SMC & NICE eligibility for GLP-1 medications will be too narrow and exclude many obese and sick people.

[domestictea]

Earlier this month the Scottish Medicines Consortium (NICE to follow soon if it hasn't already) approved Mounjaro for for the treatment of obesity in adults which is great of course and hopefully it will mean that more people can get help with their obesity.

I was sad to see though that the criteria for getting these medications still includes the requirement that as well as a BMI over 30 the patient must also have at least one weight related co-morbidity. While this may sound reasonable to many the reality is that for people like myself is that we can be morbidly obese and have devastating health implications from our obesity but still not meet the criteria for any support on the NHS for weight management.

In my case (I am mid 40's) at my highest weight I was 255lbs with a BMI of 42 and a body fat percentage of 54%. I suffered from severe Chronic Migraine which only became chronic due to my weight gain after an accident left me unable to walk for a prolonged period of time. My migraines are so severe and so frequent that I haven't worked now in over 10 years. My migraines are refractory and so far no medication has helped them, my neurologist believes weight reduction would be the most helpful course of action but I have been told repeatedly by my GP that I do not qualify for any assistance with weight loss because I do not have any additional weight related conditions which specifically means high blood pressure, diabetes, high cholesterol or heart disease. I have literally been told to go away and come back when I have high blood pressure or diabetes to get help then, my actual health issues are not taken into account. There are people who become morbidly obese who do not develop metabolic disease, perhaps due to genetic reasons. However that doesn't mean that our health isn't affected negatively by obesity in other ways such as poor mobility, joint pain and other kind of chronic pain.

I have tried everything over the years to lose weight and always struggled and failed until recently starting on Mounjaro and now finally I am consistently losing weight week after week, month after month and all the time my health improves bit by bit. I am doing the same things I did before but now it is actually working! I am currently paying privately for this medication out of my very small savings and I am hoping that when lose more weight my migraines will be improved enough that I can start to work again but I also worry that when I stop the medication I will regain and my health will go backwards. If I was eligible on the NHS then I might have a chance to access a maintenance dose in future to try and keep my weight off and to support a return to work but unless I develop one of the narrow criteria of weight related health conditions then I have no chance.

A person my height who is 50lbs + lighter than be with even slightly elevated blood pressure would potentially be eligible for these medications to lose weight as well as ongoing maintenance while morbidly obese people like myself with multiple health issues impacted by my weight would be excluded because we don't fit the very narrow criteria. I do not grudge anyone access to these medications at all, if they could help someone then I think they should be able to get them but I just think it is short sighted to exclude those who for whatever reason haven't developed the few conditions listed even when they are at a very high weight / body fat percentage.

Currently I can afford this medication and I will do all I can to try and keep the weight off without needing additional help but it just is frustrating that it looks likely people like me would continue to be excluded from any help with obesity which is a disease in and of itself.

https://www.pharmiweb.com/press-release/2024-06-11/scottish-medicines-consortium-accepts-tirzepatide-mounjaro-for-obesity-in-eligible-adults

I agree OP. Last year my GP Practice referred me to Weight Management with a BMI of 38 and chronic asthma which is worse when my weight is higher. I too have tried every diet and club you can think of.
I was declined as asthma is not on the list of included conditions (although COPD with largely similar symptoms is) and, like you, was told I needed to be fatter or sicker to get help.

My only concern about GLP-1s on the NHS is that people often do not value and engage with treatments provided at no cost. I know numerous T2 diabetics who have had GLP-1s and not made the effort to change diet and exercise that I see those buying them making

@QueenOfHiraeth I am sorry to hear that you too were refused help. It is really frustrating that only a few select conditions are considered and that obesity itself isn't enough to warrant help. If you are at the point where you are asking your GP specifically for help with your weight to improve your health and have a list of things you have tried and failed at then I think that shows a person who is more than ready to engage with any help available.

I agree that it is possible that some people might see GLP-1's for free on the NHS as a quick fix to weight loss and as a way to lose weight while not bothering with changing their diet and habits and ideally use of these medications would be part of a larger programme to assist with diet and lifestyle change although that would be very expensive I imagine.

