Hur is a professor of medicine and epidemiology, and a healthcare innovations researcher. Lim is a research analyst.
Anti-obesity medications have been making major headlines in the news. From nationwide shortages to publicized usage by celebrities, there is constant buzz about how these medications can lead to weight reduction in a relatively short time frame. However, the majority of this conversation has focused on adults. With obesity currently affecting more than one in five children and adolescents in the U.S., anti-obesity medications are an important treatment option for this population too.
Earlier this year, the American Academy of Pediatrics (AAP) released its first clinical practice guideline for the treatment of obesity among children and adolescents. They now recommend pediatricians and other healthcare providers offer anti-obesity medications as an adjunct to intensive health behavior and lifestyle treatment for adolescents 12 years and older. This announcement followed the publication of results from several clinical trials that assessed the safety and efficacy of liraglutide (Saxenda), phentermine/topiramate (Qsymia), and semaglutide (Wegovy) for adolescent patients with obesity, and their subsequent FDA approvals for treating obesity in adolescents.
With the release of the AAP guidelines and clinical trial data, we pursued a timely evaluation of the cost-effectiveness of anti-obesity medications for adolescents with obesity.
Cost-effectiveness analyses allow us to compare the relative costs and health outcomes of different interventions. The goal is to determine which intervention leads to health outcomes that are “worth” its associated cost. In our study, recently published in JAMA Network Open, we evaluated the cost-effectiveness of lifestyle counseling alone and accompanied by liraglutide, mid-dose phentermine/topiramate, top-dose phentermine/topiramate, and semaglutide for the treatment of obesity in adolescents.
We estimated health outcomes using quality-adjusted life years (QALYs), which adjusts total years lived by a patient based on the quality of their health. For example, if a patient lived 5 years in poor health they would have fewer quality-adjusted life years than that of a patient who lived 5 years in perfect health. In our analysis, quality-adjusted life years was primarily affected by changes in weight. Quality-of-life was assumed to increase with weight reduction and decrease with weight gain.
We found top-dose phentermine/topiramate to be the preferred and the only cost-effective treatment among the interventions compared in our analysis. This means within the context of the U.S. health system, top-dose phentermine/topiramate had the most health benefits at an acceptable cost. While we projected top-dose phentermine/topiramate to be the only cost-effective treatment, semaglutide resulted in the greatest gain in QALYs as it was associated with the greatest weight reduction among all strategies. However, the benefits of semaglutide over top-dose phentermine/topiramate were not substantial enough given semaglutide’s much higher cost. We used an incremental cost-effectiveness ratio (ICER) to determine the cost-effectiveness of one intervention compared with another. In the U.S., an intervention is typically considered cost-effective if its ICER is below $100,000 per QALY gained. We estimated that the ICER for top-dose phentermine/topiramate was $56,876 per QALY gained when compared with lifestyle counseling alone after 5 years. In comparison, we found the ICER for semaglutide was $1.1 million per QALY gained. Therefore, semaglutide was not cost-effective by a large margin as it is much more expensive than top-dose phentermine/topiramate (monthly cost $1,295 vs $191). Additionally, semaglutide only had a slight increase in QALYs compared to that of top-dose phentermine/topiramate over 5 years (3.181 QALYs vs 3.127 QALYs). We estimated that the cost of semaglutide would need to be reduced by 85% to be considered a cost-effective treatment after 5 years.
Over a 5-year time horizon, liraglutide and mid-dose phentermine/topiramate were “strictly dominated” strategies, meaning they resulted in higher costs and fewer QALYs when compared with the other strategies we examined. Therefore, they were excluded from any further cost-effectiveness analysis as they represent an inefficient use of resources when compared to other available strategies.
While our analysis estimates that anti-obesity medications can be cost-effective for adolescents on a relatively short time horizon, our results need to be considered in the context of several limitations. There is a current lack of long-term data regarding the use of anti-obesity medications by adolescents. Clinical trials only provided follow-up data for about 1 year. Therefore, we made several assumptions in order to project outcomes to 5 years. It is unclear if weight reduction is maintained during long-term treatment and how much weight regain may occur after discontinuation of treatment in adolescents. It is also possible we may have underestimated the cost-effectiveness of anti-obesity medications as they may prevent the development of comorbidities in adulthood. To properly evaluate the efficacy and safety of anti-obesity medications in adolescents, longer term studies are needed to evaluate how early and aggressive treatment may affect future health outcomes during adulthood.
Overall, our analysis found that liraglutide, phentermine/topiramate, and semaglutide were all effective in terms of weight reduction. They were associated with a greater gain in QALYs compared to lifestyle counseling alone. However, despite the effectiveness of these medications, costs are a major barrier to uptake by patients. Most state Medicaid plans do not cover anti-obesity medications, and private insurance often require patients to meet strict criteria before approval. High out-of-pocket costs may deter patients from receiving the early, aggressive treatment the AAP now recommends. If we expect patients to begin treatment with anti-obesity medications and adhere to treatment on a long-term basis, these patients should have easy and affordable access to these drugs. Even if anti-obesity medications are effective in reducing weight among adolescents, these health outcomes are not achievable if many patients are not able to obtain the drugs.
Chin Hur, MD, MPH, is a professor of medicine and epidemiology, and director of Healthcare Innovations Research & Evaluation (HIRE) at Columbia University Irving Medical Center in New York City. Francesca Lim, MS, is a research analyst with HIRE at Columbia University Irving Medical Center.