Dr. Sarah Stombaugh:
This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast.

Announcer:
Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here’s your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh.

Dr. Sarah Stombaugh:
Maybe you have previously been on a GLP medication and the experience was miserable, where you’re thinking about starting out and you’re like, “Well, where should I go? I feel like I’m seeing these medications all over the place.” That is exactly what we are talking about today. Who should you go to to prescribe your GLP medications? Because I think right now these medications have become incredibly abundant. We see them prescribed all over the place and you’re like, “Which medication should I be taking? How much do these things cost? Is there value to this clinic versus that clinic? Is there even someone in my community who prescribes this for me or is willing to prescribe it for me? ” And if I go to that person or if I go to an online platform, am I going to get the support that I need because I don’t want to just feel like I’m totally alone in this journey.

I felt alone in my weight loss journey for long enough and I know that I don’t want that. So let’s talk about that today because I think this is one of the most common questions that we get from listeners when people reach out. A lot of times I have friends and family who are in other states and they’re like, “Well, it would be great if I can see you, but I don’t live there. And so what should I be looking for in someone who is prescribing a GLP medication or supporting me in a weight loss journey?” Now, of course, we’re talking about GLP medications, but I even want to say it may not necessarily mean that this person is prescribing GLP medications. Sometimes a really green flag, something we should look for is someone who is not just prescribing GLP medications. If that is all the person does, you might want to look the other way because if someone is … If they’ve got a hammer, everybody looks like a nail, and if they have one tool, they are going to treat with just that one tool.

So let’s dive in and talk about this because this will absolutely make the difference between are you having a good journey that feels like when you have questions, when you’re having issues with your insurance company, do you get the support that you need or do you feel frustrated? Do you feel sick with side effects? Do you feel alone? It can make a really big difference. Now, one of the things I really want to normalize is there are a lot of people who are appropriate to be prescribing GLP medications. So this comes up sometimes where people are like, “Oh my gosh, my sleep medicine doctor recommended the medication. My cardiologist recommended the medication.” Wow, I’m really surprised that I didn’t know that these were the type of people or the type of physicians who would be writing these medications. And the reality is that’s absolutely appropriate.

We have seen that these medications, whether we’re talking about Zepbound, Wegovy, they are being indicated for things beyond the treatment of metabolic disease. So I’m sure you all remember, but these medications, the GLP medications and the GLP- GIP medications. So medications like Zepbound, Wegovy, Ozempic, Mounjaro, Saxenda, Victoza, Liraglutide, Tirzepatide, semaglutide, all of these medications. These are medications that two decades ago we were only talking about for the use of type two diabetes or for the treatment rather of type two diabetes. So these medications have been on the market for a while for the treatment of type two diabetes. And one of the things that was pretty rapidly demonstrated with these medications was that they were not just affecting blood sugar, but they were affecting our metabolic health. That makes sense. The blood sugar is just one symptom of metabolic health. Weight gain is another symptom of metabolic health.

And so it makes sense that these medications were supporting when we think about the way that these medications work in the body. So they started studying these medications for the treatment of weight disorders. And what we saw is that medications that were traditionally available for diabetes were then rebranded for the treatment of weight. So we saw medications like Victoza, this is the generic liraglutide. This medication was first available for the treatment of type two diabetes. This was the first GLP medication that was FDA approved for the treatment of obesity under the brand name of Saxenda. So everybody’s out here talking about Welgovy and Zepbound, and of course those are excellent medications and we’ll talk about those in a second. But Saxenda was the first one that was FDA approved for the weight reduction indication. Now it didn’t get the same popularity as some of the newer agents because these newer agents are once a week agents.

They are more potent and more effective agents compared to Saxenda. When you looked at Saxenda a decade ago, it did not stand out demonstrably above other medications that were in the market at that time for weight reduction. And it was the only injection at the time. So people were like, why would I take an injection? It’s also a once per day injection. So a lot of people are like, “I don’t really want to take a shot in general. I certainly don’t want to take a shot every single day.” And when it doesn’t stand out compared to some of the older pill agents that were on the market, or not even older ones, there were some that were being approved right around the same time as Xenda that were similarly effective for the treatment of weight disorders that Xextenda didn’t stand out in the same way.

