Making Obesity Care Affordable: Patient Views on Deprescribing GLP-1 RAs

ABSTRACT

Objective: To assess the acceptability of deprescribing injectable incretin mimetics for weight management (IMWMs) among self-identified individuals with obesity in the US.

Study Design: An online survey was conducted in November 2024.

Methods: Respondents (N = 704) watched 2 videos summarizing IMWM risks and benefits. The primary quantitative outcome was agreement with insurers paying for IMWMs during active weight loss and encouraging lower-cost alternatives during maintenance. Descriptive statistics and χ² tests were conducted to analyze the data. Qualitative analysis centered on inductive content analysis of respondents’ responses to a free-text question about concerns with transitioning from IMWMs to an alternative weight management strategy.

Results: Most respondents agreed with encouraging the strategy (n = 582; 82.7%) and would support their friends or family members switching to low-cost alternatives to expand access to IMWMs (89.8%). Broad coverage of effective, lower-cost treatment options was identified as a critical component of such programs. Common response themes included attitudes toward weight loss medications (44.4%), such as adverse effects (26.9%) and the fear of worsening health if the IMWM is stopped (30.2%), primarily related to gaining weight back or maintaining weight loss (25.2%).

Conclusions: IMWM deprescribing programs are, in principle, acceptable to individuals with obesity. Additional research is needed to determine the feasibility and real-world outcomes of adults with obesity switching to lower-cost alternatives during weight maintenance.

Am J Manag Care. 2026;32(10):In Press

Takeaway Points

We assessed the acceptability of deprescribing injectable incretin mimetics for weight management (IMWMs) among self-identified individuals with obesity in the US.

• Most respondents agreed that lower-cost alternatives should be encouraged during the weight maintenance phase.
• The most common concerns shared by participants in free-text responses when they considered using a lower-cost alternative during the weight maintenance phase were adverse effects and fear of gaining weight back.
• Additional research is needed to determine whether individuals would accept lower-cost options to maintain weight loss and whether alternative dosing and allocation strategies achieve clinical outcomes similar to those of full-dose IMWMs.

Newer antiobesity medications, including glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and GLP-1/glucose-dependent insulinotropic polypeptide agonists (collectively referred to as GLP-1 RAs for brevity), can substantially reduce body weight and improve outcomes for weight-related conditions.¹ However, insurance coverage for incretin mimetics for weight management (IMWMs), as opposed to other conditions such as diabetes, is limited by the prevalence of treatment-eligible individuals, significant consumer demand, high drug list prices, and recommendations for lifelong therapy to prevent weight regain.² The expectation that long-term use of these therapies is necessary to maintain weight and related health benefits is a key driver of anticipated IMWM spending, but clear evidence for this requirement is lacking.

Clinical efficacy trials demonstrate that weight is rapidly regained after abrupt discontinuation of IMWMs.³ Less is known about whether gradual de-escalation of therapy and/or transition to lower-cost weight management treatment options (eg, first-generation, oral antiobesity medications) could support weight maintenance.⁴ Modeling studies estimate that maintenance therapy accounts for most IMWM expenditures, intimating that reductions in drug spending for maintaining weight loss provide an opportunity for savings, even if they lead to slightly worse outcomes for some individual patients, compared with full-dose maintenance IMWMs.⁵ An obesity care paradigm marked by (1) broad access to IMWM initiation to support significant weight loss, (2) deintensification of maintenance IMWM dosing to the minimum dose needed to maintain weight, and (3) broad access to the full range of weight management treatment options in the maintenance phase may be the most equitable and cost-effective allocation of resources.

Although deprescribing of IMWMs has been reported, little is known about whether potential IMWM deprescribing strategies would be acceptable to the broad populations needed for these approaches to work at scale with, for example, large private insurers or government payers.^6,7 Accordingly, we conducted a survey of self-identified individuals with obesity (ie, those who could have access to such drugs) to assess the acceptability of IMWM deprescribing.

METHODS

Sample

In November 2024, adults who reported being either self-diagnosed or medically diagnosed with obesity were recruited to complete a web-based survey administered by Dynata, which used opt-in methods to assemble the panel. Recruitment continued until prespecified quotas for age (40% aged 18-39 years, 40% aged 40-64 years, 20% aged ≥ 65 years), gender (50% female), race (25% Black), ethnicity (25% Hispanic), and education (80% with less than a bachelor’s degree) were attained to ensure a sample that reflected the demographics of US adults with obesity. Strategies such as internet protocol address checking were used to prevent multiple responses by one respondent. All data were collected anonymously using Qualtrics software. Respondents were compensated based on the conditions of their panel agreement. We reported our study according to the Strengthening the Reporting of Observational Studies in Epidemiology checklist.⁸ The University of Michigan Institutional Review Board declared the study exempt (HUM00263067).

