PCPs need to be ‘familiar with and skilled in’ GLP-1 prescribing as use rises in US

Key takeaways:

• Tirzepatide use increased significantly since January 2021, particularly among people without diabetes.
• Shifts in prescribing are “multifactorial” and reflect evolving evidence and guidelines, a researcher said.

Dispensations of tirzepatide and semaglutide increased significantly in recent years while the use of other glucose-lowering and weight-lowering therapies declined, an analysis showed.

The findings “enhance understanding of the rapidly shifting landscape” of these medications’ utilization, the researchers wrote.

“Substantial biomedical innovation over the past few decades has culminated in a rapidly expanding cadre of medications for both type 2 diabetes and obesity management, with tirzepatide being the most recently approved,” John W. Ostrominski, MD, a fellow in cardiovascular medicine and obesity medicine at Brigham and Women's Hospital, told Healio. “However, trends in the use of diabetes and obesity medications since tirzepatide approval have not been explored.”

He explained that such information “is critical to inform patients and health care professionals, identify research objectives and set public health policy priorities.”

In the study, Ostrominski and colleagues assessed two cohorts of adults aged 18 years or older with or without type 2 diabetes who were prescribed glucose-lowering medications (GLMs) or weight-lowering medications (WLMs) between January 2021 and December 2023.

The GLMs assessed in the study include GLP-1 receptor agonists, sodium-glucose cotransporter-2 (SGLT2) inhibitors, metformin, insulin, thiazolidinediones, sulfonylureas and dipeptidyl peptidase-4 (DPP-4) inhibitors.

WLMs included several drugs given FDA approval for short-term and long-term use, like semaglutide 2.4 mg (Wegovy, Novo Nordisk), liraglutide, phentermine and benzphetamine.

Patients’ use of WLMs and GLMs were classified as:

• any use, defined as medication dispensation regardless of prior use; or
• incident use, defined as medication dispensation with no use in the preceding year.

The researchers found that tirzepatide (Mounjaro/Zepbound, Eli Lilly) — a dual glucose-dependent insulinotropic polypeptide/GLP-1 receptor agonist — markedly increased among adults with type 2 diabetes with any and incident use of GLMs after its entry into the market, accounting for 12.3% of all GLMs dispensed by December 2023.

Dispensations of GLP-1s (19.5% to 28.5%) and SGLT2 inhibitors (14.5% to 24.4%) also rose “but more modestly,” Ostrominski and colleagues wrote.

Metformin and insulin remained the most used GLMs but declined from 69.2% to 56.2% and from 42.3% to 34.1% during the study period, respectively.

The use of DDP-4 inhibitors, sulfonylureas and thiazolidinediones also declined.

The researchers reported that tirzepatide (0% to 40.6%) and semaglutide 2.4 mg (0% to 32.2%) increased significantly among adults without diabetes with any or incident use of WLMs, though semaglutide 2 mg (37.8% to 45.7%) was the most initiated medication among this population.

Meanwhile, phentermine declined from 39.6% of all dispensations in January 2021 — making it the most used medication — to less than 10% by December 2023.

All other WLMs also declined during the study period.

Ostrominski emphasized that the overall use of GLP-1s and tirzepatide among individuals with obesity remains “exceedingly low” despite rising uptake.

He told Healio that the shifts in WLM and GLM prescribing “are likely multifactorial, but likely, in part, reflect evolving evidence, guideline recommendations and patient preferences.”

“As such, primary care clinicians — as providers central to the health of all communities — should be familiar with and skilled in the prescribing of GLP-1s and GLP-1-based medications to enhance health outcomes, especially among individuals with obesity and any of its wide range of complications, such as diabetes, hypertension, CVD, kidney disease, sleep apnea, osteoarthritis, steatotic liver disease, etc.,” he said.

“With great power to change body weight and composition, comes great responsibility,” Ostrominski added. “For persons receiving GLP-1s or tirzepatide, healthful diets and regular physical activity are imperative not only to enhance health benefits, but also to prevent/manage side effects and reduce loss of skeletal muscle mass over long (indefinite in most persons) expected treatment durations.”

For more information:

John W. Ostrominski, MD, can be reached at jostrominski@bwh.harvard.edu.