How to navigate the NHS rules on weight loss drugs

iStock/ ugurhan

By Emma Wilkinson

As NICE approves GLP-1s for more patients, keeping track of who is eligible for the drugs, when and for what conditions is becoming even more complicated. Here's what to know.

NICE have recommended that patients with existing cardiovascular disease who are also overweight are eligible for weight loss drug semaglutide. It adds to a complex picture for clinicians who are working to multiple different guidelines on who can and cannot access GLP-1 medications on the NHS. Emma Wilkinson looks at the advice.

What is the latest recommendation?

NICE have recommended that semaglutide (WeGovy) can be used alongside a reduced calorie diet and increased physical activity “as an option” for people with established cardiovascular disease who are also overweight.

To be eligible patients must have already had a heart attack or stroke or have symptomatic peripheral arterial disease and a body mass index (BMI) of at least 27 kg/m². A maintenance dose of up to 2.4mg weekly is advised.

The NHS has come to a commercial arrangement with Novo Nordisk, makers of Wegovy, and NICE said it was “well within” the range that it considers an effective use of resources.

Evidence for the recommendation comes from the SELECT study, a multinational randomised double-blind placebo-controlled phase 3 trial involving 17,604 people with a BMI of at least 27 kg/m² and established cardiovascular disease but not diabetes.

All patients had healthy lifestyle counselling and standard medications to reduce cardiovascular risk. But in the half of participants who also were having once weekly injections of semaglutide, risk of further cardiovascular events was reduced by 20%.

In the results published in 2023, reductions were also seen in hospitalisation for unstable angina and heart failure.

Professor Martin Whyte, professor of metabolic medicine at the University of Surrey, welcomed the recommendation. 

“These individuals face a significantly elevated risk of further cardiovascular events, and we know that traditional lifestyle and medical approaches alone are often insufficient.”

Which other groups are eligible for weight loss jabs?

NICE guidance on managing type 2 diabetes updated in February recommends the lower dose of semaglutide (Ozempic) up to 1mg a week in those who also have atherosclerotic cardiovascular disease.

It advises medicines to be introduced in a stepwise manner with a GLP-1 receptor agonist added once others are stabilised. In this guidance, semaglutide is being offered for its cardiovascular, renal and glycaemic benefits and the person’s weight is not considered.

The guidance on these drugs is confusing for doctors, particularly around the issue of cardiovascular risk and diabetes

A GLP-1 receptor agonist or tirzepatide can also be offered in adults with early onset type 2 diabetes, the guidance says.

The drugs can be considered for patients with type 2 diabetes and obesity if their blood glucose remains uncontrolled on other treatments.

In 2023, semaglutide (WeGovy) was recommended by NICE for weight management alongside diet and exercise advice, but only for two years and within specialist weight management services. For this, patients must have a BMI of at least 35kg/m² or 30.0 kg/m² if they met criteria for referral to NHS weight management services, and at least one weight-related co-morbidity.

The following year NICE initially approved GP prescribing of tirzepatide (Mounjaro) diet and exercise advice for people with a BMI of at least 35kg/m² and one weight-related comorbidity.

But NHS England requested a slower, phased roll out to avoid overwhelming GPs and busting ICB prescribing budgets.

Starting in June 2025, the first year’s cohort included those with a BMI greater than 40kg/m² and at least four related co-morbidities.

Dr Stephen Lawrence, a GP and associate clinical professor in primary care at Warwick University, said the guidance is confusing for doctors, particularly around the issue of cardiovascular risk and diabetes.

He is also worried that without clear messaging, the latest recommendations will not be implemented effectively and exacerbate inequalities in access.

“SGLT2 inhibitors are a good example of this. The NICE guidance on diabetes update said prescribe SGLT2 straight after metformin, don’t wait for a deterioration in blood glucose. It’s probably been the biggest shake up in 10 years, but even though we’ve had that update for a few months, doctors are still unsure what to do.

“I think this is a marker of what we’re going to see with GLP-1s, but with an even greater complication that people can buy them privately which puts pressure on availability.”

Why is tirzepatide (Mounjaro) being rolled out so slowly?