Survey

The survey consisted of 2 brief videos describing the potential benefits and risks of new IMWMs and the proposed alternative strategy for maintaining weight after initial weight loss (eAppendix A [eAppendices available at ajmc.com]). The primary outcome was level of agreement with the statement “Patients receiving injectable weight loss medications should be encouraged to try lower-cost options to maintain weight,” which was measured on a 6-point Likert scale with scale anchors “strongly disagree” (1) and “strongly agree” (6). Preferences for specific elements of the alternative weight loss program were assessed. Respondents were prompted to respond to a free-text question: “What concerns, if any, would you have about transitioning from a full-dose injectable weight loss medication to an alternative weight management strategy?” Demographic and clinical characteristics were also collected.

Data Analysis

We calculated descriptive statistics and conducted χ² tests to compare the percentage of respondents who agreed (scores of 4-6) and disagreed (scores of 1-3) with the affordable weight maintenance strategy by demographic characteristics and weight loss experiences. We conducted an inductive content analysis to examine respondents’ thoughts about stopping IMWMs.^9,10 The free-text responses were read, and a framework with 22 codes was developed (E.B., D.R.R., and S.E.V.). Responses could be assigned multiple codes. A total of 150 free-text responses were independently coded (E.B. and D.R.R.), resulting in acceptable interrater reliability (Cohen κ ≥ 0.80), followed by independent coding of the remaining free-text responses. Themes with similar meanings were grouped into 6 domains, 1 of which had 2 subdomains. We reported the number of domains and subdomains in which the participant had at least 1 comment. Based on findings from the initial quantitative analysis, we conducted χ² tests to evaluate differences in domain frequencies by gender and highest level of education. All analyses were conducted with Stata/SE 18 (StataCorp LLC), and a P value less than .05 was statistically significant.

RESULTS

Participant Characteristics

Respondents (N = 704) were predominantly female (n = 360; 51.1%) and White (n = 453; 64.3%), and their mean (SD) age was 47 (16) years (Table 1). Nearly all respondents were interested in losing weight (n = 674; 95.7%), and many reported experiences with oral antiobesity medication (n = 251; 35.7%), IMWMs (n = 222; 31.5%), or bariatric surgery (n = 61; 8.7%).

Support for the Deprescribing Strategy

After watching the video describing a lower-cost weight maintenance strategy marked by deprescribing injectable IMWMs, most respondents agreed that the strategy should be encouraged (n = 582; 82.7%) and would support a family member or friend switching to allow more patients to receive IMWMs for active weight loss (n = 632; 89.8%). Male respondents were more likely to agree with the strategy (n = 295; 86.5%) than female respondents (n = 285; 79.2%) (P = .010) (eAppendix B). Respondents with a bachelor’s degree or higher were more likely to agree with the strategy (n = 130; 88.4%) than those with less than a bachelor’s degree (n = 452; 81.2%) (P = .038). However, there were no differences in the percentage of respondents who agreed with this strategy based on weight loss experiences or other demographic characteristics.

Concerns About the Deprescribing Strategy

A total of 603 respondents (85.7% of all respondents) provided a free-text comment that could be coded (Table 2), and most of these respondents (n = 478; 79.3%) shared specific feedback. Respondents most frequently reported concerns about adverse effects (n = 162; 26.9%) or gaining weight back/maintaining weight loss (n = 152; 25.2%) or reported no concerns (n = 125; 20.7%). We did not observe any differences in the frequency of themes, domains, or subdomains by gender or highest level of education.

Perceptions of Additional Resources Needed

Respondents reported that it would be extremely important (Likert score of 6) for insurance companies to cover medically tailored meals and nutrition support (n = 320; 45.5%), gym memberships (n = 273; 38.8%), lower doses of injectable antiobesity medications (n = 248; 35.2%), oral weight loss medications (n = 244; 34.7%), and/or less frequent dosing of injectable IMWMs (n = 236; 33.5%) as part of the alternative program (eAppendix C).

DISCUSSION

Our survey-based study of individuals with obesity in the US demonstrated that most respondents would support lower-cost options during the weight maintenance phase, with savings enabling more generous coverage of IMWMs for active weight loss. We were surprised to find that male participants were more likely to agree with the approach, despite women being more likely to enroll in an online multidisciplinary study that included lower doses of IMWMs.¹¹ However, respondents also raised concerns about deprescribing IMWMs, most often regarding adverse effects and the risk of weight regain. These findings help fill the gap in qualitative research on patients’ experiences with IMWMs.¹²

IMWMs are a powerful tool to address the global obesity epidemic, but affordability and equitable access remain major challenges. The high prevalence of obesity and high drug costs have thus far required payers to institute policies that restrict access, such as prior authorization, step therapy, or total spending/duration limits. These policies often exacerbate disparities for groups disproportionately affected by obesity and its sequelae.^13,14 Novel approaches that seek to minimize IMWM spending on weight maintenance may allow patients and payers to navigate these constraints better.

