Price, Not Science, Drives Obesity GLP-1 Access: Holly Lofton, MD

Shared decision-making that lets a patient choose a less-effective drug, a regain plan built before a patient ever starts tapering off, and prior authorization renewals stacked up to 4 times a year are shaping day-to-day obesity care as much as the prescriptions themselves, said Holly F. Lofton, MD, clinical associate professor of medicine and surgery and director of the Medical Weight Management Program at NYU Langone Health.

Lofton discussed how she counsels patients through drug interactions when switching between the oral glucagon-like peptide-1 (GLP-1) agents, why it's still too early to say whether persistence on oral agents will outperform injectables, and how insurer body mass index (BMI) cutoffs that sit well above FDA label criteria keep technically eligible patients from starting treatment. She also predicted that drug pricing, more than access algorithms, will determine which GLP-1 becomes first-line within the next year and made the case for scaling back how often patients must requalify for coverage through prior authorization.

In part 1 of her interview with The American Journal of Managed Care^® (AJMC^®), Lofton discussed how new oral GLP-1s, the Medicare GLP-1 Bridge program, and expanded label indications are widening access to obesity treatment, and why weight bias among clinicians and patients still holds many people back from starting therapy.

This interview was edited for clarity.

AJMC: Are there clinical considerations, like drug interactions, that factor into a decision to switch a patient between GLP-1 formulations?

Lofton: With the oral agents, specifically, because the pills—both semaglutide [Wegovy; Novo Nordisk] and orforglipron [Foundayo; Eli Lilly]—get metabolized by the liver to a degree, we have to look out for patients who have severe liver disease. I mean significantly severe, not just fatty liver—really severe liver disease, classified as Child-Pugh class C or greater. It's not ideal to give them those pills, because their liver can't metabolize them correctly.

With Foundayo, there are drug interactions with medications called CYP3A4 inhibitors. For example, if patients are taking Foundayo with simvastatin, it could drive the level of simvastatin up to a dangerous level. So, that's something you want to think about when switching: drug interactions and other conditions that may cause harm.

AJMC: How do you balance patient preference against clinical trial efficacy when a patient strongly prefers a modality that may yield lower weight loss?

Lofton: I like to present the options to the patient with shared decision-making. I present all of the options they have, then give the benefits or risks of each one and let the patient make the decision. Honestly, after I've given them all the information about clinical efficacy, side effects, drug interactions, and how it will benefit other conditions, a patient with fatty liver disease and heart disease who would benefit more from Wegovy based on the trials may still pick tirzepatide [Zepbound; Eli Lilly]. And I tell them, “This is the decision that you made; just know we're not really addressing the fatty liver potential benefit with this choice.” But it's better for the patient to lose some weight than none, or to gain weight.

I also think the shared decision-making discussion strengthens the relationship between the provider and the patient. If, on another day, you decide to switch medications, they know that you have their best interest in mind and it's not just your choice of medication or no other way.

AJMC: With the injectables, there's documented research showing challenges with persistence, patients staying on the medication. Are there any early signs, or is it too soon to tell, that we're seeing something different with persistence on the oral formulations?

Lofton: From what I've seen, I do think it's too soon to tell—we don't have that data yet, because the data we have from injectables is looking at large groups of patients in an electronic medical record, and we just don't have enough of that for the orals right now. We'll look at it and see when we ask patients about their ability to take the medication and also when we see the degree of weight loss they're having. If I have you on an oral and you're losing less than 5%, it's not working well enough anyway, so maybe you're not taking it, and we need to address that.

I do think this gets to the question of if a patient says the drug isn't working, the first thing isn't to switch the drug or even switch the dose—it's to assess compliance, lifestyle, changes in other medications, sleep patterns, protein intake, those types of things, before we just say it's not working.

AJMC: When patients are discontinuing a GLP-1—whether by choice, side effects, or an access disruption—what does your practice do to manage weight regain and keep them from falling out of care altogether?

Lofton: I talk about maintenance at the first visit, before we prescribe anything for the patient, and I tell them what maintenance looks like. I like to answer the question scientifically and then practically. I'll bring up a withdrawal trial like SURMOUNT-4¹ or STEP 4² and explain the data: patients went up to the highest dose of Wegovy or Zepbound, and then they were discontinued—unknowingly, but continued their lifestyle—and we saw weight regain of about two-thirds within 6 to 8 months. I tell them, “This is a trial; you're an individual person, and you may have a different experience, but I think what that trial is teaching us is that we should never stop without a plan, because these patients were just stopped unknowingly, and they had weight regain.”

I often tell patients, if they want to stop, that's the time we really need to have a discussion about what maintenance looks like. That's when we go back to the guidelines for weight maintenance of caloric intake and physical activity of 4 hours a week. We look at your environment: is this a good time to go off? Are you going away for your birthday party for the entire month? Probably not the best time. Are you on a weight-gain medication that's going to make maintenance really difficult? We have all those conversations to decide when to start what we call a trial off.

