GLP-1 Coverage Often Denied for Teens With Obesity

Insurance companies frequently deny insurance coverage of glucagon-like peptide-1 (GLP-1) receptor agonists for adolescents, according to a new analysis. 

For those whose GLP-1 prescriptions were covered, few patients had good adherence to their treatment plans, and many did not reach their prescribed dose.

“This has significant clinical implications, since the expected improvements with the use of GLP-1s in weight or glucose control are likely dose-dependent,” said Gabriel Castano, MD, of Texas Children’s Hospital in Houston, in a press release. He presented the research at the 2024 Endocrine Society annual meeting in Boston. “If patients are unable to reach the prescribed dose, they will likely not experience the full beneficial effects of the medication.” 

In 2019, the US Food and Drug Administration approved the first GLP-1 receptor agonist to treat type 2 diabetes (T2D) in adolescents, liraglutide, followed by exenatide in 2021 and dulaglutide in 2022. Liraglutide was also approved to treat adolescents with obesity in 2020, with semaglutide approved for the same indication in 2022. While insurance approval rates for these drugs are around 85%-90% for adults with diabetes, Castano said, there is not much known about insurance approvals and use of these medications in adolescents.

In this retrospective chart review, researchers followed 599 patients prescribed GLP-1s from July 2019 to July 2023 at Texas Children’s Hospital. Patients were on average 15 years of age, nearly three-fourths had T2D, and 68% used Medicaid for insurance. Liraglutide made up most prescriptions (91%), followed by exenatide (4%), semaglutide (4%), and dulaglutide (1%). For individuals who completed at least 6 months of liraglutide, researchers collected data on medication titration, adherence, and side effects.

For patients with diabetes, Medicaid covered 70% of prescriptions and private insurance covered 60%. For those with obesity without a T2D diagnosis, Medicaid only covered 29% of prescriptions and private insurance covered 41%.

This lack of access is incredibly common, said Eric Bomberg, MD, an assistant professor in the Division of Pediatric Endocrinology at the University of Minnesota Medical School in Minneapolis. He was not involved with the research. 

“One of the primary issues is that there are insurance companies that just have blanket statements around coverage for anti-obesity pharmacology: that they will not cover these drugs,” he told Medscape Medical News. “It’s really a shame when you know a person would benefit from this medication, but they just can’t afford it out-of-pocket, or insurance isn’t going to cover it. 

Slow Titration, Poor Adherence

For patients who did start taking medication, half did not reach their prescribed dose within 3 months of initiation, with 19% never reaching the treatment dose. This percentage was higher in patients without T2D, where 44% never reached their treatment dose.

Researchers also found that few patients had adequate medication engagement, defined as missing less than two doses per week. In the T2D group, 20% had good medication engagement, 26% had poor adherence, while medication adherence of the remaining 54% was unknown. Good medication engagement appeared higher in the non-T2D (44%), while adherence for the remaining 56% was unknown. 

Castano noted that more frequent follow-up may be necessary for adolescents to remind them to up-titrate their dose as prescribed. In terms of compliance, advising patients to construct a daily routine for their medication, like setting an alarm, might help with compliance, as might “reminding them that the medication only works if you take it,” he said in a presentation. 

While compliance and adherence are always an issue with patients, medication shortages also contribute. 

“One of the major issues with this class of medication has really been the intermittent access to it,” Bomberg said. “There are definitely people who will be on the medication for a month or two, and then they’ll go to get the next titration dose, and it won’t be available.”

Castano did not think that GLP-1 shortages applied to this cohort, as data was collected up until July 2023. The FDA first listed liraglutide as “in shortage” on July 18, 2023.

Side Effects

Across 356 approved prescriptions, 19 patients never started and 84 stopped the medication. The most common reason for stopping medication was gastrointestinal issues (36%). Other reasons for stopping included shot reaction (12%), expensive co-pay (10%), and lack of efficacy (8%). There was also one case of hypoglycemia that required medication discontinuation.

There were four cases of pancreatitis — two severe — while taking liraglutide. Severe pancreatitis had not been reported in the pediatric clinical trials, Castano noted. While this is just an association, and it is not clear if liraglutide contributed to these severe cases, “it’s something that we have to keep an eye on as we continue to prescribe these [medications],” he said. 

Bomberg added that pancreatitis is a rare side effect, and for many patients — using shared decision-making with their physician — the benefits outweigh the risks. 

“Any medication, even the safest ones out there, could have the potential for very adverse serious side effects that almost never happen,” he continued. “We do know what the side effects of not prescribing medications are, because decades and decades of experience have shown us that obesity is a growing public health issue.”

Bomberg has worked as a site investigator for Novo Nordisk for various clinical trials. Castano reported no relevant financial relationships.