Pharmacists on the Front Lines of Obesity Management: Insights From Clinical Forums in Denver and Charlotte

Author(s)Kennedy Ferruggia, Associate Editor

Fact checked by: Ron Panarotti

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Key Takeaways

Coverage constraints dominate real-world initiation and agent selection, frequently overriding ideal timing and guideline logic even as patients increasingly request therapy through direct-to-consumer awareness.
Trial programs (STEP/OASIS/SCALE/SURMOUNT/ATTAIN) inform efficacy tradeoffs; higher-dose semaglutide increased weight loss but drove high GI toxicity, while tirzepatide CVOT noninferiority leaves comparative gaps.
Practice-based safety monitoring extends beyond labels, including delayed GI adverse effects, weight-loss–driven changes in warfarin/levothyroxine exposure, and potential heightened hair-loss risk postbariatric surgery.
Implementation strategies improved execution, including structured titration targets and Epic-based staged prescribing to prevent dose-sequencing errors and reduce patient harm from premature pharmacy fills.
Early Medicare Bridge Program experience showed rapid approvals when coded and documented correctly, but formulary shifts and class-based refill windows can strand patients in access loopholes.

Increasingly, pharmacists are leading the obesity management team.

As the pharmacologic landscape for obesity management continues to evolve, clinical pharmacists are navigating a complex intersection of evidence, access, and patient-centered care. Two recent Pharmacy Times clinical forums—one in Denver, Colorado, and another in Charlotte, North Carolina—brought together pharmacists from leading health systems to discuss pivotal trial data, real-world challenges, and practical strategies for managing obesity as a chronic disease. Both sessions surfaced consistent themes, including that coverage barriers remain the central obstacle and that pharmacists are uniquely positioned to bridge the gap.

Denver, Colorado: Evidence, Access, and the Limits of Guidelines

The Denver forum was moderated by Jennifer Trujillo, PharmD, a professor at the University of Colorado and a clinician in The University of Colorado Center for Adult Diabetes Care and Research. The group included pharmacists from the University of Colorado, Intermountain Health, Saint Joseph Hospital, and Denver Health.

Initiating Therapy

The Denver group immediately identified coverage as the dominant variable driving treatment decisions—but also acknowledged a meaningful shift in how patients now arrive at the conversation. Wesley Nuffer, PharmD, of the University of Colorado, noted that direct-to-consumer advertising has fundamentally changed the dynamic. “A person came in last week and said, ‘Medicare’s about to cover this; I want this.’ That patient-driven advocacy is a pretty new thing, and it's real,” he shared.

The group agreed that waiting for patients to demonstrate lifestyle failure before initiating glucagon-like peptide-1 (GLP-1) receptor agonists no longer makes clinical sense. “Getting [patients] on board early vs saying you need 6 months of lifestyle before we go to this seems like a waste of time, and opportunity for comorbid disease progression,” said Liza Claus, PharmD, of the University of Colorado.

Additionally, Sara Panahi, PharmD, of Saint Joseph Hospital, captured the broader tension plainly. “Starting a GLP-1 before [patients] have any clinical risk factors or comorbidities would be ideal. It’s affordability and access—unfortunately, that’s it.”

Key Trial Data and Safety Considerations

Trujillo walked the group through the major trial programs—STEP, OASIS, SCALE, SURMOUNT, and ATTAIN—noting that the phase 3b STEP UP trial (NCT05646706),¹ which evaluated semaglutide at 7.2 mg vs the standard 2.4 mg, showed superior weight loss but gastrointestinal (GI) adverse effects in 70% of participants at the higher dose. Nuffer noted that in the phase 3 SURPASS-CVOT (NCT04255433)²trial, tirzepatide demonstrated noninferiority to dulaglutide. This leaves some uncertainty for evidence-based prescribers because semaglutide was not compared with tirzepatide.

Panelists also raised underappreciated safety concerns from clinical practice. Brooke Trudeau, PharmD, a clinical pharmacist with Intermountain Health at Lutheran Hospital, described patients developing significant GI adverse effects after months of stable dosing—a late-onset pattern not well characterized in the literature. Trujillo flagged downstream effects of weight loss on drug absorption as a particular concern for patients on warfarin or levothyroxine, advising extra vigilance around any dose changes.