The trial off looks like this: let's do everything we can from a lifestyle perspective, and try your hardest during this time. And I give them an alarm weight of 5% weight regain, and if they hit that, we need to have another discussion about doing something else, either restarting the medication or readdressing everything. In the studies, people who gained 5% pretty much gained everything back after a year. That tells me where you are in this trial: you gained 5%, you're likely to gain 10%, and then all 20% that you lost, back. I tell them that weight regain is commonly reported. You may or may not regain weight, but if you gain too much, we need to do something else.

AJMC: Where would you say current prior authorization criteria and formulary restrictions are most out of step with real-world clinical practice?

Lofton: I think over the last 3 or so years, we've seen a move away from required step therapy, where the prior authorization would require that patients try Qsymia (phentermine and topiramate), Contrave (naltrexone and bupropion), and other things before they're considered for a GLP-1. I think that comes from the fact that the GLP-1s are so much more effective than these medications but also treat other conditions that could land people in the hospital. There's still always a question of, “Have you tried diet and exercise? Will you be working with a skilled prescriber? Will you continue dieting and exercising during this?” Those questions are appropriate.

What I've seen that's disheartening is a patient who meets the medical criteria based on the label for the drug—say, they have a BMI of 27 and up with fatty liver, sleep apnea, or high blood pressure, and they meet the criteria—but the insurance has a much higher BMI cutoff of 40 and up, where they could have bariatric surgery at that weight as well. It's really creating a gap between people who qualify technically but don't have coverage,³ so they're waiting until they have class 3 obesity to even treat with medical weight management, which can be to the detriment of the patient.

AJMC: If you had to predict how patient selection algorithms for obesity therapy might look a year from now, what do you think might be different versus today?

Lofton: I think we'll have more medications a year from now, and that will drive prices down for current medications. As prices come down, insurers tend to like those medications more. If we look at what's the oldest one on the market now, Wegovy, that price will come down, so that might become the first-line choice, whereas Zepbound or retatrutide⁴ might be harder for someone to get. I think the prices that patients, or insurers, are able to pay will really drive access.

But also, as we do more research on which comorbidities patients benefit from with GLP-1s, if a patient just doesn't have access for weight loss, they'll maybe get it for sleep apnea, arthritis, fatty liver, or something else. There are still not enough obesity management doctors to say you need an obesity management specialist to get this drug prescribed.⁵ I think that would be a ridiculous change, because the whole point of making orals, making more drugs, and decreasing weight stigma is so that non-specialists can prescribe these medications, because we still have so many people with obesity and overweight.

AJMC: What do you think needs to happen clinically, on the access side, for obesity treatment to feel less like navigating a maze and more like a standard chronic disease management option?

Lofton: I think the easiest thing to change would be the prior authorization. We have to do a prior authorization for every medication, every 3 to 6 months, and I don't know any other drug—unless we're talking about cancer drugs—that so many people have to do that for. I think that will look like prior authorization not being needed every so often; not 2 to 4 times a year once someone's demonstrated benefit would be more feasible and would increase the durability of people being able to stay on the medications. A lot of times discontinuation happens when someone moves, or changes primary care doctors or prescribers, and the new clinic just doesn't have the staff to do all the prior authorizations, so the drug drops off—not because the patient doesn't want it or shouldn't have access to it. I think fewer prior authorizations would be helpful.

References

1. Aronne LJ, Sarrar N, Horn DB, et al; SURMOUNT-4 Investigators. Continued treatment with tirzepatide for maintenance of weight reduction in adults with obesity: The SURMOUNT-4 randomized clinical trial. JAMA. 2024;331(1):38-48. doi:10.1001/jama.2023.24945
2. Rubino D, Abrahamsson N, Davies M, et al; STEP 4 Investigators. Effect of continued weekly subcutaneous semaglutide vs placebo on weight loss maintenance in adults with overweight or obesity: the STEP 4 randomized clinical trial. JAMA. 2021;325(14):1414-1425. doi:10.1001/jama.2021.3224
3. McCormick B. Gaps in persistence, coverage limit GLP-1 impact in obesity. AJMC. April 14, 2026. Accessed September 14, 2026. https://www.ajmc.com/view/gaps-in-persistence-coverage-limit-glp-1-impact-in-obesity
4. Grossi G. Retatrutide achieves up to 30.2% average weight loss in phase 3 TRIUMPH-1 trial. AJMC. May 21, 2026. Accessed September 15, 2026. https://www.ajmc.com/view/retatrutide-achieves-up-to-30-3-average-weight-loss-in-phase-3-triumph-1-trial
5. Bajaj SS, Teegala S, Stanford FC. Shortage of obesity medicine specialists in the United States. Mayo Clin Proc. 2026;101(2):348-350. doi:10.1016/j.mayocp.2025.10.015