Latest news with #BeverlyTchang
Boston Globe
07-07-2025
- Health
- Boston Globe
Obesity drug prices are dropping, but getting a steady supply remains a challenge
Doctors say the situation forces them to get creative in treating patients, but there's hope that prices may fall more in the future. The drugs are still in high demand Wegovy and Zepbound are part of a wave of obesity medications known as GLP-1 receptor agonists that have soared in popularity. Zepbound brought in $2.3 billion in U.S. sales during this year's first quarter, making it one of drugmaker Eli Lilly's best sellers. Advertisement Novo Nordisk says Wegovy has about 200,000 weekly prescriptions in the U.S., where it brought in nearly $1.9 billion in first-quarter sales. Get Starting Point A guide through the most important stories of the morning, delivered Monday through Friday. Enter Email Sign Up Insurance coverage is increasing — for some The benefits consultant Mercer says more businesses with 500 or more employees are adding coverage of the injected drugs for their workers and family members. And Novo says 85% of its patients who have coverage in the U.S. pay $25 or less per month. Plus some patients with diabetes can get coverage of the GLP-1 drugs Ozempic and Mounjaro from Novo and Lilly that are approved to treat that condition. But most state and federally funded Medicaid programs don't cover the drugs for obesity and neither does Medicare, the federal program mainly for people age 65 and older. Advertisement Even the plans that cover the drugs often pay only a portion of the bill, exposing patients to hundreds of dollars in monthly costs, said Dr. Beverly Tchang. Drugmakers offer help with these out-of-pocket costs, but that assistance can be limited. 'Coverage is not the same as access,' said Tchang, a New York-based doctor who serves as a paid advisor to both Novo and Lilly. But coverage remains inconsistent Bill-payers like employers are nervous about drugs that might be used by a lot of people indefinitely. Some big employers have dropped coverage of the drugs due to the expense. Pharmacy benefit managers, or PBMs, also are starting to pick one brand over the other as they negotiate deals with the drugmakers. One of the nation's largest PBMs, run by CVS Health, dropped Zepbound from its national formulary, or list of covered drugs, on July 1 in favor of Wegovy. That forced Tchang to figure out another treatment plan for several patients, many of whom took Zepbound because it made them less nauseous. Dr. Courtney Younglove's office sends prospective patients a video link showing them how to check their insurer's website for coverage of the drugs before they visit. 'Then some of them just cancel their appointment because they don't have coverage,' the Overland Park, Kansas, doctor said. Cheaper compounded drugs are still being sold Compounding pharmacies and other entities were allowed to make off-brand, cheaper copies of Wegovy and Zepbound when there was a shortage of the drugs. But the U.S. Food and Drug Administration determined earlier this year that the shortage had ended. That should have ended the compounded versions, but there is an exception: Some compounding is permitted when a drug is personalized for the patient. The health care company Hims & Hers Health offers compounded doses of semaglutide, the drug behind Wegovy, that adjust dose levels to help patients manage side effects. Hims says these plans start at $165 a month for 12 months, with customers paying in full upfront. Advertisement It's a contentious issue. Eli Lilly has sued pharmacies and telehealth companies trying to stop them from selling compounded versions of its products. Novo recently ended a short-lived partnership with Hims to sell Wegovy because the telehealth company continued compounding. Novo says the compounded versions of its drug put patient safety at risk because ingredients are made by foreign suppliers not monitored by US regulators. Hims says it checks all ingredients to make sure they meet U.S. quality and safety standards. It also uses a third-party lab to verify that a drug's strength is accurately labeled. Prices have dropped Both drugmakers are selling most of their doses for around $500 a month to people without insurance, a few hundred dollars less than some initial prices. Even so, that expense would eat up about 14% of the average annual per person income in the U.S., which is around $43,000. There are some factors that may suppress prices over time. Both companies are developing pill versions of their treatments. Those could hit the market in the next year or so, which might drive down prices for the older, injectable doses. Younglove said some of her patients save as much as 15% by getting their doses shipped from a pharmacy in Canada. They used to get them from an Israeli pharmacy until the Canadians dropped their prices. She says competition like this, plus the introduction of pill versions, will pressure U.S. prices. Advertisement 'I think price wars are going to drive it down,' she said. 'I think we are in the early stages. I have hope.'