But then five years passed and we saw the approval of Ozempic, a once a week semaglutide medication for the treatment of type two diabetes. It got rebranded a couple of years later as Wegovy. So Ozempic and Wegovy are the exact same medication for the treatment for diabetes or obesity respectively. And then a couple of years later, we saw the approval of Mounjaro. Then Zepbound, those are both the same medication. Those are both Tirzepatide medications, the Mounjaro for type two diabetes and Zepbound for the treatment of obesity. So we saw these initial indications for diabetes then for obesity. But what’s been really fun over the last couple of years is we’ve seen these medications studied for other indications as well. We have seen that Wegovy is studied for cardiovascular risk reduction. So people who’ve had a heart attack, people who’ve had a stroke, people who have had these serious vascular events in the past and have a BMI of greater than 27 rather, they have been studied for the prevention of secondary cardiovascular events for mortality.

How likely are these patients to die if they do or do not take Wegovy? And the amazing thing is that Wegovy improved cardiovascular outcomes for these patients. That medication has also been studied in metabolic liver disease. So formally thought of as fatty liver disease, but we know that the liver can store fat, which can impact the effectiveness and the function of the liver, and that can have significant health consequences even leading to cirrhosis of the liver. And so Wegovy can be helpful in the treatment of that metabolic liver disease. We also look at medications like Zepbound, which now has an FDA approval for the treatment of sleep apnea. We know that increasing weight, gaining just 10% of your body weight sixfold increases your risk of sleep apnea compared to before you had that weight gain. And so Zepbound, whether it’s through the treatment of weight reduction alone, there may be other mechanisms as well that are causing that reduction in sleep apnea that happens, but it’s been studied for the treatment of obstructive sleep apnea and approved for obstructive sleep apnea for patients with moderate or severe obstructive sleep apnea with a BMI of 30 or higher.

And so all of this to stay, we’re seeing these medications approved for other indications. We know that they’re being studied for other indications, whether those are large pharmaceutical sponsored clinical trials, whether those are smaller independent trials happening at academic centers, for example, or whether that is even just the clinical experience of the physician or care team that you have where they see, “Hey, we’ve started to use this medication in this patient population and we’re seeing a benefit.” And a lot of times they can tell you exactly why. We know patients with polycystic ovarian syndrome, for example, that is a metabolic associated health disease or state. And so therefore, can we treat with these same medications? And a lot of prescribers are starting to see, wow, these medications are having impacts beyond just weight. We’re seeing that there’s really a lot of value to these, which then leads me to the fact that we’ve got all sorts of people who are prescribing these medications.

It might be your endocrinologist, it might be your obesity medicine physician, it might be your primary care physician or your OBGYN or your cardiologist or your sleep medicine, ear, nose and throat pulmonologist, neurologist, whoever is managing sleep medicine that can come from a few different locations. So we’ve got all of these different people, and that’s probably just a subset. Certainly there’s others. I have friends who are rheumatologists who are prescribing this medication or dermatologists or reproductive endocrinology, infertility doctors, for example. There’s a lot of people who are prescribing these medications because we see benefit across so many different disease states. And so if you were in your cardiologist’s office, your OBGYN’s office and they offer you these medications in response to a condition that you’re discussing, that may be appropriate. And so I just want to say don’t get caught off guard. And it’s not necessarily wrong to be getting it from any number of those specialists.

But I think the really important question here is not who is prescribing, but are they set up to give you the level of support that you need on your GLP medication? And this will be everything from when you’re very first starting out the medication to as you’re on your journey for a couple of months and then as you’re on your journey long term, are they equipped to support you in this? Now, you don’t just have one shot with these medications. If you’ve had experience in the past that hasn’t gone well, you can absolutely try again, but I’m sure you’re thinking about, okay, this time I want to do it right. This time I want to do it with a level of support that I haven’t felt like I’ve had in the past. So when someone is talking to you about these medications, things that you want to be asking about, understanding so that you feel like, “Hey, am I getting the support that I need?” You want to know what does it look like from an insurance standpoint?

