, first looking at side effects and contraindications, then cost, and finally efficacy.
“If the patient has prediabetes, metformin might be a good option. If someone has migraines, topiramate is a good option because it treats migraines also,” Machineni comments.
Ro notes that around 20%-30% of her patients respond well to metformin, emphasizing the unpredictable nature of its effectiveness.
“It’s hit or miss if you’re going to be a responder,” she explains. “When it works, it works well.”
Behavioral Interventions: The Complementary Approach
What works for a majority of patients is combining medication with behavioral interventions, particularly those focused on nutrition.
Kane insists, “You don’t get out of my office without a behavioral intervention.” He focuses on education and logistics, including exercise, stress management, and sleep quality.
Ro has successfully integrated dietary counseling into her visits without overwhelming the doctor or the patient.
Starting with a lifestyle inventory, she helps patients identify their eating habits and sets small, achievable goals. For instance, transitioning from three sodas daily to one soda daily can make a significant impact.
Sarah Ro, MD
They’re crying in my office because, for the first time, they’re seeing success, not with a GLP-1 but with metformin and topiramate and somebody walking them through what to do.
Exercise plays a minor role in weight loss, so these discussions typically come later. Ro advises basics such as reducing processed foods, increasing protein intake, and adding fruits.
“What I’m doing doesn’t require a 10-hour course on nutrition. It’s basic — let’s do less processed foods, let’s eat more eggs and Greek yogurt, and add a little banana,” Ro concludes.
While lifestyle changes are crucial, they cannot address obesity alone because it is often driven by brain dysfunctions. Medications like GLP-1s and older drugs open the door to healthier diets.
“It’s the food that drives the weight gain, so that’s what I focus on,” Ro elaborates.
Conclusion
The rise of GLP-1 receptor agonists has sparked interest in weight loss medications, but the high costs associated with these drugs have led patients and clinicians to consider more affordable alternatives. Older medications like phentermine, bupropion-naltrexone, topiramate, and metformin offer effective treatment options when combined with intensive behavioral interventions.
Primary care providers play a crucial role in obesity management, and with education and proper training, they can effectively prescribe and manage these treatments. By integrating behavioral counseling and addressing individual patient needs, healthcare professionals can provide comprehensive care for obesity.
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