The role of GLP‐1 receptor agonists in the management of obesity: risks and opportunities for the Australian health care system

To the Editor:

We read with great interest the perspective by Kanellis and colleagues1 discussing funding of glucagon‐like peptide‐1 receptor agonists (GLP‐1 RAs) for obesity. Health care resources will always be finite and to allow for the most equitable distribution of funding, subsidy of medications is governed by the Pharmaceutical Benefits Advisory Committee (PBAC). For this, the PBAC usually employs economic evaluations, which assess expected improvements in morbidity and mortality of a new medication, tempered against cost and comparison with existing therapies.2,3 The PBAC does not have a fixed threshold for subsidy; however, A$45 000–60 000 per quality‐adjusted life year (QALY) has been viewed as acceptable previously.4

International cost‐effectiveness analyses generally demonstrate that treating obesity with GLP‐1 RAs yields more QALYs compared with existing interventions, but it is not always cost‐effective. Results vary depending on the duration of the analysis, with studies over a longer time horizon demonstrating more favourable outcomes for GLP‐1 RAs. This is because the initial outlay of capital takes time to be recompensed by the improvements in morbidity associated with weight loss, and the downstream mitigation of sequelae such as diabetes and cardiovascular disease. Cost‐effectiveness ratios have been reported ranging from US$19 162–505 414/QALY,5 but in studies with time horizons of 30 years or more, GLP‐1 RAs are generally cost‐effective.

These drugs could revolutionise health for millions of Australians and so perhaps a disruptive approach may be warranted. The semaglutide pilot trial employed by the National Health Service could be repeated in Australia, potentially on a smaller scale in a targeted population. While cost‐effectiveness is an important outcome, consideration also needs to be given to the prevalence of disease (in this case, up to one‐third of the population) as this is what determines the ultimate financial outlay. Improving access to GLP‐1 RAs may offer significant gains in morbidity and mortality for many Australians, but more evidence is needed regarding whether this is cost‐effective from a public health perspective.