Are they going to run this prescription through your insurance? At this time, we are still living in an environment where there are many people who even despite having good insurance health coverage otherwise may not have great coverage or any coverage for GLP medications, especially when we’re talking about indications beyond the treatment of type two diabetes. Now, people who do have type two diabetes, broadly speaking, have pretty good coverage for GLP medications. And that is an indication that I feel 95% comfortable that we’re going to be able to get one of these medications approved for a patient. Of course, there’s always exceptions. Sometimes we have to try other medications first before we’ll get the GLP medication approved, but we do have generally pretty good coverage in this country for the treatment of type two diabetes. What we do not yet have great coverage for is the treatment of weight reduction and long-term weight maintenance.

We’re treatment of some of these other FDA approved indications, whether it’s liver disease, cardiovascular disease, sleep apnea, we’re not always seeing great coverage for those. And so when you are sitting there face-to-face with the prescribing physician, understanding like, “Hey, are they familiar with prescribing this medication? Have they done the prior authorization process? Are they talking to you a little bit about what to expect from a cost perspective? What are the things that maybe you should go and look for in terms of finding out do you or do you not have insurance coverage for these medications?” And then when the prior authorization comes up, that’s the paperwork between the prescriber and the insurance company to say, “Hey, does patient meet criteria for these medications? Is that prescriber actually going to do the prior authorization paperwork?” Now, I will say that process, we’ve talked about that before.

It’s probably worth actually addressing again because we’ve seen a lot of changes in that space, but just because a prior authorization can be done does not mean that it’s going to be approved. It doesn’t mean that even if you are the perfect candidate for these medications that it’s going to be approved, it’s really going to depend more on whether your insurance is opted in. And by insurance, I really just mean employer. If you have commercial insurance, has your employer opted into or out of the coverage of weight reduction medications? So all of that to say, is your prescriber aware of these different things? Are they able to counsel you on that piece of it? Once they send in the prescription, are they going to be willing to do the prior authorization? If so, even if it gets denied, are they going to be able to talk to you about the other options for medications?

One of the crazy things that I see is that these medications have an incredibly high list price, often the range of $1,200 to $1,500 for these medications. And so one of the things that happens is that people who have insurance coverage, they go to the CVS, Walgreens, whatever retail pharmacy that’s near them with their prescription, their doctor has sent it in and let’s say either they don’t have an approved prior authorization yet or the prior authorization is denied for the medication. So they have a denial at hand and they go to the pharmacy and the pharmacy’s like, “Okay, it’s going to be $1,200 for this prescription.” And the patient’s like, “Wait, $1,200, that’s a lot of money.” And they call their doctor’s office or their prescriber’s office and they’re like, “Hey, is that right?” And they’re like, “Well, yep, it’s just an expensive medication.” Well, the reality is there are other options for getting these medications.

There’s a lot of really good cash pay options that have come on the market over the last couple of years. When we look at very traditional cash pay options, both Zepbound and Wegovy, those weekly, more potent GLP medications have really good cash pay options available. They’re still somewhat expensive in the range of $199 to $449 per month, depending on which medication and which dose that we’re talking about. But there are cash pay options that are certainly less than the $1,200, $1,500 that you may be quoted at your pharmacy. So does your prescriber know about those cashpay options and say, “Okay, do not pick up your prescription. Let me send the prescription for cash pay.” And that might mean sending it to a different prescription or maybe there’s a coupon you can use through that. And are they or their staff able to help you navigate through that coverage situation or do you find that, “Oh my gosh, I just spent $1,200 on this prescription.” Now there are very few people who do have to do that towards meeting a deductible, for example.

So just because you did pay high for a month or two isn’t necessarily a problem, but you should see that that price then comes back down into the rate that your insurance company has negotiated, which should be much, much lower. But is your prescriber aware of the cash pay options? Are they aware of the copay cards? I think a lot of times we’re talking about, okay, there is insurance coverage or there’s not insurance coverage and what are the self-pay options? There’s actually really great copay cards for these medications as well as you can go online and fill out a application for those and they’ll send you a copay card that can help to bring the copay down. Those are not significant. They make a dent in the cost of the medication, but may be a decent option for someone who does have coverage, but has a higher copay that can help to bring the cost down.