Reading the detailed advice from the SMC, the restriction to BMI 30+ and a weight-related comorbidity was requested by the company who make the drug (point 1.3 here if you're interested https://www.scottishmedicines.org.uk/media/8389/tirzepatide-mounjaro-final-may-2024-amended-050624-for-website.pdf)

This means that the clinical and economic case presented by the company for assessment will have only considered patients with these characteristics. SMC/NICE have to consider the evidence presented and make a decision on that basis.

@ChairOfInvisibleStudies Perhaps that is true but it still is about restricting access due to cost most likely as opposed to clinical need. If the manufacturers didn't want these medications used for weight loss in the case of obesity why is it so easy to get a prescription for it privately?

It's not cost per se - it's cost effectiveness, which combines clinical benefit and cost. Essentially the manufacturer has to demonstrate a certain amount of clinical benefit to justify the cost. I don't have any inside information on this particular drug (and wouldn't share it if I did!) but if the manufacturer is proposing a restricted population then the most likely explanation is that the data don't demonstrate enough clinical benefit for patients without a weight-related comorbidity to justify the price they want to charge the NHS. Of course, the manufacturer could lower the NHS price to achieve cost effectiveness in a broader population...

Of course I'd like to get mounjaro on prescription from the GP for £10 rather than £200 but given the cost to the nhs of the medication they have to ensure it's financially worth it. Of course obesity raises the risk of other health issues but frankly my obesity doesn't cause me any issues NOW that cost the nhs money so why should the nhs pay for my medication now? In 10 years I am likely to have some obesity related health issue if I don't lose weight and at that point I would argue it's financially worth it. Your migraines sound miserable and if they are clearly related to your weight then that should qualify but there needs to be clear evidence that it's weight related rather than just a strong correlation.

This is certainly down to what is best value for money. Hypertension, CVD and diabetes are incredibly expensive in the long run to the NHS. These conditions require lifelong monitoring and medication and are related to even more expensive hospital admissions and A&E attendances. Anecdotally I know people with T2 who do not comply with their diet needs and meds and who are putting themselves at risk of severe health complications further down the line )I think the risks of T2 are often not taken seriously enough)

in England, diabetics get free prescriptions. It’s even more complex that there are no prescription charges in Scotland, so there will need to be be some criteria to ensure that the highest risk groups are accessing the drug in order to potentially make the biggest saving.

As you age you start to cost the NHS more money. The NHS nowadays only works on the basis that if you need emergency care at any age it’s technically there but the top percent of high needs patients use up the majority of the services and funding - chronically sick and elderly/frail. If you open out something like this to a wider cohort of patients it just costs too much money. The concept is that adults are meant to help themselves using self care until they become frail and need healthcare services. The government has been promoting this for many years with the onus on the patient to do the work. Push to Self care policy is only increasing. I am not sure people realise this. But the expectation is that you will care for yourself until you reach a certain threshold where you cannot.

In reality virtually no one can get an English NHS script for weight loss drugs, and those who do qualify for help or even bariatric surgery are waiting up to 2 years for an assessment. The system cannot realistically cope with the number of patients it would create

this is not my subjective opinion on obesity it is a commentary about NHS policy (in my experience and opinion)

In the eyes of the NHS, obesity falls into this category of self care. I can’t see it ever falling into the remit of the NHS in England purely due to cost because the NHS is struggling to function as it is. Scotland devolving it to primary care is a huge step

@DracoDormiensNumquamTittilandum I don't disagree with your overall premise but just to say that this and similar drugs will have been evaluated over what is called a lifetime horizon i.e. they try to predict the change in length of life, quality of life and costs over the entire life of the patient to determine the cost effectiveness, precisely to try to understand the benefit of averting future health problems.

I didn't think I could afford it privately but you need to factor in how much less food you are eating . The money I saved on monthly food I spent on mounjaro and was still slightly better off . I would have met the criteria for nhs treatment but it became suddenly crucial health wise that I lose weight quickly so I bought it myself and it arrived the next day

Fantastic responses here. Frankly the proportion of the population who would try and access what is seen as a ‘cheat’ medication is too high. There are just too many fat people. Many of whom will struggle with the discipline that’s required alongside the medication and need additional NHS support.

