A recent decision by the Centers for Medicare & Medicaid Services to cover popular new weight loss drugs that provide additional health benefits could be a “game changer” for potentially thousands of obese nursing home patients struggling with comorbidities.

Experts said the drugs could help chronically overweight patients lose extra pounds that have led to a cascade of other conditions — including diabetes, kidney disease, cardiac problems and pressure injuries — that impact their mobility and complicate their care.

The result, should the list of Medicare-covered uses grow, could mean better outcomes and longer lives for patients and fewer staff challenges and costly accommodations for skilled nursing providers.

“It really could be a game changer for so many of these residents that have just been struggling for so long,” said Lisa Davis, RD, a clinical dietitian with Healthcare Service Group who works with nursing homes in Oregon and Washington. “There are so many patients I see that are in their 50s and 60s. That’s decades of living in these skilled nursing facilities. That is just such a loss of quality of life.”

Often it’s a lack of mobility and the need for assistance with activities of daily living that land obese patients in a nursing home, said Karl Steinberg, MD, a long-time nursing home medical director and chief medical officer and past board president of AMDA — The Society for Post-Acute and Long-Term Care Medicine.

But caring for a patient with Class III obesity, previously called morbidly obese, requires more  staff, specialized equipment and careful training. Some facilities have a practice of limiting bariatric admissions because they may not have enough staff members to provide multi-person lifts or otherwise keep a patient safe, Steinberg said. Even some facilities that bill themselves as having bariatric programs have an upper weight limit.

Affordable medications could help patients reduce their weight and regain the mobility needed to reduce the risk of developing comorbidities or seeing them worsen.

Steinberg has become a believer in the power of drugs like semaglutide and has prescribed them to patients with diabetes, and at least one without for whom insurance coverage was a battle. That patient has obesity and significant sleep apnea leading to respiratory issues.

“They’re remarkably effective. They really work,” Steinberg said. “On the downside, and I think there are some significant downsides, those of us who work in this care setting better get used to being asked for it. It’s everywhere … but they really do cause some significant GI problems in people. You’re already morbidly obese and you’re probably going to be prone to gastroesophageal reflux to begin with and it really makes that worse.”

It also can worsen constipation or cause nausea. And patients on the drugs need to stay on them, creating a supply-and-demand issue that is already becoming apparent even before Medicare-covered patients begin to seek the drug in large numbers.

How weight loss drugs work

The new class of drugs stimulates hormones to control blood sugar levels and reduce appetite. They include the GLP-1 receptor agonists Wegovy and Ozempic, and Zepbound and Mounjaro, which target GLP-1 and glucose-dependent insulinotropic polypeptide (or GIP).

Ozempic and Mounjaro are technically diabetes medications that lead to moderate weight loss, while Wegovy and Zepbound are FDA-approved specifically for weight loss and are linked to more significant pounds lost.

Last month, the Food and Drug Administration approved Wegovy as a way to reduce the risk of cardiovascular death, heart attack and stroke in overweight or obese adults with heart disease.

But the implications extend far beyond cardiac conditions. A JAMA article published Friday outlined a bevy of possible conditions for which the drugs show promise, including smoking cessation and alcohol use disorder.

In that piece, Lance Alan Sloan, MD, medical director of the Texas Institute for Kidney and Endocrine Disorders, predicts that the next FDA-approved use for the drugs will be related to chronic kidney disease in people with type 2 diabetes. Approximately 40% of people with type 2 diabetes have chronic kidney disease, according to Wegovy’s maker, Novo Nordisk, whose trials showed patients on the drug were 24% less likely to experience kidney disease progression or kidney or cardiovascular death.

Davis sees chronic kidney disease as a promising frontier. It is one of the most challenging conditions to manage when obese, diabetic patients live in a nursing home, she said. They require careful nutrition management, especially if they develop pressure ulcers, and attempts to address both needs can work at cross purposes.

“There is a huge risk with pressure ulcers for those that are in the obese population and with the pressure ulcers they have much higher calorie and protein needs with and then it’s hard to get those wounds to heal often. They have to have some type of reducing mattresses or they have to be turned periodically, but it’s very painful for them,” she said.

Wounds also require more protein, often provided in expensive active liquid proteins or arginine or vitamin C or zinc — some of which can be contraindicated for chronic kidney disease.

Venturing cautiously

Davis, who shared that she is on a GLP-1 herself, said managing the nutrition of patients who begin to take GLP-1s is her biggest concern moving forward. Currently, there is little-to-no information provided about appropriate diet for an independent patent, much less standards for those living in an institution and dealing with multiple chronic conditions.

Others see the drugs as potentially inappropriate for older patients, whose nutritional needs may make them more prone to frailty and for whom a certain amount of “extra” weight has actually been proven protective.

“The older you are, the more reason you have to be cautious,” John Batsis, MD, associate professor in the division of geriatric medicine and the department of nutrition at the University of North Carolina at Chapel Hill, told AARP. “Our bodies change with age, so the results in younger people don’t necessarily apply to those who are older.”

He noted that weight loss can cause additional bone deterioration, already a risk for people who have long carried excess weight around their stomachs.

Every prescriber must look at the individual profile of the patient and weigh risks and benefits, such as the ability to move from being bed bound to having an active life again, Steinberg said.

The opportunity for careful dietary monitoring and access to rehab therapists who could guide recovery would give some nursing home patients on the drugs far more support than community-dwelling individuals, Steinberg and Davis added. But even as the cost becomes less restrictive and more people clamor for the drug, skilled nursing prescribers appear to be entering the fray slowly.

“As a general rule, nursing home practitioners, doctors and other prescribers, are not the most early adopters,” Steinberg said. “And I think anyone in this care setting, taking care of somewhat frail high-risk people who are functionally dependent, you don’t want to be taking unnecessary risks with meds that maybe you’re not familiar with yet. … I’m sure we’re going to see a gradual increase.”