GHA actively considering oral GLP-1 drugs as weight management service evolves

The GHA is considering whether to offer oral GLP-1 weight-loss drugs, with the service expected to change significantly within the next decade as new treatments become available, the Director of Public Health, Dr Helen Carter, has said.

Dr Carter said the new pill form of GLP-1 was discussed by the GHA’s Drugs and Therapeutics Committee last Friday, but any decision would depend on NHS guidance, licensing, how the medicines could be provided locally and their cost.

She added the development of GLP-1 drugs had already transformed the GHA’s approach to specialist weight management, which had previously centred largely on bariatric surgery.

“Going back a few years, the GHA basically just had the bariatric surgery service,” Dr Carter said.

“The advent of these drugs and the popularity of them as well has really transformed the specialist weight management service and I think it is going to be unrecognisable probably in five to ten years' time because hopefully we'll be in the position of not needing to do bariatric surgery.”

“Hopefully these drugs will continue to be used, developed, evaluated so that there's
injections and the oral tablets.”

“Eventually in the future we won't need to do surgery but we're a long way off that yet. Dr
Carter also stressed that the medicines were prescription-only and should not be taken without medical supervision.”

Dr Carter said new oral medicines were going through clinical trials and that more drugs could become available for a maintenance phase of treatment.

In the UK, the Medicines and Healthcare products Regulatory Agency (MHRA), recently approved the first semaglutide (Wegovy) tablet for weight loss and weight management and unlike the jab, the pills do not need to be kept in the fridge.

The pills will not be offered by the NHS until it is assessed by the National Institute for Health and Care Excellence (NICE).

“I think we're going to see more oral drugs coming through for that maintenance phase but I'm not aware that any have come through licenced as yet,” Dr Carter said.

The GHA is also reviewing the wider impact of the medicines on weight trends in Gibraltar.

Dr Carter said updating the Joint Strategic Needs Assessment was on her list of priorities,
including reviewing data from primary care to establish what changes had occurred in weight
levels over time.

She said there were also significant health benefits when the medicines were used appropriately, particularly among people with a high body mass index.

Global studies had shown reductions in heart attacks, strokes and high blood pressure risks,
while the drugs were also used in the treatment of diabetes, she said.

“From a population perspective, that is a good thing,” Dr Carter said.

She said obesity was increasingly being treated as a long-term health condition rather than
simply the result of individual choices.

“We fundamentally need to help and support people to keep the weight off, because we're
now classifying obesity as a long-term health condition,” she said.

The GHA currently uses different GLP-1 medicines for different purposes.

Dr Carter said its weight-management criteria were a body mass index of between 35 and 40 alongside one comorbidity, such as diabetes or high blood pressure, or a body mass index above 40 without a comorbidity.

Mounjaro is currently reserved for diabetes treatment because of global stock issues, while Wegovy is used by the GHA for weight management.

Dr Carter said there were currently 438 patients prescribed with Wegovy through the GHA.

“Now we're looking at actually, rather than do the bariatric surgery, because it's not for everyone, can we use the drugs around preventing people from needing surgery?”

Dr Carter said the GHA would continue to review its criteria as more medicines became available and costs potentially fall.

“It’s going to become a competitive marketplace and hopefully the costs will come down and we'll be able to review our criteria,” she said.

She said that the drugs were currently licensed for two years, meaning that patients can take the drugs for a maximum of two years.

She added that patients needed to be assessed before starting treatment and monitored while taking them, and that these drugs are prescription
only.

“One thing I'd want to get across very firmly is please do not start taking these drugs,” she said.

“I’m aware people access them in the private sector, they need to be prescribed by a doctor
and the reason that's really important is we're all contributing to global surveillance of the side effects of these drugs.”

Dr Carter said adverse reactions were monitored through reporting systems, including the UK’s MHRA Yellow Card scheme.

She said deaths had been associated with GLP-1 use and that inflammation of the pancreas, known as pancreatitis, was one of the concerns being monitored.

“This is why it's really important that before you start the drugs there is an assessment by a doctor and then monitoring because we are watching that carefully in terms of who we use it on and who has the ability to benefit,” she said.

Dr Carter also raised concerns about people restricting their food intake too severely while taking the medicines.

She said the drugs were designed to make people feel full and reduce food and calorie consumption by affecting hormones linked to hunger.

If people stopped eating sufficient essential minerals, vitamins and fibre, she said, they could
develop problems including electrolyte imbalances.

However, she said her understanding was that most of the deaths associated with the drugs had been linked to pancreatic inflammation.

Another concern was weight gain after patients stopped taking the medicines.

Dr Carter said people could experience rapid weight gain if they came off the drugs without support to change their diet and exercise habits.

She also warned that losing significant amounts of muscle mass could have consequences later in life, particularly because muscle helps with balance and core stability.

“We've heard about osteoporosis risk, that's like brittle bones in older women after they've been through the menopause and this worries me that we're seeing a group of people who are going to be off and on these drugs and their risk is going to increase,” she said.