The UK’s National Institute for Health Care and Excellence (NICE) has recently released guidance for use (and public reimbursement) of semaglutide 2.4mg (Wegovy) for managing overweight and obesity.  While it is encouraging that the United Kingdom’s National Health Service (NHS) has some public reimbursement for obesity medication, restrictions have been included in this new guidance which are surely intended to control the costs associated with coverage.  While it can certainly be appreciated that the cost of paying for obesity medication is high, I have concerns regarding the perceptions this guidance may generate regarding how to use weight management medications in clinical practice. Here are my top 5 concerns:


CONCERN #1: BMI criteria are higher than globally accepted criteria for weight management medication.

The NICE guidance requires a body mass index (BMI) of at least 35.0 kg/m2, or BMI of 30.0 kg/m2 to 34.9 kg/m2 and meeting the criteria for referral to specialist weight management services in NICE’s guideline on obesity.
Compare this to evidence-based, widely accepted criteria for obesity medication, which includes adults with a BMI of 30 or greater, or BMI ≥27 with health issues associated with elevated weight.
The NICE guidelines site that the majority of patients in the largest clinical trial of semaglutide 2.4mg (called STEP 1) had a BMI of over 35, though patients who fit the above widely accepted criteria for weight management medication could be included in the trial.
Extensive data in obesity pharmacotherapy trials demostrate health benefits across BMI ranges included in these studies (including BMI of 30 or greater, or BMI ≥27 with health issues associated with elevated weight), and treatment should not be restricted to higher BMI categories.



CONCERN #2: The maximum recommended duration of treatment is 2 years.
The NICE guidelines cite the longest duration of published study with semaglutide 2.4mg, which is 2 years.
The concern here is that studies of pharmacotherapy consistently show that weight goes back up when medication is stopped.    A powerful analogy here is to look at hypertension treatment.  What would happen if a blood pressure medication is stopped after 2 years? Blood pressure would go back up.  Hypertension medication is intended to be lifelong.  We don’t stop a hypertension medication at the longest duration of formal randomized control trials.  Weight management is no different.



CONCERN #3: Stop treatment if less than 5% weight is lost after 6 months.

As per our Canadian Obesity Guidelines 2022 pharmacotherapy chapter, percentage weight loss should not be a sole target of therapy.  Targets of treatment should include improvements in health, regardless of the numbers on the scale. This also does not take into account prior weight trajectory. For example, if a person loses 10% with lifestyle changes before starting weight loss medication, then maintains weight and prevents weight regain with medication,  this is a success!  Note that in Canada, the Wegovy product monograph does not require a particular amount of weight to be lost to continue treatment.



CONCERN #4: Retreatment might be appropriate for some people who have lost and regained weight and who become eligible for treatment again according to the same starting criteria.
The concern here is that successful treatment  with obesity medication should not be stopped in the first place!  Yo-yo weight cycling may result in worse metabolic health later in life.  Also, when weight is regained after dietary restriction, fat is regained before muscle, more weight is usually regained than was lost, and proportionally more fat than muscle is regained.



CONCERN #5:Treatment is required to be within a specialist weight management service.
The majority of adults in the UK, as in Canada, USA, and many countries around the world, have elevated weight.  It is important that primary care (family doctors) are empowered to treat obesity, as well as any specialist who sees people with health conditions associated with elevated weight (which is essentially every specialty).



BOTTOM LINE:  Obesity medication should not be considered as a niche treatment only for those with the highest BMIs, nor should they be prescribed in a temporary fashion, nor should prescribing be restricted to obesity specialists.  Fair, equitable, and affordable access is important.   We would not restrict hypertension treatments to those with only the highest blood pressure, temporarily, by hypertension specialists only – obesity treatment should be no different.



Disclaimer:  I receive honoraria as a continuing medical education speaker and consultant from Novo Nordisk, the maker of semaglutide (Wegovy, Ozempic). I am/have been an investigator in clinical trials of semaglutide.



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