Medscape
10-06-2025
- Health
- Medscape
Understanding Weight Gain in Women During Perimenopause
Women in midlife commonly come to Beverly Tchang, MD, with concerns about gaining weight, even though their diet and exercise routines have not changed. The patients are frequently frustrated about the uncontrollable changes and are usually experiencing a range of hormonal shifts as they go through perimenopause, said Tchang, an endocrinologist and associate professor of clinical medicine at Weill Cornell Medical College, New York City. 'Perimenopause is a natural phase of a woman's life, but because so much of it is out of our control, it's frustrating because many women feel like they can't fix it,' she said. 'They can't get back to where things were in their prior decades. A second source of frustration is that often, when they do see a healthcare professional, the professional doesn't know how to help them because they identify this as something that naturally happens.' Studies show women in midlife generally experience a change in body composition around perimenopause, primarily faster accumulation of fat around their waistline. Aging-related changes — such as decreased energy expenditure and less physical activity — are common culprits for weight gain in midlife women, according to Maria Hurtado, MD, PhD, an endocrinologist at the Mayo Clinic in Jacksonville, Florida. Hurtado analyzed this subject in the journal Current Obesity Reports . 'Weight gain affects the majority of midlife women, irrespective of race or ethnicity,' Hurtado said in an interview with Medscape Medical News . 'However, evidence suggests that women with lower socioeconomic status and those from racial and ethnic minority groups, such as African American and Hispanic women, tend to have higher baseline body weight and may be more vulnerable to weight gain and its clinical ramifications in the long term.' The health consequences for such body changes in midlife include the development of cardiometabolic diseases, osteoarthritis, and cancer, as well as the worsening of cognition, mental health, and menopause symptoms, according to Hurtado's analysis. Although perimenopause is normal, Tchang said it doesn't mean women have to suffer through the experience without help or intervention. 'I think we need to have more open conversations about what women are experiencing during this time and to be open to intervening on it to improve that quality of life, even though what they're experiencing may not be considered pathological,' she said. Treating Weight Gain in Midlife Women When women in midlife share their worries about weight gain, Wisconsin-based obesity specialist Leslie Golden, MD, first normalizes what they're experiencing, she said. Patients should understand the problem is not a failure of willpower — it's physiology, said Golden, founder of Weight In Gold, a clinic specializing in sustained weight health using health coaching and the latest medications. 'Then, we take a step back and look at the full picture,' she said. Some questions to consider are: Is the patient eating sufficient protein? Are they preserving muscle mass through resistance training? How is their sleep? Are there signs of metabolic conditions, such as insulin resistance or early changes in blood sugar? At her practice, Golden takes a science-based, whole-person approach that may include medication, shifting the type of movement patients are doing, or improving the quality of patients' nutrition, she said. 'It's rarely about doing more,' Golden said. 'Often, it's about doing things differently and supporting the body instead of fighting it.' Tchang noted that some healthcare professionals may not feel comfortable intervening on menopausal management. If so, it's important to direct patients to trusted resources, or if time allows, to educate themselves on this period in women's lives, she said. She recommends The Menopause Society's website, which has information and education that can be helpful for both patients and providers. Clinicians may also want to consider initiating preventative treatment for women with normal or overweight BMI to prevent excess weight gain, ideally starting in their 30s, Hurtado said. This approach should proactively address potential weight gain through four key pillars: Consciously adjusting caloric intake, emphasizing a diet rich in fruits, vegetables, and lean protein Encouraging regular and optimized exercise to combat age- and menopause-related lean mass loss Addressing menopausal symptoms, such as sleep disruption and vasomotor symptoms Providing mental health support and stress management resources Hurtado said that while early counseling focusing on tailored nutrition, exercise, and behavioral strategies is essential, many patients will require additional support due to metabolic and behavioral adaptations that hinder sustained weight loss. 'For those who do not achieve desired results with initial interventions, second-line therapies — such as obesity medications, endoscopic interventions, or bariatric surgery — should be considered within a multimodal and individualized approach that prioritizes the patient's health, contraindications, and preferences,' said Hurtado. How Sleep and Stress Impact Weight Management If patients in midlife are doing 'everything right' and still not seeing progress on their weight loss, sleep and stress are often the missing pieces, Golden said. Chronic sleep deprivation and stress can promote fat storage, particularly in the midsection, by disrupting hunger and fullness signals, increasing cravings, and raising cortisol levels, she said. One study found that nearly 52% of postmenopausal women have a sleep disorder. When women in midlife report sleeping problems, Golden looks at their daily routines, talks through what's realistic, and sets small goals. Sometimes, it's about creating a nighttime schedule, reducing screen time or caffeine, or identifying stressors and figuring out what's in their control, she said. When needed, Golden brings in a behavioral health or coaching team to help them build skills in these areas. 'Very often, it also means challenging some deeply held beliefs — especially the idea that rest is a luxury or that taking care of themselves is somehow selfish,' she said. 'I remind them: You're on the list of people you take care of. Giving yourself permission to rest, to pause, to protect your energy; those aren't indulgences. They're essential parts of healing and sustainable change.' With sleep problems, it's also critical to make sure you're not missing an actual disease diagnosis, such as constructive sleep apnea, Tchang said. 'This is something that I am particularly cognizant of because many of my patients also come in with obesity,' she said. 'The obesity, plus the age, midlife, and these hormonal changes, are associated with increased risk of sleep apnea. So when someone comes to you with a sleep concern, it's important to investigate a sleep disorder or refer to a sleep specialist who can do that.' In addition to hormonal changes, women may be developing a new career, or they may have more family responsibilities at this point in their lives. 'Multiple needs are often converging in this fourth decade of life that can add to stress,' Tchang said. For many women in this phase, it's a good time to reassess personal boundaries and redefine what self-care looks like, Golden said. That might mean making space for rest without guilt, saying 'no' more often, or investing in their own health in ways they may have deprioritized for years, she said. 'When those shifts happen alongside medical and behavioral support, that's where we see real, sustainable change,' Golden said.
