Despite Obesity Epidemic, Doctors Don't Prescribe Obesity Drugs

"Weight-loss medications are rarely prescribed to eligible patients," say the authors of a newly published study of prescribing patterns in more than 2 million Americans from 2009 to 2015.

The study by David R. Saxon, MD, an endocrinologist at the University of Colorado, in Aurora, found that overall, only 1.3% of eligible patients filled a prescription for an antiobesity medication, and prescribing rates ranged from 0.6% to 2.9%. It was first reported by Medscape Medical News at Obesity Week 2017.

A key finding was that more than 75% of prescriptions for obesity drugs were for phentermine, and just a quarter of physicians surveyed prescribed 90% of all the obesity drugs.

These results "illustrate the obesity treatment conundrum: why, despite five effective FDA-approved drugs for weight loss, is the highly prevalent problem of obesity undertreated?" says Willian H. Dietz, MD, PhD, a public health expert at the George Washington University, Washington, DC, in an editorial that accompanies the published study.

Both appear in the December issue of Obesity.

Dietz goes on to suggest several reasons for the low uptake of these drugs, but he puts the onus on healthcare providers to improve this number.

"The most effective strategy may be to recognize that obesity is a disease and needs to be treated as such and to hold providers accountable for the care that they provide or don't," he concludes.

Main Findings From Data From PORTAL Network

Saxon and colleagues analyzed electronic health records from 2009 to 2015 from participants in the Patient Outcomes Research To Advance Learning (PORTAL) network, which is funded by the US Patient-Centered Outcomes Research Institute.

They identified 2,248,407 patients who were eligible for weight-loss medications — ie, they had a body mass index ( BMI) > 30 kg/m² or a BMI between 27 and 29.9 kg/m² with at least one weight-weight-related comorbidity — from eight healthcare organizations: HealthPartners, Denver Health, and Kaiser Permanente Northwest, Southern California, Mid-Atlantic, Hawaii, Colorado, and Washington state.

They also identified primary care and other providers who had written prescriptions for these drugs

The 6-year study period covered the time before, and after, the US Food and Drug Administration (FDA) announced the removal of sibutramine for the treatment of obesity from the market (October 2010) .

It also covered the time before and after the agency approved new weight-loss medications: lorcaserin (Belviq, Eisai) in May 2012, phentermine/topiramate extended release (Qsymia, Vivus) in July 2012, naltrexone/bupropion sustained release (Contrave, Currax) in September 2014, and liraglutide 3.0 mg (Saxenda, Novo Nordisk) in December 2014.

In addition to the low uptake, the main findings were as follows:

77% of the scripts were for phentermine, which, more than half of the time, was prescribed for longer than the 3 months it was approved for in 1959.
Diethylpropion, orlistat, sibutramine, and locaserin accounted for 12.2%, 4.3%, 2.8%, and 2% of scripts, respectively.
Women, blacks, and patients with higher BMIs were more likely to receive a prescription.
24% of the prescribers accounted for 90% of all filled prescriptions.
In 2015, just 2.7% of the prescribed drugs were for one of the newer agents.

Possible Reasons for Undertreatment

Dietz suggests that the following factors may contribute to the very low rates of prescribing of antiobesity drugs that Saxon and colleagues found:

Lack of recognition in the patient's chart that the patient has obesity: "If obesity is not recognized, it should be no surprise that it is not treated," Dietz writes.
Lack of patient demand: patients may not expect or ask their provider for advice regarding weight loss.
Provider knowledge: in a 2016 survey, "only 8% of providers correctly identified the recommended threshold for the initiation and continuation of pharmacotherapy for obesity."
Provider bias: "69% of people with obesity reported experiencing weight-loss bias from physicians."
Time and cost: "Few providers and patients may be able to meet the recommendation of the US Preventive Services Task Force (USPSTF) that patients with obesity receive intensive behavioral therapy delivered in 12 to 26 visits over the course of a year" and insurance plans may limit counseling and may not cover pharmacotherapy.
Provider and patient knowledge: Even if antiobesity pharmacotherapy is covered, "providers and patients may not be aware of the benefit."

How to Remedy This?

The main strategy to stop the obesity pandemic is for providers to treat obesity as a disease, stresses Dietz.

In addition, patients need to ask for appropriate care, in shared decision making with providers.

And federal and state policy makers need to ensure that public health insurance programs cover FDA-approved drugs for obesity.

The study was funded by Kaiser Permanente, HealthPartners, and Denver Health through a Patient-Centered Outcomes Research Institute (PCORI) award. Saxon and other coauthors were also supported by grants from the NIH and the Veterans Affairs (VA). The authors have disclosed no relevant financial relationships. Dietz reports receiving research grants from Novo Nordisk and the Kresge Foundation, holding consulting positions with the National Academy of Medicine Roundtable on Obesity Solutions and WW (formerly Weight Watchers), and serving on boards for Partnership for a Healthier America and the JPB Foundation.

Obesity. December 2019. Full text, Editorial

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