Affordability is a gate, not a tiebreaker

Most guidance on anti-obesity medicines ranks the options by efficacy and outcome data, and mentions cost at the end, as a tiebreaker. That order works where insurance pays. It does not work in my clinic in Hyderabad, where almost every patient pays for every pen from their own pocket, every month.

My position is simple. A medicine the patient cannot afford for a year is not an option for that patient, however good its trial results. So affordability is the first filter I apply, not the last.

Why the order matters

Obesity is a chronic disease and its treatment is long term. When the medicine stops, the weight comes back. In the STEP 1 extension, people who stopped weekly semaglutide regained about two thirds of the weight they had lost within a year. SURMOUNT-4 showed the same pattern after stopping tirzepatide.

So the patient who starts the most effective medicine, empties their savings by month three and then stops, ends up close to where they began, poorer and more discouraged. For that patient, a less potent medicine they can sustain for twelve months would have been the better prescription.

How I apply it

1. First, decide whether medicine is indicated at all. I use Edmonton Obesity Staging (EOSS) for that, not BMI alone. See why I stage before I prescribe.
2. Ask about the monthly budget in the first consultation, in the same matter-of-fact way I ask about kidney function. Patients are rarely offended. They are usually relieved.
3. Strike out every option the patient cannot sustain for twelve months, including the dose escalation. A starting-dose price is not the price of treatment.
4. Rank what is left by evidence, and by the patient's own comorbidities: diabetes, cardiovascular disease, kidney disease, sleep apnoea, fatty liver.
5. Quote the cheapest innovator option of a molecule, not the dearest, and say plainly that the prices will change.

A worked example on cost

At the MRPs I was quoting in September 2026, a month of full-price innovator semaglutide at 2.4 mg cost roughly the same as a month of tirzepatide at 5 mg, about Rs 16,400. In SURMOUNT-5, the head-to-head trial in obesity without diabetes, tirzepatide produced a mean weight loss of about 20 per cent against about 14 per cent with semaglutide at 72 weeks.

So when a patient is quoted that price for semaglutide, I tell them that the same money buys tirzepatide, which lost more weight in the direct comparison. That is a prompt for discussion, not a rule.

What this asks of us

It asks us to treat cost as clinical information, because it decides adherence, and adherence decides outcome. It also asks us to keep our price knowledge current. Indian prices for these medicines have moved a great deal in 2026, and a figure quoted from memory can be months out of date.

For patients, we built a free planner that applies the same order, budget first and evidence second, at caspianhealthcare.in/obesity/treatment-options. Colleagues are welcome to send their patients to it.