So are they helping you to navigate this insurance coverage piece of it? One of the things that’s really surprising to me is patients will come into my clinic, they’ve been working with someone else and they’re like, “Oh, I don’t have insurance coverage for this medication.” And I’m like, “Actually, I’m quite sure that you do. ” I live in a small community where we have a lot of the same employers and it is very common that we know what those employers do or do not cover. And so I have had patients who say, “Oh, I don’t have coverage for these medications or my previous doctors said I wouldn’t be able to get this medication covered.” And I’m like, “Oh, actually this is a covered benefit for you. ” And we’ve been able to get them these medications for sometimes very affordable. I have a patient who pays $25 per month for these medications who was previously told that she did not have coverage and nothing changed.

She didn’t change employers. They didn’t change plans. Her previous prescriber was just aware or did not have the support staff to be able to do the prior authorization for this patient in order to get the medication covered. And so the best thing you can do is understand, do you or do you not have coverage? You can go to your insurance formulary online. You can look up the, it’s called the drug or the pharmaceutical formulary and see, okay, do I have Zepbound coverage? Do I have Wegovy coverage? Those are the two that I would look for just to get an indication of, okay, is there a route to coverage for this medication? So look those up so that when you go in to see someone, if you’re thinking about asking about these medications, you at least know, should I be expecting or not expecting coverage of these medications?

So are they going to help you from an insurance standpoint? Are you going to see them for follow-up appointment? When you’re leaving that appointment, do they have a clear like, “Hey, I’d love to see you back in a month, for example.” See how that first dose is feeling in your body. Talk about are we continuing on that dose versus making a dose adjustment? I think a major red flag is like, “Okay, this sounds great. Here’s the prescription. We’re going to start you on the lowest dose and then I’ve sent a prescription for the next dose for you to fill next month, the next dose for you to fill the month after that. ” And then the next dose, I’ve actually heard stories like this where prescribers are like, “Okay, let me just send in all five or six doses of the medication so that you can get that medication and you can just, every month you can go and pick up that prescription.

The pharmacy’s going to hold those on file for the next 12 months. And so I’ll just send in every dose of medication just every month, just take the next higher dose and let me know if there’s issues.” And that’s a major red flag. Someone should not be just prescribing the next dose of medication automatically for you. They should have a plan of what checking in looks like. It doesn’t necessarily have to be an in- person appointment or a telemedicine appointment, I should say like a face-to-face one-on-one visit. I think that’s preferable so that you’re checking in of what is the effect of the medication, what are the side effects of the medication? How is it feeling? What are the numbers you’re seeing on the scale? Maybe the numbers you’re seeing in your blood sugar, for example, how are you doing? I think that check-in certainly at a month point makes a lot of sense, but even if you’re not having a face-to-face appointment, is there a very dedicated, okay, we’re sending a couple of MyChart messages back and forth to understand, okay, how is this feeling?

What are your side effects? Do we stay on this dose versus do we titrate this dose? If someone is like, “Yep, here’s all the prescriptions or just every month we’ll just send in the next dose for you. Just let us know when you’re ready.” That is a major red flag. It is shocking to me how often I talk to patients who’ve been in this situation, people who’ve reached out to our clinic and they’re like, “Hey, I’m on the top dose of Zepbound. I’m on the top dose of Wegovy and I feel miserable. I vomit all of the time. I’m not able to eat well.” I was talking to this sweet older woman who’s like, “Yeah, I haven’t eaten in the last two months. I just have one or two saltine crackers per day. I’ve been sipping on Gingerio and I’ve lost a lot of weight, but I just … Is this how this medication is supposed to work?” And I was like, “No, that is not the goal.

Not eating or being so sick that you’re vomiting all the time, that you’re not able to eat anything.” That is not the goal of these medications and that is a problem. And it was so sad to me because she was in a situation where her primary care physician was very enthusiastic, was wanting to be able to support her in this, but he did not have the bandwidth to be able to support her in his practice. His appointments were booking four to six months in advance. And so even when she was having issues, the front desk care team was like, “Okay, let’s get you an appointment and we’ll get you on the schedule.” And so she had an appointment coming up in two months from when I’m talking with this woman, but she had been suffering for two months. She had just been feeling totally miserable and then she was still getting dose escalations of the medication.