The Health Foundation recently reported that as many as 2.4 million people are accessing weight loss drugs in the UK but most of those will be buying it privately.

Overall, it is thought that 3.4 million people will be eligible for the drug but in order to set up the support services and increase clinical capacity, NHS England set out cohorts based on clinical need over a maximum 12-year period.

The first three years will increase in stages to treat 220,000 patients. Cohort two, which starts this June for nine months will be people with a BMI of 35 to 39.9kg/m² and four or more weight-related co-morbidities. Then it will be expanded to those with a BMI of over 40kg/m² but three co-morbidities that increase cardiovascular disease and diabetes.

If it had not taken this approach, by the second year of use it would have cost £2.9bn for the medicine alone, equivalent to 28% of the entire primary care medicines budget, NHS England had warned.

How will the NHS implement the latest recommendation?

Integrated care boards will be required to comply with the technology appraisal within 90 days, which could apply to around 1.2 million people.

Patients will not be automatically prescribed semaglutide. A GP or specialist will assess whether it is the right option based on individual circumstances, NICE said.

It is not clear how GPs will be expected to follow the guidance in practice, in terms of proactively identifying eligible patients

But it is not exactly clear how GPs will be expected to follow the guidance in practice, in terms of proactively identifying eligible patients.

Neither is it spelled out exactly what the diet and exercise support will consist of.

Dr Lawrence said local guidance and pathways will need to be clarified for this to be done properly.

“There will need to be proper follow up. You need to identify patients. Often, people are taking other medications that we need to take into account.”

Professor Robert Storey, professor of cardiology at the University of Sheffield said the latest recommendations were a “step towards even more effective management of heart attack and stroke risk”.

But he added that prescribing of semaglutide will need to be appropriately targeted since GLP-1 drugs can reduce muscle mass so physical activity, such as resistance training, is important to counteract potential negative effects, which may not be feasible in frail people. 

“The benefits also need to be balanced against the risk of side effects. 

“These issues and the need for training people to inject the drug as well as ongoing monitoring and prescribing requires the allocation of NHS resources to ensure the benefits of this NICE guidance can be fully realised.”

What does this mean for patients?

Professor Naveed Sattar, professor of cardiometabolic medicine at the University of Glasgow, said the latest recommendation was “very good news” stemming directly from high quality trial evidence. 

“We now have medicines that not only reduce heart attacks, strokes, and peripheral arterial disease, but also simultaneously lead to meaningful weight loss – which in turn lowers the risk of many weightrelated conditions. 

“These treatments also improve patients’ quality of life in a meaningful way, making this a genuine win–win,” he said.

But individual patients will need to discuss whether it is right for them with their doctors, experts added.

This is also an addition to the standard care of antihypertensive, lipid-lowering, antiplatelet and anticoagulant treatments.

Unlike other NICE guidance, in the latest technology assessment, there is not a lower BMI threshold for ethnic groups who are more at risk of cardiovascular disease, he noted.

“It risks at clinically alienating people who are already disadvantaged, both metabolically and through equity and access. I was disappointed with that.”

Are we relying too much on weight loss medicines?

With patchy NHS access and guideline confusion, there is a real risk of widening health inequalities, Dr Lawrence adds.

The drugs could be transformational for some, but it would be a societal failure to let people become obese only to then medicate them for life

“But more than that, I think the obesogenic environment, the housing, the commercial aspects, the access to services, all need to be addressed.

“I can go to a gym if I want to, because I can pay for it. But many people can't, they don't have access to open spaces.

“This is not just about medication. I worry that's the effectiveness of [these drugs] is going to be diluted, unless we actually look at these wider issues.”

In a speech to the Medical Journalists’ Association last month, chief medical officer professor Chris Whitty noted that the drugs could be “transformational” for some but that it would be a “societal failure” to let people become obese only to then medicate them for life.

“Is our answer to say ‘give up on public health’ and then just rely on drugs to get us out of a hole?"

“I do not think that is a socially acceptable answer, actually I don't think that's a medically acceptable answer, because these drugs are not benign,” he said.

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