A glowing endorsement of GLP1s by cardiologists

While the research behind GLP1 has never been under question, many people report difficulty finding primary physicians who were willing to recommend GLP1s as a first stop in a weight management journey.

While a lack of evidence is rarely an issue, the objections to GLP1 as the first approach in getting body weight under control have been varied:

• Taking the "easy way" is sometimes seen as reducing discipline
• Hesitance around side effects were as of yet under-explored
• Affordability and Insurance coverage issues

Without commenting on the validity of such objections, the results that have been generated by GLP1 Receptor Agonists have spoken for themselves – GLP1 is now recommended by the American College of Cardiology as a first-approach for weight management:

To summarize the guidance, the conclusion is an easy read:

Beyond improvement of CVD risk factors, third-generation obesity medications (NuSH therapies) have been shown to reduce adverse cardiovascular events among those with obesity and established atherosclerotic CVD and/or HFpEF. [..] Obesity management by the cardiovascular community needs to be embraced, given both the prevalence of obesity and the impact it has on many forms of CVD.

While the end pint is muted, reading the guidance closely shows a massive appreciation for the positive impact that GLP1s have on cardiovascular health.

The biggest problem? Access

Let's start with the bad news (as most are already familiar with the benefits of GLP1s) – the biggest problem that the ACC was able to find was access:

Despite profound cardiovascular and weight loss benefits with NuSH therapies, medication coverage serves as a major barrier for patients.¹³³ Whereas the average yearly cost for semaglutide, liraglutide, and tirzepatide in the United States is $14,080, $15,738, and $8,126, respectively, cost is significantly lower in other countries (eg, $2,066 for liraglutide, Switzerland).¹³³

While Medicare Part D does cover GLP1s, the ACC notes that this is not for only obesity as a primary reason:

NuSH therapies are covered by Medicare Part D for patients with obesity and other comorbid conditions, including T2DM and specific CVD diagnoses; however, these medications are not covered for obesity alone.¹³⁴ Initial strategies to improve access to NuSH therapies include identifying individuals most likely to benefit, close monitoring of treatment outcomes, and price negotiations.¹³³

With the context on obesity as a debilitating disease, the ACC highlights the need to increase accessibility (and help people avoid turning to gray market or other compounded formulations).

How GLP1s benefit patients

The newly published clinical guidance mostly covers what those who have been following GLP1s already know, but it's worth covering again mostly because of the source of the endorsement – the ACC is a trusted institution that is certainly qualified to comment on cardiovascular effects of medication.

Here are the highlights:

Lifestyle changes alone may not reduce cardiovascular risk

Weight loss through lifestyle changes alone does not always result in reduction of adverse cardiovascular events

Somewhat counter-intuitively even taking the "hard path" may result in worse outcomes with regards to cardiovascular health.

GLP1s are more effective and less risky than alternatives

More effective than lifestyle interventions and with less risk than procedure-based interventions, modern obesity medications are increasingly relevant to cardiologists for CVD modification.

As most have already surmised, GLP1s are more effective than lifestyle interventions alone, and are (clearly) less risky than surgery.

Obesity is a huge problem (that GLP1s help effectively address)

As severe obesity is associated with significant reduction in life expectancy of 9.1 years in men and 7.7 years in women, treatment is critical.⁴

While most people can easily point out how devastating the effects of obesity can be, nearly a decade difference in life expectancy is outside of what most might expect for how serious the problem is.

Lifestyle changes are difficult, and failing should not be a prerequisite to trying GLP1s

Whereas prior guidelines suggested a trial of lifestyle intervention prior to pharmacotherapy,⁵⁰ data from phase 3 trials evaluating semaglutide and tirzepatide show minimal additional weight loss when combined with intensive behavioral therapy/lifestyle intervention.^51,52

Patients should not be required to “try and fail” lifestyle changes prior to initiating pharmacotherapy; nonetheless, lifestyle interventions should always be offered in conjunction with NuSH therapies.

Up until now, many physicians have stuck to recommending lifestyle changes first and foremost, which don't work reliably for many. This guidance gets at the heart of the issue – forcing people to try and fail with a solution that may not work for them is not optimal for public health.

ACC recommendations for the full list of FDA approved GLP1s

It can be easy t0 forget that there are only a handful of fully FDA approved GLP1s Receptor agonists.

The ACC inclued a helpful table which spells out treatments, positive and negative side effects (scroll left to right to see the whole table):

This is a massively helpful table, and concisely explains the current state of the art in FDA-approved treatments.

A table showing GLP1 impact on cardiovascular health

At this point most people know how effective GLP1 is for weight loss (and classically, type 2 diabetes), but some may not still be aware just how effective GLP1 is at something that isn't a stated goal – cardiovascular health.

The ACC produced another massive table that shows how effective GLP1s are in helping with cardiovascular health (scroll left to right to see the whole table):

The scope of GLP1's positive effects is wide

There is another massively impressive table detailing all the areas in which GLP1 helps alleviate issues (scroll left to right to see the full table):

This isn't new, but science moves slowly

Of course, this association of benefits of GLP1 isn't new – many papers have been released up until now, including this one from 2023:

The benefits of GLP1 receptors in cardiovascular diseases - PMC

Glucagon like peptide-1 (GLP-1) receptor agonists are well established drugs for the treatment of type 2 diabetes (T2D). In addition to glycemic control, GLP-1 receptor agonists have beneficial other effects. They act by binding to GLP-1 receptors,…

NCBI home page

While the facts aren't new, it's great to see more cardiologists taking a bold stance in support of GLP1s, unequivocally.