IMA Weight Management
Session 2
Shyam Sundaresh, MD, Dipl. ABOM
Recap of Session 1
Patient-First Language
> obesity, not obese
# class III obesity with comorbidities including HTN and GERD
achieved {how much weight loss} with {what intervention} over {how much time}
Screening Tests
> MASLD, dyslipidemia, dysglycemia
Direct Observation
> Apply motivational interviewing and seek feedback
Objectives
1. Compare risks and benefits of antiobesity medications in order to prescribe them safely and effectively for guideline-eligible patients. (Medical Knowledge)
2. Collaborate with other disciplines for guideline-eligible patients e.g. community resources and surgical and medical specialties to effectively treat obesity. (Systems-Based Practice)
Objectives
1. Compare risks and benefits of antiobesity medications in order to prescribe them safely and effectively for guideline-eligible patients. (Medical Knowledge)
2. Collaborate with other disciplines for guideline-eligible patients e.g. community resources and surgical and medical specialties to effectively treat obesity. (Systems-Based Practice)
Select Antiobesity Medication (AOM) Based on Insurance
NY Medicaid
NO COVERAGE OUT-OF-POCKET
Medicare
ASCVD Wegovy
(hx MI, stroke, symptomatic PAD)
Commercial MAYBE COVERAGE FDA-APPROVED
Select Antiobesity Medication (AOM) Based on Insurance
NY Medicaid
NO COVERAGE OUT-OF-POCKET
Medicare
ASCVD Wegovy
(hx MI, stroke, symptomatic PAD)
Commercial MAYBE COVERAGE FDA-APPROVED
Out-of-pocket options (NY Medicaid & Medicare)
.ANTIOBESITYMEDICATIONS
Out-of-pocket options (NY Medicaid & Medicare)
1) phentermine/topiramate daily (10% weight loss)
separate generics = $30/mo (GoodRx) BEST
Qsymia = $100/mo (direct delivery pharmacy)
2) metformin XR 750mg 1-2x/d (5% weight loss but LOW EVIDENCE)
= $0/mo
3) naltrexone/bupropion bid (6% weight loss)
separate generics = $30/mo (GoodRx) WORST
Contrave = $100/mo (direct delivery pharmacy)
tolerability
Patients without T2D with commercial insurance in NY
FDA-approved for obesity
Zepbound (tirzepatide)
Wegovy (semaglutide)
Saxenda (liraglutide)
Qsymia, Contrave, Orlistat
Don’t bother if Medicaid or Medicare
FDA-approved for T2D
Mounjaro
Ozempic
Victoza
Trulicity
Bydureon
unless ASCVD (MI, CVA, sxPAD)
Objectives
1. Compare risks and benefits of antiobesity medications in order to prescribe them safely and effectively for guideline-eligible patients. (Medical Knowledge)
2. Collaborate with other disciplines for guideline-eligible patients e.g. community resources and surgical and medical specialties to effectively treat obesity. (Systems-Based Practice)
Objectives
1. Compare risks and benefits of antiobesity medications in order to prescribe them safely and effectively for guideline-eligible patients. (Medical Knowledge)
2. Collaborate with other disciplines for guideline-eligible patients e.g. community resources and surgical and medical specialties to effectively treat obesity. (Systems-Based Practice)
Intensive Behavioral Therapy (≥ 12 sessions/y) = 5%
Intensive Behavioral Therapy (≥ 12 sessions/y) = 5%
Intensive Behavioral Therapy (≥ 12 sessions/y) = 5%
MOST do not achieve clinically significant weight loss with less sessions than that
BUT, believe and support your patient’s choice!
Intensive Behavioral Therapy (≥ 12 sessions/y) = 5%
Diabetes Prevention Programs ($0)
Intensive Behavioral Therapy (≥ 12 sessions/y) = 5%
Diabetes Prevention Programs ($0)
.IMADPP
Intensive Behavioral Therapy (≥ 12 sessions/y) = 5%
Diabetes Prevention Programs ($0)
.IMADPP
Weight Watchers, Jenny Craig, Noom, etc. ($10-20/mo)
MBS is recommended for:
1) patients with BMI ≥ 30 and T2DM
2) patients with BMI ≥ 35 regardless of comorbidities
3) patients with BMI 30.0-34.9 who do not achieve durable improvement of weight or comorbidities with nonsurgical methods
(The ASMBS guidelines were updated!!!!!)
Summary
NY Medicaid and Medicare does not cover AOMs
.ANTIOBESITYMEDICATIONS (out-of-pocket options are 0-$30/mo)
Commercial insurance may cover FDA-approved AOMs
(only erx T2D medications if patient has T2D)
Refer patients:
Diabetes Prevention Programs (5% weight loss) .IMADPP
Metabolic-Bariatric Surgery (BMI ≥ 35 regardless of comorbidities)
59yoM s/p LSG now class II obesity, HTN, and prediabetes with NY Medicaid
Options?
59yoM s/p LSG now class II obesity, HTN, and prediabetes with NY Medicaid
- Diabetes Prevention Program
- Separately prescribed phen/top, nal/bup, metformin
- Revision surgery
34yoF class II obesity and PCOS who heard weight loss can improve fertility, with commercial insurance
34yoF class II obesity and PCOS who heard weight loss can improve fertility, with commercial insurance
- Diabetes Prevention Program
- metformin
45yoM class II obesity and T2D looking for options that will work with busy schedule, working a full time job and single father, NY Medicaid
45yoM class II obesity and T2D looking for options that will work with busy schedule, working a full time job and single father, NY Medicaid
- Mounjaro, Ozempic
- Noom, Weight Watchers
65yoF class I obesity, ICM rEF, AF with stroke, CKD Stage IIIb, Medicare
65yoF class I obesity, ICM rEF, AF with stroke, CKD Stage IIIb, Medicare
- Wegovy
- Diabetes Prevention Program
- surgery
89yoF class I obesity, well-controlled HTN, commercial insurance
89yoF class I obesity, well-controlled HTN, commercial insurance
- Diabetes Prevention Program
- metformin, (phen/top, nal/bup, GLP1A with caution)
51yoM class II obesity, prediabetes, HTN, glaucoma, bothersome GERD, with NY Medicaid
51yoM class II obesity, prediabetes, HTN, glaucoma, bothersome GERD, with NY Medicaid
- Diabetes Prevention Program
- metformin
- surgery except not LSG
62yoF overweight BMI > 27, HTN, dyslipidemia with NY Medicaid
62yoF overweight BMI > 27, HTN, dyslipidemia with NY Medicaid
- Diabetes Prevention Program
- phen/top, nal/bup, metformin
DO NOT COMPLETE UNTIL DONE SEEING PATIENTS
This is a 5 minute voluntary survey to improve the weight management curriculum.