Carlos Campos, a 72-year-old retired machinist who lives with his wife and daughter in Tukwila, Wash., says his life is looking up. He was diagnosed with type 2 diabetes about 20 years ago, but about a year ago his blood sugar levels started to drop. I was happy to see the dramatic improvement. , when I started drinking Ozempic.
During a weekly, hour-long appointment, he shared his improved numbers via a continuous glucose monitoring app with Maureen Chomko, a diabetes educator who works with his doctor at NeighborCare Health near South Seattle.
“I tried many different types of drugs, but I had the best control when I started taking Ozempic,” Campos said.
Medicare subsequently stopped covering Ozempic. His cost per vial ballooned from $47 a month to $239 a month, more than he could afford. In insurance parlance, he ran into a Medicare “donut hole,” a gap in prescription coverage during which people would have to pay thousands of dollars more in drug costs out-of-pocket. Because he had to take more insulin in addition to the antihypertensive and blood thinners prescribed for his other cardiovascular problems, his blood sugar levels rose dramatically and erratically, leading to high and low blood pressure. The lows have become more intense.
The explosion of GLP-1 drugs like Ozempic has brought with it the attendant challenge of logistics that are too complex for a single physician to handle. To fine-tune prescriptions and ensure patient access, medical practices are increasingly relying on team approaches. This is not easy for many patients with multiple chronic conditions, but it is even more difficult when patients also face food, housing, and employment insecurity.
“When you talk about things that they’ve touched on, like arthritis, sleep apnea, heart failure, kidney disease, heart disease, diabetes, weight loss, they’re like absolute miracle drugs,” Beth’s Cardiac Critical Care Unit says Dhruv Kazi, director of . Israel Deaconess Medical Center said of GLP-1 drugs: But, he said, “it will take more than this molecular breakthrough for these drugs to have the greatest impact on public health.” It will take longer than a clinical trial. We need to understand the implementation science and the health economics involved so that people who benefit from these drugs can access them and take them long-term. ”
of Diabetes treatment standards 2025A paper published in December by the American Diabetes Association supports a team approach to diabetes treatment, a theme discussed at an academic conference in June.
“Obesity is a chronic disease that, like high blood pressure, heart disease, and diabetes, requires ongoing care and preventing weight gain is critical,” said Nouha El-Sayed of the Joslin Diabetes Center. told STAT. He is also senior vice president for healthcare improvement at the American Diabetes Association, where he oversees standards of care for diabetes and obesity. “Expanding the team by involving others in the full range of practice is something we strongly believe in.”
Dietitians and nurses are stepping up to fill gaps in patient care, whether the goal is better control of diabetes or weight loss to reverse other chronic conditions. The team-based model works in independent clinics that cannot accept patients covered by Medicaid or Medicare, or in federally qualified community health centers like NeighborCare that primarily serve people covered by Medicaid or Medicare. It’s gaining momentum.
When Campos was unable to afford Ozempic due to Medicare claims, his older diabetes medication was no match for him. That’s when Chomko helped Campos apply to the patient assistance program of Novo Nordisk, the maker of Ozempic, to get the drug for free. She says that’s another benefit of having a diabetes specialist on the team.
“Primary care physicians don’t know about patient assistance programs and have to fill out nine-page applications, coordinate with patients to obtain the necessary documentation, and follow up with multiple phone calls about the status of their applications. “I don’t have time to do anything,” she said of two Medicare patients whose coverage was cut off. “When I hit the donut hole, everything fell apart and I needed even more insulin.”
A new class of drugs that lead to incredible weight loss was originally developed and approved for type 2 diabetes, and has since been used to treat not only obesity but also potentially many other chronic diseases, from addiction to Alzheimer’s disease and heart failure. It’s easy to forget that we’ve had success in treating . Kidney disease.
When taken to control diabetes, special attention should be paid to proper dosage and nutritional needs, as it is a powerful treatment. Calibration becomes more urgent when insulin levels are critical, not just when shortages leave pharmacy shelves empty or patients fall into donut holes. When medical questions arise amidst food, housing, and employment insecurity, the need for on-demand, team-based care increases.
Adjusting a patient’s medication regimen takes time. Bariatric clinics, staffed by teams of experts ranging from doctors to nurses and other skilled health care providers, are not available to all patients in the United States due to geography and insurance coverage.
“My people are losing housing and losing control of their blood pressure,” said Chomko, a registered dietitian and certified specialist in diabetes care and education. “I’m there to help the health care workers do whatever else they need to do so they can treat diabetes in the clinic.”
When patients with diabetes begin taking these medications, the dietitian, diabetes educator, or nurse should consider not only the initial dose but also how to titrate insulin, as GLP-1 reduces the required amount. There is. Nurses have prescribing privileges, and certified diabetes care and education professionals are trained to adjust medication regimens.
