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With the NHS starting a rollout of Mounjaro there’s set to be a growing market for GLP-1 receptor agonists to help people manage their weight, and a bigger role for community pharmacy. By Saša Janković

NHS England has announced a multi-million investment in rolling out Eli Lilly’s Mounjaro (tirzepatide) GLP-1 receptor agonist weight loss medicine from March, following final draft guidance from the National Institute for Health and Care Excellence (NICE) recommending it is offered to people with a body mass index (BMI) of more than 35 and at least one obesity-related problem, alongside advice on diet and exercise.

Estimates suggest this could benefit some 3.4 million people, but fears that demand could overwhelm services have resulted in NICE granting the NHS more than a decade to introduce it, and spurring on both community and online pharmacies to set up their own weight loss prescription services.

The supply of GLP-1 RA medicines online, in particular, has led to concern from pharmacy bodies that only eligible patients receive these drugs. In January the National Pharmacy Association (NPA) warned the General Pharmaceutical Council (GPhC) “tougher regulation” of online pharmacies providing weight loss medicines was needed to protect patients.

In February, the GPhC responded with updated guidance that all online pharmacies are expected to follow, relating to unsafe prescribing and supply of medicines online.

The guidance emphasises that for high-risk medicines, the prescriber cannot base prescribing decisions on the information provided in an online questionnaire alone, and must “independently verify the information the person provides, either through timely two-way communication with the person, accessing the person’s clinical records, or contacting the person’s GP, their regular prescriber, or a third-party provider”. 

The GPhC added that medicines used for weight management and medicines requiring physical examination before a prescribing decision is made to the list of high-risk medicines requiring extra safeguards before being prescribed.

Before providing medicines for weight management, the prescriber now has to “independently verify the person’s weight, height and/or body mass index, to support safer decision making and ensure that the supply is appropriate for the person”. 

Welcoming the update, RPS president Professor Claire Anderson, said: “The inclusion of measures to ensure prescribers independently verify information provided by the patient, and weight loss medicines being added to the list of high-risk medicines, is a key step toward protecting patient safety.

Questionnaire-style prescribing should never become the norm, particularly for prescription-only medications and those with additional risk factors.”

Potential risks

Nonetheless, the MHRA subsequently issued a warning regarding potential risks for patients taking GLP-1 receptor agonists when undergoing anaesthesia or deep sedation, highlighting an increased risk of pulmonary aspiration due to the medication’s ability to slow stomach emptying, which could lead to stomach contents entering the airways during surgery. 

The MHRA stressed that patients should inform their healthcare team, including the anaesthetist, if they are on GLP-1 medications before any procedure requiring anaesthesia or deep sedation – but this raises concerns about people who are using these medicines either with a private prescription or even ‘under the radar’ as these methods of supply wouldn’t show up on their medical records. 

Anderson comments: “To support safe prescribing and information sharing, pharmacists in all settings should have read-write access to patient records. Clear communication and ensuring patients are fully informed about the medicine being prescribed are key to patient safety.”

Tightening supply guidelines may make it harder for ineligible patients to access weight loss medicines they should not be using, but it creates a valuable opportunity for community pharmacies to get further involved in weight loss services.

Graham Thoms is CEO of pharmacy-based clinical service packages provider Pharmadoctor – currently enabling over 1,079 community pharmacies in the UK to deliver weight management services – and was himself recently diagnosed with type 2 diabetes and hypertension thanks to his local pharmacy offering the Pharmadoctor service.

Thoms says he is “hugely optimistic” about the service, but adds: “I do not believe it is clinically appropriate to deliver weight management services online.

"Patients should undergo a full medical assessment including having their weight and waistline measured and have their blood pressure measured each month as well as agreeing monthly goals in relation to diet, exercise and lifestyle during a face-to-face consultation with their pharmacist/pharmacy technician delivering the service.”

Pharmacist Satyan Kotecha is vice chair of Community Pharmacy Leicestershire and clinical champion with Diabetes UK, and runs diabetes clinics two days a week in Leicester.

He says while the rise of private weight loss services has been “controversial” there is “no doubt that GLP-1 receptor agonists are game-changing for diabetes and obesity management”, but “the challenge is ensuring they are used responsibly and with proper wraparound care”.

And while NICE’s guidance mean the NHS must make Mounjaro available, Kotecha points out some added barriers to access: “Funding remains a challenge, and Integrated Care Boards (ICBs) are struggling to define eligibility criteria, likely restricting it to patients with BMI >35 and a co-morbidity such as hypertension or high cholesterol.”

No quick fixes

Someone else who is cautiously optimistic about the benefits of offering private weight loss services in community pharmacy is Graham Phillips – director and superintendent pharmacist of iHeart Pharmacy Group, founder of the ProLongevity diabetes reversal service, and a trustee of the Public Health Collaboration, a charity dedicated to helping people achieve sustainable lifestyle changes.

“GLP-1s help people shed pounds quickly and seemingly effortlessly but they are not a silver bullet,” says Phillips, who strongly believes “there are more effective, safer solutions for most people”. 

Indeed, Phillips argues that the pharmaceutical industry is pushing a lifetime dependency model for these drugs, rather than encouraging sustainable weight loss strategies. “While GLP-1 medications help suppress appetite, they don’t address the root causes of obesity, such as poor diet and ultra-processed food consumption,” he says. “Although many people using these medicines experience reduced appetite, they are still eating the wrong foods; they’re just eating less of them.”

Another of his concerns is about the high dosing of these medications. “The way the drugs are currently prescribed means patients are often told to increase their doses systematically which can lead to dose stacking where the effects accumulate over time, potentially resulting in increased side effects, tolerance and diminishing effectiveness,” he says.

Unlike many commercial weight loss services, Phillips’ approach is focused on long-term health rather than just weight reduction. He plans to offer microdosing of tirzepatide (Mounjaro), starting with very low doses and spacing injections further apart to avoid unnecessary dose escalation. 

“So far, none of our patients have needed more than 5mg, and most never go beyond 2.5mg,” he says. “Our goal isn’t to keep them on the drug indefinitely, it’s to help them reduce their dosage over time and transition off the medication within three months. Our aim is to switch off the food noise to help people regain control over their appetite and glycaemic response so that they can make sustainable dietary and lifestyle changes. If we do this right, patients should be able to stop taking the drug rather than staying on it for life.” 

However, Phillips still sees the GLP-1 rollout as a missed opportunity. While he acknowledges that these drugs have a role to play, he believes the current approach is flawed, prioritising short-term weight loss over true metabolic health improvements: “What happens when you stop the medication? Without addressing the root causes of weight gain, maintaining progress becomes a challenge.”