I was like, “Oh my gosh, this is not how it’s supposed to be designed.” And even if I had talked to that physician, I’m sure he recognizes that’s not how the medication should be prescribed, but the problem was that his support staff, when the patient’s calling in, there’s not a schedule who’s looking at this saying, “Oh wow, this patient’s really sick. Should we be messaging the triage nurse to be thinking through this and trying to prioritize this patient for a sooner appointment?” It wasn’t escalated to the point where my guess is her physician wasn’t even aware that this was going on, but that’s a problem too. If you are reaching out to your office and trying to get ahold of your prescribing provider, whoever they are, and you’re getting caught up in a call center or a front desk and they’re giving you an appointment that’s three months, six months, some far period of time away, that is not acceptable.

And so even if you have the nicest physician in the world, if they are not able to see you and you are not actually able to talk to a human being, whether it’s a nurse, whether it’s a PA, an MP, a doctor, someone on the care team who knows you, knows these medications and can help guide you through it, that is not going to be A, a satisfying experience.You’re going to feel frustrated, you’re going to feel physically ill and unwell, and then physically it’s not great for your health. That is going to greet other consequences or you are at risk for predominantly, I’m thinking about malnutrition, are we going to waste away from a muscle standpoint and you’re just feeling miserable that whole time. And so it’s not just is your prescriber great, are they enthusiastic? Are they willing to do the insurance coverage, but are you going to get the support you need?

When you have questions that come up, do you have someone that you can either reach out and ask those questions to, or do you have someone that is going to be able to get you in for an appointment? And these are some of the biggest challenges that I see. So people are wanting to support their patients, they’re wanting to help them, but their clinic just does not have the bandwidth to support them in that way. And sometimes there are people who very reluctantly prescribe these medications. So one of the really sad realities is that we live in a society with significant obesity bias. And this is not limited to just the world at large. We see many people in the healthcare profession who have bias towards those with chronic excess weight. And we see it come up in all sorts of different ways, whether that means in not understanding the disease process itself, not being able to support someone in it, or even if you are willing to support someone in it, kind of rolling your eyes, making a patient feel badly, making them feel that they failed.

Well, because you haven’t been able to exercise enough, because you’ve been a glutton and you’ve just been eating so much and you can’t control yourself, well, now we have to take this step and prescribe these medications. I have patients all the time who’ve been told that or felt that at least certainly, I don’t know that anyone has told me that they’ve been called a glutton by their physician, but they have felt that power that they are being judged for being asked about these medications. And even if the prescriber will write the prescription, they’re like, “Ugh, I mean, if you really think so, like you’re lazy person.” And if you are getting those, if you are getting that feeling, like if you go in to meet with a healthcare provider for any reason, whether we’re talking about weight or honestly for any indication and you leave feeling judged or belittled or talked down to in any way, that is completely inappropriate and this is not a therapeutic relationship.

And I would recommend that you see a different doctor immediately find someone else because even like it doesn’t matter what they’re talking down to you about. I mean, for one, let’s say you’ve had a great relationship with a physician for decades and they have one bad day. We are all human and people can have bad days and you may give someone grace, but if you notice your first time meeting them, if you have never had a positive experience with that person, that is not a therapeutic relationship. That is not someone that you feel like you can trust that when you’re having a serious medical concern, that you’re going to be able to both share that concern and have them listen, as well as be, have them effectively respond to that. And so begging you to find another doctor if you are in that type of relationship.

Now, what happens very frequently in the weight loss space is that someone may feel that they have a doctor who has supported them through a lot of things and continues to be a great doctor for them in a lot of ways, but maybe they are not the right person to be prescribing a GLP medication for their weight loss journey. They may find that, “You know what? I am going to outsource this part of my care. I’m going to see a board certified obesity medicine physician for this part of my care, but I still recognize that this doctor may be appropriate for me in many other ways.” But if you are going into a doctor who’s like talking you out of the medication, telling you all of the severe side effects of the medication, I will tell you, I have patients with side effects from these medications.