Limitations

The primary limitation of our study is that we recruited a self-selected population, which may not fully represent the broader population of adults with obesity, especially those with limited access to IMWMs or lower digital literacy. Future research could employ probability-based sampling or recruit participants through a wide range of clinical settings to overcome this limitation and improve generalizability. Prospective studies could be conducted to track actual deprescribing behavior, rather than relying on self-reported preferences. Furthermore, additional demographic and socioeconomic data could be collected in future studies to clarify how acceptability varies based on context. Although we were unable to determine whether respondents watched the videos, future studies could require them to be played or include comprehension checks to ensure informed responses. Furthermore, respondents without access to IMWMs may be inclined to support the strategy, especially if those who currently have access to IMWMs are perceived as privileged. That is, our sample’s preferences may not be as altruistic as they appear; this is not an uncommon phenomenon in scarce resource allocation.¹⁵ Conversely, there was no difference in agreement with the strategy between respondents with and without personal experience with IMWMs. Finally, some free-text responses were very brief (eg, “side effects”), which could limit our understanding of their meaning. In future studies, this could be overcome by employing interviews or focus groups to obtain more robust qualitative data for analysis.

CONCLUSIONS

Our survey-based study of individuals with obesity in the US demonstrated that most respondents would support lower-cost options during the weight maintenance phase, with savings enabling more generous coverage of IMWMs for active weight loss. Additional research is needed to determine whether individuals will accept lower-cost options to maintain weight loss and whether alternative dosing and allocation strategies achieve clinical outcomes similar to those of full-dose IMWMs. A shift to a lower-cost maintenance option could allow more people access to IMWMs, especially because most of the financial impact is attributed to the weight maintenance phase. The value proposition of such strategies to a given insurer is that spending on members of the risk pool may, in the long run, be lower than either (1) perpetual IMWM use in the maintenance phase or (2) not providing it at all and having to assume all long-run costs of obesity-related complications. These findings support the need for real-world demonstration projects to test maintenance strategies that balance effectiveness, affordability, and equitable access to obesity treatment medications. 

Author Affiliations: University of Michigan College of Pharmacy (SEV, EB), Ann Arbor, MI; University of Michigan Medical School (DRR, EWC, DHG, AMF), Ann Arbor, MI; US Department of Veterans Affairs (VA) Center for Clinical Management Research (GWS, DHG), Ann Arbor, MI; University of Michigan School of Public Health (AMF), Ann Arbor, MI.

Source of Funding: University of Michigan Elizabeth Weiser Caswell Diabetes Institute.

Author Disclosures: Dr Strohbehn is supported by a Career Development Award from the VA Office of Research and Development (IK2 HX003682). Dr Griauzde has a pending grant with Eli Lilly. Dr Fendrick reports receiving consulting fees from AbbVie, Better Medicare Alliance, Centivo, Clover Insurance Company, Community Oncology Alliance, Eebu Health, Elektra Health, Employee Benefit Research Institute, Exact Sciences, GRAIL, Hopewell Fund, Johnson & Johnson, Medtronic, MedZed, Merck, Mother Goose Health, Phathom Pharmaceuticals, Proton Intelligence, Sempre Health, Sera Prognostics, Silver Fern Healthcare, UnitedHealth Group, Virginia Center for Health Innovation, Washington Health Benefit Exchange, and Wellth and serving as a partner for VBID Health and co–editor in chief of The American Journal of Managed Care. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SEV, GWS, EWC, AMF); acquisition of data (SEV, DRR, EWC); analysis and interpretation of data (SEV, EB, DRR, GWS, EWC, DHG, AMF); drafting of the manuscript (SEV, EB, EWC, DHG, AMF); critical revision of the manuscript for important intellectual content (SEV, EB, DRR, GWS, EWC, DHG, AMF); statistical analysis (SEV, AMF); provision of patients or study materials (AMF); administrative, technical, or logistic support (SEV, EWC); and supervision (SEV, AMF).

Address Correspondence to: Sarah E. Vordenberg, PharmD, MPH, University of Michigan College of Pharmacy, 428 Church St, Ann Arbor, MI 48109. Email: skelling@med.umich.edu.

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