The era of safe and effective medications for the treatment of obesity is well underway, but consequent to societal weight bias, which doesn’t spare health care professionals, sometimes it can be challenging to get a prescription. Some doctors “don’t believe” in these drugs. Others think you should “just eat less, and move more”. While others simply haven’t taken the time to familiarize themselves with these medications despite 30-40% of their practices’ adult patients meeting medical criteria for their use. If you’re looking to try an anti-obesity medication, what can you do to try to overcome your physician’s reluctance?
Like all prescription medications, your primary care provider serves as their gatekeeper. For various reasons physicians may be reluctant to prescribe these medications, however with a thoughtful and respectful discussion, you may be able to advocate for yourself for their use. Ultimately, if you meet the medical criteria for a medication’s use, a physican’s beliefs should not preclude that medication’s prescription and denying your access to it without a defensible medical rationale may be contrary to the requirements of their medical licenses. Ensuring you understand the medical criteria for these medications’ use as well as their potential side effects and dosing considerations can set you up for a discussion with your physician. Understanding and conveying too that generally these medications are meant for long term use and that they are complemented by a broader weight management plan may also help to change your reluctant physician’s mind.
There is no other category of medication that so regularly sees physicians wanting patients to audition for its usage. It is not at all uncommon to hear of physicians telling patients that before prescribing this safe and effective medication they want to ensure they try to do so through lifestyle means alone first. Given that virtually everyone whose weight is having an impact on their health or quality of life has tried multiple efforts and approaches to lose weight, it may be worthwhile to prepare a summary of those efforts so that when your physician says you should try on your own first, you can review the extent of the efforts you’ve already made. It can’t hurt too to inquire if there are other conditions where there are safe and effective medications where that physician requires a patient to prove they’ve tried lifestyle efforts first before their prescription.
Another thing for you to have before your meeting is an understanding of how you qualify for this medication. Simply put, if your BMI is between 27-30 and you have a weight responsive medical condition (such as high blood pressure, diabetes, GERD, sleep apnea, etc) you meet the medical criteria for anti-obesity medication usage. You also meet the criteria if your BMI exceeds 30 regardless of whether you have weight responsive medical conditions as well.
In Canada currently approved medications for weight loss include Wegovy, Saxenda, Contrave, and Xenical which are listed here in order of average impact on weight loss with Wegovy showing the greatest impact. For the most part, the bulk of anti-obesity medication use comes from those first two medications which are from a category of drug called GLP1 analogues.
The main contraindications to GLP1 analogues’ use are a history of medullary thyroid cancer, multiple endocrine neoplasia, an active eating disorder, or plans to conceive in the near future (the recommendation is to have a 3 month washout of medication prior to trying to conceive).
Generally speaking GLP1 analogues are extremely well tolerated drugs if they are started at low dosages and where increases in dosages occur at least a month apart. If a person is to experience side effects, the most common are gastrointestinal - constipation, diarrhea, heartburn, and the most common being nausea - but these side effects tend to disappear with ongoing use. We would not recommend increasing your dosage if you’re still facing a significant side effect.
Going back to the 3 main objections your physician may have:
It’s possible that your physician will want to conduct a medical assessment prior to the prescription of these medications. That assessment may include a physician examination and the measurement of your BMI and vitals as well as a medical history to ensure there are no contraindications to these medications’ usage. They may also order blood tests to explore whether you have any underlying weight responsive medical conditions including but not limited to diabetes, liver dysfunction, and more.
If you meet medical criteria for these medications’ usage your physician will review with you their risks and benefits and discuss what measures they will utilize to assess these drugs’ efficacy and ongoing prescription.
As with nearly all other chronic medical conditions, weight will certainly benefit from lifestyle changes and the prescription of these medications doesn’t change that fact. That said, it’s also true that even with both medication and lifestyle changes, there will come a point for any one where they cannot happily eat less and they cannot happily exercise more and their weight living with that life, regardless of where it might fall on a BMI chart, is their best weight, and these medications’ ongoing use and prescription should not be contingent on achieving a particular BMI (though many insurers do require sustaining a 5% weight loss in order to maintain coverage for a medication).
As with all medications for chronic conditions, these medications are likely to be used long term, and while some patients may be able to reduce or come off of them entirely, you should be comfortable with the likelihood that you will need them long term to see their benefits sustained when they are prescribed.
As noted, the GLP1 analogues Wegovy and Saxenda are the medications you’re most likely to be prescribed. GLP1 analogues work by way of binding to a receptor in the appetite control centre of the brain and when bound, lead people to experience decreased hunger, decreased cravings, and feel full more rapidly. Patients also regularly report an overall decrease or disappearance of food noise.
Mounjaro, also known as Zepbound, is a drug called tirzepatide. It is a combination of a GLP1 analogue with something called a glucose-dependent insulinotropic polypeptide (GIP). In Canada it is currently only formally approved for the treatment of type 2 diabetes (Mounjaro), while in the US it is also approved for the treatment of obesity (Zepbound). It has a similar mechanism of action and side effect profile to Wegovy and Saxenda but may lead to more weight loss with slightly lesser side effects.
Contrave is a combination of an antidepressant medication and an anti-addiction medication and it is thought to work by way changes to the reward pathway with respect to food.
Xenical is a drug taken before meals which leads to 30% of that meal’s dietary fat content to not be absorbed.
As with all drugs, there is the risk of side effects, however as mentioned, with GLP1 analogues side effects tend to dissipate with time. With Contrave the side effects are those of both bupropion and naltrexone and with xenical the very common side effects are flatulence and fecal urgency (which likely explains why it is not in widespread use)
If your doctor is not regularly prescribing these medications, you can offer to see them frequently in follow up to discuss these medications impact. If the medications are well tolerated, dose increases tend to be monthly and it’s best for patients themselves to determine what dosage they need whereby they will evaluate the medication’s effect on hunger, cravings and fullness and let their physician know at what dose these are sufficiently well controlled that there is no need for further dose increases.
Once a person’s dosage is established, the frequency of follow up visits can be decreased.
It can be discussed with your physician that of course if the medication is not having an impact, or if side effects don’t diminish with time, that the medication should be discontinued.
You should also mention to your physician that you will certainly continue to do your best in living the healthiest lifestyle that you can enjoyably sustain and that your hope is that with the support of the medication, that will in fact mean smaller portions and healthier choices as your body will no longer have the same influence on you through hunger and cravings.
Physicians as members of a society rife with weight bias aren’t immune to it and as a consequence may oppose prescribing medications for weight loss or not understand why they might be required or why they as physicians might want to familiarize themselves with their use.
If you meet the medical criteria for the use of anti-obesity medications but your physician is reluctant, it’s worth having a respectful discussion with them to try to understand why and if their reasoning is not rational, to hopefully make that clear to them as well and in turn, gain access to these helpful medications.