Medscape
09-06-2025
- Health
- Medscape
Managing Weight in Older Adults Isn't About Weight at All
While weight loss is often the goal of weight management, weight management in older adults should go beyond weight loss to focus on functional health outcomes, comorbidity improvements, and harm reduction. Beverly Tchang, MD Weight management in older adults requires greater mindfulness and clinical nuance than in younger populations, owing to the increased risk of potential harm. Aging is commonly accompanied by a rise in medical complexity — older adults are more likely to live with multiple chronic conditions and to take several medications, which adds important layers of consideration when pursuing weight loss interventions. Over 50% of older adults have three or more chronic diseases. These overlapping conditions demand coordinated, multidisciplinary care. Within this context, clinicians must consider how meaningful weight loss might improve obesity-related complications, while also weighing the potential for unintended consequences that can arise from rapid or unmonitored changes in health status. Polypharmacy is a common concern in geriatric care and adds to the complexity of weight management. Among adults aged 65 and older with Medicare insurance, the median number of prescription medications was four. Older patients may be prescribed medications associated with potential weight gain, such as first-generation antihistamines or beta-blockers. Polypharmacy not only increases the risk of adverse drug-drug interactions but also necessitates vigilant monitoring during weight loss, particularly when medications are weight-dependent. A case report on thyrotoxicosis in the setting of 30% weight loss with tirzepatide highlighted the importance of adjusting weight-based medications like levothyroxine. Because obesity is the root cause or contributor to several other cardiometabolic diseases, obesity treatment has been demonstrated to improve several weight-related consequences. The Look AHEAD trial of adults with type 2 diabetes reported an average 8.6% weight loss and associated improvements in blood pressure, lipid profiles, and glycemic status. Obesity pharmacotherapy advances, which now grants access to 15%-20% weight loss thresholds, have been associated with de-escalation of antihypertensive and lipid-lowering therapies. In a secondary analysis of trials for semaglutide 2.4 mg, 34% vs 15% of participants experienced a discontinuation or dose reduction in their anti-hypertensive medication, while maintaining normal blood pressures. While such observational data is insufficient to establish recommendations, they implore attention: As weight loss is achieved, medication regimens should be regularly reviewed for potential deprescribing to reduce the risk of overtreatment, adverse effects, and polypharmacy-related complications. Beyond cardiometabolic disease, sarcopenia— the age-related decline in muscle mass and function — is another critical consideration. Clinicians should focus on evidence-based nutrition and physical activity recommendations demonstrated to preserve lean mass and function. Higher protein intake has been consistently demonstrated to preserve lean mass or improve body composition in the setting of weight loss. High protein diets (ie, greater than 0.8 g/kg/d) are commonly recommended alongside a progressive strength training program. In a weight loss study of adults with obesity, participants were randomized to a high protein supplement vs an isocaloric supplement and participated in a resistance exercise program 3 times/week for 13 weeks. While weight loss and fat mass loss between groups did not differ, those on the higher protein supplement (1.1 g/kg/d of protein) gained 0.4 kg +/- 1.2 kg of appendicular muscle mass while those on the isocaloric supplement (0.85 g/kg/d of protein) lost 0.5 +/- 2.1 kg ( P =.03). Similar studies focusing on resistance training have replicated these benefits across studies. A systematic review and meta-analysis of six randomized controlled trials that enrolled older adults with obesity compared weight loss via caloric restriction alone vs weight loss via caloric restriction plus resistance training; resistance training reduced 93.5% of the lean body mass loss associated with calorie restriction. Additionally, the strength-to-lean body mass ratio improved when resistance training accompanied calorie restriction compared to calorie restriction alone (20.9% vs -7.5%). However, muscle preservation is only half the story. Bone health is an equally important concern during weight loss in older adults. Rapid or sustained weight reduction can have unintended effects on bone density, which in turn can increase the risk of fractures. Few studies have examined the incidence of fracture rate after long-term and sustained weight loss. In the aforementioned Look AHEAD study of adults with type 2 diabetes, no significant difference in incident fracture rate was observed over a median of 9.6 years (373 participants randomized to intensive lifestyle intervention vs 358 randomized to standard diabetes education), but a composite of the first occurrence of a hip, upper arm, or shoulder fracture was found to be 39% higher in the intervention group. Long-term outcome studies examining risk of fractures with medical weight management have not been conducted, but the increased risk of fractures observed among individuals who have undergone bariatric surgery informed guidelines to recommend earlier, repeated osteoporosis screening and higher vitamin D supplementation to optimize bone health. Overall, obesity management in older adults requires a careful and tailored approach that is attentive to comorbidity management and that prioritizes risk mitigation. Increasingly, the effects of obesity on all aspects of a person's quality of life is being recognized, and patients should be informed on how weight loss may interact with coexisting medical conditions, medication regimens, and musculoskeletal health. Clinicians who treat obesity in older adults should be prepared to manage patients across these intersections, or coordinate care with registered dietitian-nutritionists, exercise physiologists, endocrinologists, and primary care professionals.
