When patients can’t access the GLP-1 you prescribe, keep the conversation going

In some ways, glucagon-like peptide-1 drugs (GLP-1s) have changed everything. In others, they have exposed familiar problems with cost and access in the country’s health care system. We now have medications that can make a meaningful difference for patients with obesity and related conditions, but whether a patient can actually obtain them often depends on what their insurance will cover and what they can afford out of pocket.

Consider this example: I had a patient who was taking Mounjaro come through my clinic. This person was not looking for vanity drugs to help lose a few pounds; they were experiencing an array of comorbidities, including obesity and polyendocrine metabolic ovarian syndrome (PMOS). Many providers at the time, including myself, were appropriately prescribing Mounjaro off-label for obesity and conditions on the metabolic/endocrine spectrum, such as PMOS. In this case, the GLP-1 was working, significantly benefiting multiple organs.

Then Zepbound hit the market. Zepbound and Mounjaro have the same active ingredient, tirzepatide, and the same dose schedule. However, the U.S. Food and Drug Administration (FDA) has approved Zepbound for weight management and obstructive sleep apnea while Mounjaro is approved specifically for diabetes. The two drugs are made by the same company. The moment this newer drug was available, my patient’s out-of-pocket costs went from $25 per month to $600 per month — with insurance. We found a direct-pay savings program that would get the cost down to $450 per month. But on a public schoolteacher’s salary, the cost may as well have been $1 million per month.

When the math doesn’t work but the medication does

Some, maybe even most, patients simply do not have the resources to continue on an FDA-approved regimen when it costs hundreds of dollars per month. In my patient’s case, I prescribed a compounded version. Unfortunately, it has not had the same degree of success. It has helped, but not as much as the branded medication. My patient and I worked through this obstacle together, but other patients are seeking these drugs through online sources with far less oversight, sometimes without knowing exactly what they are receiving or how to use it safely.

GLP-1s work, and they are becoming more popular — and ubiquitous — by the day. When the FDA-approved option is out of reach, patients and providers are forced to navigate a growing range of alternatives, from manufacturer direct-pay programs and compounded medications to online sources that carry far greater risks.

We can’t solve the underlying access problem, but we can understand the landscape that patients are navigating and be prepared to work within it.

The way patients access care has changed

GLP-1s have underscored something that has been developing in health care for years.

From 2018 to 2023, the number of clinicians participating in direct primary care and concierge services grew by almost 80%. Last year, a Deloitte survey showed that 23% of respondents had used a direct-to-consumer (DTC) health service; among those, 52% sought prescription drug access and 29% used weight-management programs, including GLP-1s. The rise of telehealth, retail clinics, manufacturer-direct programs and online pharmacies means that patients are not tied to the town doctor or one prescribed care path. Patients have access to nearly limitless information and increasing agency over where, how and (sometimes) from whom they obtain care.

This is the environment our patients are operating in. Increasingly, health care is a marketplace. And because GLP-1s have such strong demand, there is significant commercial incentive for companies and providers to build more alternative pathways.

The concern is not that patients have more options. It is that those options come with dramatically different levels of quality, clinical oversight and risk. When cost puts the preferred medication out of reach, providers need to understand the alternatives well enough to help patients distinguish between them.

Not all GLP-1 alternatives are the same

Working within this new environment does not mean abandoning clinical judgment. If an FDA-approved medication is available and accessible to my patient, I prefer that. But when it is not, we need to be informed about other options.

That starts with where compounded GLP-1s come from. As a provider, one should vet the pharmacy, understand its credentials and regulatory status, and make sure it has the appropriate inspections and certifications. I look specifically at whether a pharmacy is operating appropriately under Section 503A of the Federal Food, Drug, and Cosmetic Act. I also talk to other providers about which pharmacies they have worked with and trust.

There are absolutely compounders that skirt regulations, and there is a growing gray market for GLP-1s, so caution is warranted. These powerful medications are increasingly sold online, with only cursory supervision or, even worse, as “research use only” peptides that do not undergo the same legal and quality processes as pharmaceuticals labeled for human consumption and that require no oversight at all.

At the same time, I do not think we serve patients well by treating all compounded medications as inherently bad. If cost has made the branded medication inaccessible and a patient is considering another route, I would rather be part of that decision and help them evaluate the safest available option.

We can’t control where patients find products or information, and imparting fear so they don’t tell us what they are considering or already taking does not make them safer. We have to be a safe place where patients can candidly ask questions, discuss what is available, learn about the risks and get help if things go wrong.

Be part of the conversation

There are legitimate costs involved in developing and producing these medications, and there are legitimate questions about how insurers, pharmaceutical companies, employers and the government should share responsibility for coverage. It is a much bigger problem than any one provider or practice can solve.

What we as providers can do right now is recognize that access has to be part of the clinical conversation. If a patient cannot afford the medication we would prefer to prescribe, telling them there are no other options won’t make the problem go away. More likely, patients may turn to an unsafe compounded medication, an unregulated DTC program or another source we know nothing about.

We may not always be able to give patients the option we would choose. But we can make sure they understand what solutions exist, know what questions to ask, and have someone in their corner who can help them weigh cost, safety and clinical effectiveness. In a health care system where access is not always straightforward, staying involved may be one of the most important things we can do for our patients.

Amanda Guarniere, M.S.N., APRN, NP-C, is a Yale-educated nurse practitioner with 15 years of clinical experience, vice president of sales and marketing at GuardianMD, and a leader in medical oversight infrastructure for clinics, medical spas and telehealth platforms.