The GLP-1 Opportunity Cost in Rheumatology Save

There is no doubt it is an incredibly exciting time to be tackling obesity-related diseases, like many rheumatic diseases appear to be, to some extent.

When I wrote two years ago that “what is for sure, however, is that rheumatology will not be able to close its eyes to the impact of Ozempic (Ozempic Will Change Rheumatology), it was, if anything, an understatement. While the evidence body continues to grow, the influence from broader society has continued unabated, in a way that did not happen with other therapeutic trends like medical marijuana. Real benefit of substantive magnitude from incretin-based therapy is hard to ignore.

So, when it comes to incretin-based therapies, we are adapting as clinicians. We are developing the right conversations to have, the right caveats to raise, the right strategies to bring to the table. We are right to be proactive and our patients are right to be keen to engage. It cannot be ignored.

However, deep down, a part of us must dread adding yet another conversation to a crowded consultation. It’s not that we don’t see the clear and obvious benefit, but we wonder where this can fit in. We are all time poor, the clinical demand is difficult to meet, and workforce shortages in rheumatology globally continue to expand. This is one of many highly worthy things competing for our limited attention, especially with the knowledge that the more things we say, seemingly the more likely they are to forget the core material that only we can deliver. Some of our patients also wonder about our focus and why these tangential conversations continue to arise, when they would like to get their biologic script from their arthritis doctor and get on with their day, please.

There is no question we can and will find time to raise weight loss with the morbidly obese patient who has clear benefit from weight loss. This may well be the key intervention that defines their life. In our societies, this scenario is increasingly common, and we are learning how to deal with this better and better in a critically important way.

It is the situations which are less clear but still with proven benefit, which are far more common and, in many ways, far harder to execute. The therapeutic gain is less certain, the patient is more likely to be skeptical and to take offense. It becomes harder to justify in amongst all the things we are meant to be doing. In many ways, tackling this in such a situation is more likely to be memorable, and more likely to overshadow DMARD adherence, safety, and action plans for flares.

There are many opportunity costs that incretin-based therapies compete for in our practice. The most obvious is financial opportunity cost. While ideally patients can afford co-pays for this (or the whole cost, too often) on top of their DMARD copayments and dispensing, primary care costs, physiotherapy, exercise physiology, nutritionally advantageous food, dental treatment, osteoporosis management, psychological care, pain management, cardiovascular screening, non-rebatable vaccinations, lung imaging, and any other medical issues they might have, it’s plausible that they might not, especially if their earning capacity is compromised by the functional impact of their arthritis.

This is a live issue in the United States. Cost-related medication behavior more frequently affects rheumatology patients and can lead to reduced use of DMARDs, let alone other medicines. Co-pays do affect biologics use. Financial distress is common in rheumatology patients with co-morbidities. And GLP-1 receptor agonist adherence, critical to its long-term value proposition, falls progressively with increased co-pays, even once clinical and socioeconomic factors are controlled for. We aspire to a world where it is not a consideration, and advocate for the best for our patients, but to pretend it doesn’t exist is wrong.

The bigger issues aren’t financial, though. Therapeutic opportunity cost might mean that attention is displaced - patients might be more likely to think that DMARDs or any of the other care proven to be useful, including rheumatologist review, are unnecessary, even when they most definitely are needed. It’s a workforce opportunity cost - every hour spent obtaining and maintaining access is an hour unavailable for another priority. From a health system opportunity cost, one has to think that spend here impacts spend elsewhere.

Ideally, none of these are an issue, and it’s plausible that incretin-based therapies often pay for themselves, deal with many problems simultaneously, offer benefits that would not otherwise happen, and belong at the top of our attention list. Ultimately, though, it is undeniable this eats into our patient time and clinical attention.

How can this be sustainable in the future, without losing other things? For that matter, how can we make any comorbidity management achievable in the long-term?

One of two things has to happen: we either outsource, or get more efficient. Ideally we can do a bit of both.

Perhaps this is the opportunity to leave metabolic care to others, but to seed or reinforce the idea, so that patients quietly triangulate the messaging in their head and get closer to the change they need. This is exactly how lifestyle change programs could have their greatest opportunity, too. There would be enormous value for systems to consider how to make this happen.

Efficiency might mean many things, many of which we have heard about this month: having the right script in our heads, using our team well, structured electronic record having the right information resources on hand (or getting better ones developed), maybe even thinking how AI can help support our patients. Part of this will be practice, but part of this will need to be highly deliberate.

The right GLP-1 prescription should add to our patient’s health without quietly subtracting from the rest of the treatment plan. It is up to us to figure out how to make that happen.