The first few weeks can be tough. If the goal is not only to improve blood sugar control but also to achieve better health through diet, it may be helpful to have patients eat broccoli, salmon, or brown rice when they are nauseous and feel like all they can stomach is crackers. It can be difficult to imagine eating .
At NeighborCare, the team at every primary care clinic includes a nutritionist and diabetes educator who are available for one-hour visits, frequent check-ins, and behavioral counseling, for example, if a patient is having trouble paying their utility bills. Referrals to social workers are also available. As a medicine. “We can really dig into the factors and barriers that make diabetes management difficult,” Chomko says.
Moving to a regular dose is life-changing for patients as they no longer need to inject the hormone with every meal, as the drug makes insulin work better as they eat less.
Until they become inaccessible due to shortages or insurance lapses.
Scarcity impedes patient progress and leads to treatment interruptions, but so do access barriers. a JAMA Network Public Survey Announced in May reported disparities in who stopped taking GLP-1 drugs. The odds of quitting after 1 year were significantly higher for black or Hispanic men, those on Medicare or Medicaid, or those living in areas of high social need.
Affordability of these drugs is a challenge, but we still don’t know why more than half of people who start taking them stop taking them after a year and end up regaining the weight they lost.
Low-socioeconomic-status populations, with their disproportionate burden of obesity and diabetes, will have the hardest time affording and sticking to these drugs at current prices, potentially exacerbating U.S. health disparities. There is. Kazi is a co-author on a paper published in November. JAMA Cardiology It is estimated that more than half of adults in the United States are eligible to take the GLP-1 drug semaglutide to lose weight, manage diabetes, or prevent recurrent cardiovascular events.
“These drugs have the potential to be transformative in their impact on people’s health, but only if we can unravel all of these real barriers to access and affordability. ”Kazi said. “I think a partnership with a nutritionist and an exercise physiologist can be very helpful, not only in the process of initiating and titrating medications, but also when discontinuing medications.”
GLP-1 generally needs to be taken indefinitely to maintain diabetes and obesity control. For Carol Gordon, weight loss has been a lifelong mission. In the 1990s she took fen-phen, a combination of: Fenfluramine and Phentermine This has resulted in the significant weight loss that we are now hoping for with new obesity drugs. However, fen-phen was withdrawn from the market in 1998 after it developed serious side effects, including dangerous heart valve damage.
Fenfen was the first of many attempts to lose weight, but Gordon had no choice but to give up. Since then, she has worn a lap band around her abdomen to limit her food intake, but in a familiar pattern, the weight she lost has been regained. “I’ve dealt with this all my life,” she said.
It wasn’t until she started Ozempic that she achieved her goal, and gradually lost weight and kept it off. Now 68 and retired from a career as a vocational rehabilitation counselor working with the sick and injured, she swims for an hour every day, gardens, and volunteers at the Seattle Humane Society. Masu.
She’s also surprised that her trusted advisor, Big Sky Medical Wellness nurse Colleen Dawkins, warns her against losing too much weight as she gets older. These were words I had never heard from a healthcare provider before.
Dawkins patients begin treatment with an online meeting before treatment begins to set health goals that are not necessarily numbers on a scale. Education is key, and nutrition is key, as a loss of appetite is expected at first, if not nausea. Is there a history of eating disorders? How do they feel about being on medication for life? Do they want to be more active and get out of pre-diabetic territory? What about other medications he is taking?
“If we can find a way to bring these resources to primary care, I think more patients will benefit from the drug, the drug will be better tolerated, and we’ll actually have better outcomes overall. ” said Dr. Dawkins, who previously practiced in an obesity center but now practices. Collaborate remotely with doctors and patients. Her patients have private insurance and submit monthly bills for reimbursement. She first trained as a nutritionist and then became a nurse, working in a clinic offering metabolic surgery and non-surgical weight management.
Despite the struggles of limiting doses to deal with sporadic shortages and high costs, Gordon has not had to deal with multiple complications. Unlike many people for whom obesity is just one chronic disease, her blood sugar, blood pressure and cholesterol are under control. She feels like her energy is coming back to her. She enjoys feasting within limits.
“I still like sweets at night, but I’ll have about one salted caramel,” she said. “I know a little bit goes a long way.”
Campos, who has been back at Ozempic for two months, admits that although he cannot say he is healthy, he is feeling better. His daughter believes he is still recovering from the interruption of Ozempic therapy. She also takes Ozempic thanks to her employer-based insurance.
“I still get my medication, and I feel like my dad needs it much more than I do, but he won’t be able to get it until Maureen comes across that program at Novo Nordisk. “It was,” Carla Campos said. . “I’m also diabetic, so I felt it was really unfair to see him lose access to it.”
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