Year after year, Mary Bucklew strategized with a nurse practitioner about losing weight. “We tried exercise,” like walking 35 minutes a day, she recalled. “And 39,000 different diets.”
But 5 pounds would come off and then invariably reappear, said Bucklew, 75, a public transit retiree in Ocean View, Delaware. Nothing seemed to make much difference until 2023, when her body mass index slightly exceeded 40, the threshold for severe obesity.
“There’s this new drug I’d like you to try if your insurance will pay for it,” the nurse practitioner advised. She was talking about Ozempic.
Medicare covered it for treating Type 2 diabetes but not for weight loss, and it cost more than $1,000 a month out of pocket. But to Bucklew’s surprise, her Medicare Advantage plan covered it even though she wasn’t diabetic, charging just a $25 monthly copay.
Pizza, pasta and red wine suddenly became unappealing. The drug “changed what I wanted to eat,” she said. As 25 pounds slid away over six months, she felt less tired and found herself walking and biking more.
Then her Medicare plan notified her that it would no longer cover the drug. Calls and letters from her health care team had no effect.
With coverage denied, Bucklew became part of an unsettlingly large group: older adults who begin taking GLP-1s and related drugs — highly effective for diabetes, obesity and several other serious health problems — and then stop taking them within months.
That usually means regaining weight and losing the associated health benefits, including lower blood pressure, cholesterol and A1c, a measure of blood sugar levels over time.
Widely portrayed as wonder drugs, semaglutide (Ozempic, Wegovy, Rybelsus), tirzepatide (Zepbound, Mounjaro) and related medications have transformed the treatment of diabetes and obesity.
The FDA has approved several GLP-1s to treat kidney disease and sleep apnea, prevent heart attacks and strokes, and for other uses.
“They’re being studied for every purpose you can conceive of,” said Dr. Timothy Anderson, a health services researcher at the University of Pittsburgh and author of a recent JAMA Internal Medicine editorial about anti-obesity medications.
People older than 65 represent prime targets for such medications. “The prevalence of obesity hovers around 40%” in older adults, as measured by BMI, said Dr. John Batsis, a geriatrician and obesity specialist at the University of North Carolina School of Medicine.
The proportion of people with Type 2 diabetes rises with age, too, to nearly 30% over age 65. Yet a recent JAMA Cardiology study found that among Americans older than 65 with diabetes, about 60% discontinued semaglutide within a year.
Another study of 125,474 people who were overweight or obese found that almost 47% of those with Type 2 diabetes and nearly 65% of those without diabetes stopped taking GLP-1s within a year — a high rate, said Dr. Ezekiel Emanuel, a health services researcher at the University of Pennsylvania and senior author of the study.
Patients older than age 65 were 20% to 30% more likely than younger ones to discontinue the drugs and less likely to return to them.
What explains this pattern? As many as 20% of patients may experience gastrointestinal problems. “Nausea, sometimes vomiting, bloating, diarrhea,” Anderson said, ticking off the most common side effects.
Linda Burghardt, a researcher in Great Neck, New York, started taking Wegovy because her doctor thought it might reduce arthritis pain in her knees and hips. Burghardt, 79, couldn’t walk far and had stopped playing pickleball.
Within a month, she suffered several bouts of stomach upset that “went on for hours,” she said. “I was crying on the bathroom floor.” She stopped the drug.
Some patients find that medication-induced weight loss lessens rather than improves fitness, because another side effect is muscle loss. Several trials have reported that 35% to 45% of GLP-1 weight loss is not fat but “lean mass,” including muscle and bone.
Bill Colbert’s cherished hobby for 50 years, reenacting medieval combat, involves “putting on 90 pounds of steel-plate armor and fighting with broadswords.” A retired computer systems analyst in Churchill, Pennsylvania, he started on Mounjaro, successfully lowered his blood glucose and lost 18 pounds in two months.
But “you could almost see the muscles melting away,” he recalled. Feeling too weak to fight well at age 78, he also discontinued the drug and now relies on other diabetes medications.
“During the aging process, we begin to lose muscle,” typically 0.5% to 1% of muscle weight per year, said Dr. Zhenqi Liu, an endocrinologist at the University of Virginia who studies the effects of weight loss drugs. “For people on these medications, the process is much more accelerated.”
Losing muscle can lead to frailty, falls and fractures, so doctors advise GLP-1 users to exercise, including strength training, and to eat enough protein.
The high rate of GLP-1 discontinuation may also reflect shortages; from 2022 to 2024, these drugs temporarily became hard to find. Further, patients may not grasp that they will most likely need the medications indefinitely, even after they meet their blood glucose or weight goals.
Of course, in considering why patients discontinue, “a large part of it is money,” Emanuel said. These are “expensive drugs, not necessarily covered” by insurers. Indeed, in a Cleveland Clinic study of patients who discontinued semaglutide or tirzepatide, nearly half cited cost or insurance issues as the reason.
Some moderation in price has already occurred. The Biden administration capped out-of-pocket payments for all prescriptions that a Medicare beneficiary receives ($2,100 is the 2026 limit), and authorized annual price negotiations with manufacturers.
The reductions include Ozempic, Wegovy and Rybelsus, though not until 2027. Medicare Part D drug plans will then pay $274, and since most beneficiaries pay 25% in coinsurance, their out-of-pocket monthly cost will sink to $68.50, or perhaps even lower if agreements announced last month between the Trump administration and drugmakers Eli Lilly and Novo Nordisk pan out.
The bigger question is whether Medicare will amend its original 2003 regulations, which prohibit Part D coverage for weight loss drugs. “An archaic policy,” said Stacie Dusetzina, a health policy researcher at the Vanderbilt University School of Medicine.
The Trump administration’s November announcement would expand Medicare eligibility for GLP-1s and related medications to include obesity. But key details remain unclear, Dusetzina said.
But given the expense to insurers, Dusetzina warned, “if you expand the indications and extent of coverage, you’ll see premiums go up.”
For older patients, questions about GLP-1s remain. Might a lower maintenance dose stabilize their weight? Can doses be spaced out? Could nutritional counseling and physical therapy offset muscle loss?
Bucklew, whose coverage was denied, would still like to resume Ozempic. But because of a recent sleep apnea diagnosis, she now qualifies for Zepbound with a $50 monthly copay.
She has seen no weight loss after three months. But as the dose increases, she said, “I’ll stay the course and give it a shot.”