There are probably patients in your practice who are transitioning away from using GLP-1 medications, and they may turn to you for strategies to help them keep progressing on their weight-loss journey. Keeping on track with a healthier lifestyle is paramount, and this can be supported through your role.

Ending the use of GLP-1s can vary from patient to patient, but there are common reasons for this.

“The three most common reasons I see in practice for patients to transition away from utilizing GLP-1 medications to manage weight are access, affordability, and significant side effects,” said Allison Rhodes, MD, an obesity medicine specialist at The Ohio State University Wexner Medical Center in Columbus, Ohio.

What Are Some Suggestions?

Some patients could be prescribed GLP-1 medications initially for obesity, but the criteria for insurance coverage could be shifting.

“Many insurance plans are stopping coverage for this class of medications if the prescribing indication is for weight management of overweight or obesity,” said Rhodes.

When patients lose coverage, if they want to continue using their same FDA-approved medication, their best options are to utilize direct-to-consumer pharmaceutical mail order, she said.

Although pricing varies at these consumer mail-order pharmacies, on average, a patient can expect to pay $499 for a 1-month supply of a GLP-1. Some health plans allow members to use their pretax health savings accounts to pay for GLP-1 medications once they are no longer covered by the plan, but that is plan-dependent and can only offset some of the total cost, outlined Rhodes.

“For many patients, this significant increase in out-of-pocket healthcare expense is not feasible or sustainable long term, and for some patients, despite our best efforts to mitigate side effects through behavioral strategies and use of medications or supplements, the gastrointestinal side effects of nausea, vomiting, reflux, abdominal pain, diarrhea, and constipation can outweigh the benefits,” she said.

As a primary care physician, you know each patient can have a unique response to any medication, and there are some individuals for whom the currently available GLP-1 medications are not a good fit because of the side effects.

Another scenario is when a patient reaches their goal weight or achieves significant improvement in cardiometabolic health, such as improved blood pressure, cholesterol levels, or blood sugar control. “I do not advise reducing or stopping GLP-1 medication as studies show that following cessation, individuals can regain up to two thirds of the weight lost while taking a GLP-1 and have reversal of the cardiometabolic health improvements,” said Rhodes.

Is a Plateau a Cause to Stop Use?

It’s not unusual for a patient to reach a plateau while using GLP-1 medication, and Rhodes said it is not a reason to taper or stop the medication. But if a patient does not have at least a 5% weight loss after reaching a maintenance dose of GLP-1 while they are also engaging in an appropriate amount and level of physical activity and nutrition, the prescriber should discuss discontinuation with the patient because we do know that there are “hyporesponders” to these medications, she said.

Patient education is vital for maintaining the success of better health and weight management. “The clinician-patient partnership to develop an individualized plan for nutrition, activity, stress, and sleep optimization should be done alongside prescribing and utilization of GLP-1 medications, and this becomes even more important if a GLP-1 medication is no longer going to be part of a patient’s weight management plan,” said Rhodes.

To that point, many patients need directives to help with managing hunger and cravings, as well as encouraging more physical activity. Here are some directives your patients can utilize.

Encourage hydration. Drinking at least 64 oz of water or beverages without added sugar or artificial sweeteners helps the body know when it is truly hungry as opposed to both hungry and thirsty, said Rhodes. For individuals who don’t prefer plain water, fruit-infused water or unsweetened tea are alternatives. “Avoid juices, sodas, and energy drinks, and limit caffeine and ‘diet’ or ‘zero-calorie’ beverages,” she said.

Prioritize whole foods and limit highly processed foods. Inform patients that highly processed foods often contain excess calories from higher amounts of saturated fat, sodium, and added sugar. Instead, direct patients to choose foods in their natural form, which provides more nutrients, fiber, and water. “This helps activate the body’s fullness and satiety feedback to the brain, which includes GLP-1 release,” Rhodes said. Also discuss topics such as portion control.

Eat small meals regularly. Eating regularly throughout the day allows for better hunger control, making it easier to eat when moderately hungry as opposed to when very hungry, which can lead to overeating. “I recommend eating three meals and one to two snacks each day, about 3-4 hours apart,” she said.

Lean in on protein. Remind patients to have a source of protein at every meal and snack. Getting enough protein is key to avoiding losing muscle mass and strength over time. It also plays a large role in managing hunger and feelings of fullness because consuming protein from real whole foods can help optimize internal GLP-1 release.

Consume fiber. Fiber supports digestion, keeps blood sugar levels steady, and promotes and prolongs fullness. “All adults should aim for at least 25 g of fiber from real whole foods each day; however, more than 35 g is better, and some of the healthiest populations in the world consume upwards of 40 or 50 g per day,” said Rhodes.

Get enough sleep. Lack of restful sleep can lead to overeating or consuming high-calorie foods, Rhodes said. Also, remind patients to avoid blue lights at least 1 hour before bed and get 6-8 hours of sleep per night in a completely dark room, she added.

Continue the healthy habits. Suggest patients continue the healthy habits they developed while taking GLP-1s, and encourage them to set small weekly or daily goals to support longer-term goals and keep track of their progress, Rhodes recommended.

Pay attention to unhelpful self-talk patterns. “Explain to patients how they can begin to ‘catch’ the negative thoughts and replace them with alternatives,” she said. “Also, they can seek support from friends, family, community, and professional resources.”

Emphasize continued exercise. Walking and other exercises are always encouraged, but kick the momentum a bit higher. Suggest strength training exercises, said Peminda K. Cabandugama, MD, an endocrinology and obesity medicine specialist at Cleveland Clinic in Cleveland. Guidelines recommend 150 minutes a week of exercise, no matter how it is split up during the week, he said.

That should include at least 25%-50% strength training, with the remainder of the training including cardiovascular exercise, Cabandugama said.

“With the concerns that some of these weight-loss medications that include GLP-1 medications lead to some lean muscle loss, it is imperative that these patients continue reaching the exercise guidelines to maintain their weight loss as well as have an improved quality of life moving forward with their weight loss.”

Use a registered dietitian for personalized nutrition plans. More insurance carriers are covering nutritional counseling, and their professional guidance can be helpful.

Rhodes is a paid consultant for Regional Women’s Health, LLC. 

Cabandugama reported no disclosures.