Obesity medications: Why the right prescription is about more than BMI

The obesity medication landscape has expanded rapidly in recent years, but choosing the right drug for the right patient is far more nuanced than checking a BMI box. Writing in Healio, internist and obesity medicine specialist Dr. Shagun Bindlish argues that clinicians must evaluate the full cardiometabolic picture — including comorbidities like type 2 diabetes, MASLD, sleep apnea, and cardiovascular disease — before reaching for the prescription pad.

Dr. Bindlish emphasizes that two patients with identical BMIs can have completely different underlying drivers of obesity, making individualized treatment essential. Factors like contraindications, polypharmacy, route of administration, insurance coverage, and patient preferences all shape whether a medication will actually work long-term. She also stresses the importance of early follow-up, proactive adverse effect management, and monitoring beyond the scale — tracking glycemic control, liver health, muscle mass, and quality of life.

Key Takeaways:

• Screen for personal or family history of medullary thyroid carcinoma or MEN2 before starting incretin-based therapy
• Insulin and sulfonylureas often need dose reduction as metabolic health improves on obesity medications
• Monitor for sarcopenia, especially in older adults and adolescents on newer, more potent therapies
• Lack of response after ~3 months at the maximally tolerated dose should prompt a full reassessment, not an automatic treatment failure label

Why it matters: As obesity drugs become more powerful, the risk of mismatched prescribing grows. A precision medicine approach — matching therapy to a patient's biology, comorbidities, and goals rather than BMI alone — could meaningfully reduce cardiometabolic risk and improve long-term outcomes.