That is absolutely true. Side effects, mild side effects are very common on these medications and almost every single side effect of these medications can be incredibly well managed. The only times that I see severe side effects from these medications are times where these medications have been escalated inappropriately. And so if you are talking to a prescriber who’s like, “Oh my gosh, these medications are dangerous. These medications have severe side effects.” All my patients who take these medications get so sick. That is a major red flag that that prescriber has not been able to support those patients in an adequate way. And I would run. I would not let that person write you the prescription. I would find somebody else to do it because you are not going to feel supported in your journey. And this is one of those things that I feel incredibly passionate about.

My background is in family medicine. I was previously working in a primary care practice supporting people across every health condition, including their weight. And one of the things that was really challenging for me, it was very difficult to support people in their way, in the way that I wanted to be able to, and the way that they deserved in the setting of that practice. My appointments would book months in advance. I had 20 minute appointment slots to support patients. When patients would reach out in between, it would land in a MyChart in basket that wasn’t even visible to me. So I had no idea that my patients were struggling with these complaints. And it was really challenging for my patients. It was challenging for me, someone who was experienced and interested and wanted to be able to support patients, I didn’t feel like I could do it in that environment.

And that is exactly why I created my current medical practice. I practice in Charlottesville, Virginia, and we have a very unique approach where we are seeing our patients incredibly regularly. I see my patients every month. I have a health coach who sees my patients every month. So every two weeks you get this one-on-one check-in to help you feel supported on your journey. We are experts in prior authorizations. I have an assistant who does this all day long and she is so good at what she does and we work through together on those complicated cases of how do we help our patients. If there’s a route to coverage, I am going to help you with that route to coverage. We have a lot of experience in that. And we have patients who’ve been told that you don’t have coverage. They’ve been paying at the med spa for semaglutide or irzepatide.

They’ve been paying for branding medication when they had insurance coverage, and we see there’s a route to coverage here and we work to get that medication approved when that is an option. When patients reach out, if they call me on a Saturday afternoon, they are calling me, Sarah Stombaugh, that is going directly to my personal cell phone such that I’m able to support them. If they started the medication on Friday and they’re having side effects come up on Saturday and they’re like, “Man, I feel miserable.” I tell them, “Please call me. I want my patients to know I am here for you. ” We have an online program that has answers to all their frequently asked questions. When patients are reaching out, we always respond within hours, usually within minutes, but sometimes it does end up being within hours if we’re in a patient visit or a couple of patient visits or something like that, but we are here to support our patients.

And it is so amazing to see the results that patients in our practice get. You look at the average weight loss in the clinical trials, patients getting 15 or 20% total body weight loss. And one of the things that we see that is just amazing is that our patients feel good while they’re taking these medications, they’re nourishing their body, they’re working on the other pieces and feel supported and layering on all the different parts of their weight loss journey. And we see patients lose 20, 25, 30, 40% of their body weight sometimes, and it is unbelievable the life change that we see. And if you are looking for a doctor like that, I would love to support you in your weight loss journey. I do see patients in person in Charlottesville, Virginia, and then by telemedicine throughout the states of Illinois, Tennessee, and Virginia. If you are not in one of those states and you’re like, “Dr.

Istanba, I wish that you could be my doctor, but you can’t because you’re not in one of my states.” For one, do reach out. I had a patient who traveled from Tennessee to see me and I was like, “Okay, now I have a Tennessee patient and I’d love to get a Tennessee license.” And so if you are in a state that I’m not licensed in, send us a message I would absolutely consider getting licensed in your state, but we also have a really great online program called The GLP Guide. This is an online program designed to support you with all of the most commonly asked questions that patients have. Right now it is just $149 for a year of access to The GLP guide and you are going to have videos too, what are these medications? How do these medications work? How do I inject these medications?

What are the side effects and how do I manage those? What should I be thinking about protein or travel or when people comment on my weight? We are talking about all of the things. We have updated videos. So when new products come out, for example, we have new demo videos explaining how those work. And so there is lots of good stuff in there that you are going to get the support that you need in an online. If you find yourself on Facebook or on Reddit, TikTok trying to get the different answers to questions, this is a great place for you to look to get those answers. You can find that at www.sarahstombaughmd.com/glp, and that is an awesome way to feel supported in your journey. Thank you so much for joining us for today’s episode. We’ll see you all next week.