People have to take personal responsibility and self funding comes under that. I am glad it’s working for you OP.

I struggle a bit with the arguments around personal responsibility. I definitely advocate for self care and personal responsibility for health, but with obesity I also think there are so many contributing factors outside of individual control. We absolutely live in an obesogenic environment, and the lack of regulation of the food industry horrifies me, particularly compared with the pharmaceutical industry.

I think in my ideal world I would want more regulation of the food/environment side of things, better provision of psychological support for those struggling to lose weight, and investment in tackling the link between poverty and obesity. But in the entrenched state we are currently in I do think that weight loss drugs may also have an important part to play. Something has to break the cycle, for society's sake as well as for individuals. One thing is for sure, continuing along the lines of "shame on fat people and their lack of willpower" is unlikely to be the solution.

Yes to all of it but paying for a private prescription IS taking personal responsibility. It's harsh that cost makes it prohibitive for many people but for those who can budget for it it's part of taking responsibility IMO.

It seems very short sighted. Surely it's better to treat obese people without current co morbidities, than try to reverse them once they have them?

Both from a financial and a clinical view point.

I mean, they give smokers help to quit ahead of them having illness.

Yep, fair play to people who put their money where their mouth is (pun fully intended) and have the means to do so. I guess I'm just sensitive to the arguments around this tipping over into the arguments you definitely do see in other places, that personal responsibility = "fat people are lazy and weak willed and why should they get magic pills to help them sort out their moral failings". Which often comes up when discussing obesity-related costs to the NHS...

Stopping smoking interventions are a LOT cheaper than weight loss injections though. It's just cost benefit analysis.

As above, just to highlight that the drug manufacturer themselves didn't present clinical or economic evidence for this group of people to the SMC (and presumably NICE at the moment). The manufacturer asked that the population to be considered should be adults with BMI 30+ and a weight-related comorbidity.

The reason for this will not be made public knowledge but one possibility is that the manufacturer couldn't provide evidence for enough clinical benefit in other patient groups to justify the cost. Maybe this will change as more evidence comes out from ongoing studies, but NICE/SMC can't make decisions on 'it stands to reason', they have to evaluate it properly based on the available clinical data and economic modelling.

I agree, I was never weak willed and lazy, I was sick and fighting a battle I could not have won until this medication became available. I am not an indulgent person, I don't smoke, or drink alcohol, I have never been in debt or cheated on a partner i.e. I am not some morally weak individual who just couldn't help stuffing her face with treats or couldn't be bothered to haul herself off the sofa and wants a miracle drug to magic her fat away. I do understand that people are worried that people will just want a drug that lets them eat cake and pizza all day and stay slim, that would be an abdication of personal responsibility. However that isn't how this medication works at all, you still need to do all the things any weight loss requires, to log your food and calories, to increase movement and exercise and so on, this drug just helps people with chronic obesity overcome the effects of that disease to help them have results with those efforts as opposed to getting none.

The sooner it is accepted that obesity is a disease in and of itself and that many obese people require help to lose weight the better rather than waiting until people have liver disease or heart problems.

Our environment is highly obesogenic, foods are designed by scientists in labs to have just the right ratios of fat and sugar to essentially be addictive to people even though they have virtually no other nutritional benefits. Perhaps governments should levy a tax on multinational companies who manufacture and sell these "foods" to people in order to redress some of the damage done by them. It is also now known that some people have differences in their biodome or their reward centre or insulin sensitivity that means that some people are more vulnerable to living in an obesogenic environment. Why don't these companies take some "personal" responsibility? No instead they are all panicking that glp-1 medications will hurt their profits and racing to devise new UPF junk foods that will be markets directly to people on these medications.

I totally agree, the initial cost would be high but ongoing it would save the NHS money and would mean many people could also return to either paid work (i.e. create new tax payers) or take up caring work for children or family which would in turn save the government money.