The group also discussed long-term management challenges, including patients who want to discontinue therapy after reaching their goal weight. Trujillo advised against absolutes: “The evidence says the majority of people will gain the weight back when they stop. But I try to partner with the patient to help them maintain the goals they want to maintain. That’s collaboration, not dictating.”

Charlotte, North Carolina: Systems, the Bridge Program, and Special Populations

The Charlotte forum was moderated by Casey Wells, PharmD, a clinical pharmacist practitioner at Mountain Area Health Education Center in Asheville, North Carolina, splitting her time between primary care and endocrinology. Participants came from Novant Health, Atrium Health, and Atrium Health One Health, representing cardiology, heart failure, transplant, bariatrics, and pharmacy benefits.

Comorbidities, Coverage, and Agent Selection

In Charlotte, agent selection consistently came down to the intersection of clinical data and what could actually be approved. Tate Drees, PharmD, of Novant Health, described using SELECT (NCT03574597)³ vs SURMOUNT program data to guide semaglutide vs tirzepatide selection based on a patient's comorbidities. Damian Hardison, PharmD, also of Novant, named the most common real-world tension. “Semaglutide has stronger [chronic kidney disease] and cardiovascular data. But if a patient has sleep apnea and cardiovascular indications, you might go with tirzepatide because of greater weight loss or patient preference.”

Catherine Helms Keaveny, PharmD, who manages pharmacy benefits for Novant employees, added a unique payer-side lens, sharing that her plan covers GLP-1 therapies only for obesity and diabetes—not secondary indications—and carries a $25,000 lifetime maximum, limiting most patients to roughly
2 years of therapy.

The Medicare Bridge Program: Early Wins and Emerging Complexity

Charlotte was among the first forums to discuss the GLP-1 Medicare Bridge Program with real implementation experience, as it had launched just 2 weeks before the event. Hardison reported successfully enrolling patients under obesity as the primary indication, with approvals returning faster than expected. “I thought it was going to be super slow,” said Ryan Larson, PharmD, of Atrium Health. Keaveny confirmed that the turnaround was averaging under 24 hours.

Practical tips shared included using the appropriate obesity diagnosis code, specifying “send a Bridge” in pharmacy notes, and ensuring the pharmacy has access to the patient's Medicare card for billing. Complications also surfaced: One panelist described a patient caught in a loophole after a formulary change left him unable to access the Bridge benefit because he had already filled under the same GLP-1 class within the prior 6 months.

Titration, Technology, and Underappreciated Safety Signals

On titration pacing, Hardison offered a structured approach: Target approximately 0.7% to 1% of body weight loss per week; hold the dose if loss exceeds 1%; and increase the dose if loss is under 0.7%. Olivia Philippart, PharmD, of Atrium Health One Health, advocated for a “low and slow” philosophy, noting that her system uses Epic’s multistep order transmittal feature to hold titration prescriptions in a queue until a specified release date—preventing pharmacies from filling the wrong dose out of sequence.

Two underappreciated safety topics stood out. Keaveny flagged orforglipron’s (Foundayo; Eli Lilly and Company) drug-drug interaction profile as more complex than other agents in the class, particularly with HIV medications and antifungals. “That is the most severe drug-drug interaction I’ve seen with one of these. I’m going to be double-checking in a way I really haven't had to do before.” Specifically for women, Keaveny shared 2 cases of severe, treatment-limiting hair loss in patients who had previously undergone gastric bypass, suggesting postbariatric patients may be at elevated risk. “For women, it’s just a big deal.”

Conclusion

Both forums closed on a shared conviction: Pharmacists are the connective tissue of obesity management, navigating prior authorizations, counseling patients through adverse effects, and translating trial data into individualized, sustainable care. As Wells said, “It kind of takes a team to make all this work.”

Increasingly, pharmacists are leading that team. The message was consistent: The science has outpaced the systems, and pharmacists are best positioned to close that gap 1 patient, 1 prior authorization, and 1 evidence-based conversation at a time.