For Weight Loss, Off-Label GLP-1s Are Increasingly the Chosen Ones | AMCP 2023

Americans are turning to diabetes drugs in droves for weight loss. Both the sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists have been shown to reduce weight. Wegovy (semaglutide) and Saxenda (liraglutide) are GLP-1s and have been approved by the FDA for weight loss, but other GLP-1s are being used off-label for the purpose, especially Ozempic (semaglutide). The SGLT2 inhibitors include Invokana (canagliflozin), Farixga (dapagliflozin) and Jardiance (empagliflozin). None of the SGLT2 inhibitors have been approved for weight loss but Jardiance is being prescribed off-label to people who want to lose weight.

Payers have been minding spending on diabetes and diabetes drugs for a long time but have been noticing an uptick SGLT2 inhibitors and GLP-1 prescriptions.

Karishma Thakkar, Pharm.D.

With this as the backdrop that Karishma Thakkar, Pharm.D., a post-doctoral fellow at Baylor Scott & White Health, a health system based in Dallas, and her colleagues set out to study the SGLT2 inhibitor and GLP-1 usage among patients without the diabetes. They shared their findings in a poster presented today at the annual meeting of the Academy of Managed Care Pharmacy (ACMP) in San Antonio.

They conducted their study by sifting through the pharmacy claims from of a 20,000-member commercial health plan that is associated with a Baylor Scott & White’s accountable care organization. Thakkar said she was not allowed to identify the health plan. They identified patients with at least one claim for either a SGLT2 inhibitor or a GLP-1 from Jan. 1, 2018, through Dec. 31, 2022.Then they used to ICD-10 codes to separate those patients into those with diabetes and those without. The diagnoses associated with SGLT2 inhibitor and GLP-1 prescriptions that were not diabetes included obesity, prediabetes, metabolic syndrome, heart failure, polycystic ovarian syndrome and essential hypertension. For these findings, Thakkar and her colleagues did not break down which of these diagnoses were the most common.

Their results show that among the patients prescribe GLP-1s the proportion of patients without diabetes grew from just 6% in 2018 to 27% in 2022. Among those prescribed a SGLT-2 inhibitor, the proportion of patients without diabetes stayed about the same: 7% in 2018 and 6% in 2022.

Thakkar and her colleagues also found that the people without diabetes with a GLP-1 prescription tended to be younger than those with diabetes (an average age of 45.9 vs. average age of 53.1). They were also more likely to be female (75% vs. 50%). The age and gender differences between those without diabetes and those with among the patients who were prescribed an SGLT2 inhibitor was slight.

The researchers also looked at per member, per month (PMPM) costs, a standard way that insurers compute the cost of drugs and healthcare services. The PMPM cost of GLP-1 prescriptions for those without diabetes grew by 16 percentage points from 2018 to 2022. The PMPM cost of SGLT2 inhibitors grew by just 3 percentage points that time.

Thakkar said this research began with a look at the PMPM of diabetes drugs and the proportion of that PMPM spent on SGLT2 inhibitors and GLP-1s. By 2021, the GLP-1 proportion had grown to 40% of the PMPM for diabetes drugs. “We saw that 40% of the PMPM (for diabetes drugs) is due to GLP-1s, so you want to look at what are these patients using it for,” she said during a brief interview when she was presenting her poster.

Thakkar said future research on GLP-1s may involve looking at the consequences of the prior authorization rules that the Baylor Scott & White health plan and other insurers are considering.

“I am interested in looking at before the prior authorization, and then after the prior authorization, and the difference in outcomes in these patients,” she said. “Is that going to cost us more as the whole healthcare system in terms of healthcare utilization? It will be very interesting to see pre- and post- prior authorization and whether there are differences in clinical outcomes for patients.”