Who can get a prescription for obesity medication, and why might a doctor refuse?

A doctor can prescribe obesity medication to an adult with a BMI of at least 30, or with a BMI of 27 to 29.9 if they already have a weight-related condition, such as high blood pressure (hypertension), prediabetes or lipid disorders. According to the 2024 guidelines of the Polish Society for the Treatment of Obesity (PTLO), the doctor suggests medication when changes to diet and more physical activity have not been effective enough (1). The prescription is issued by a doctor at the clinic or online, once contraindications have been ruled out. The doctor may refuse if the medicine would not be safe, if the patient asks for a medicine that is not licensed for treating obesity, or if the cause of the weight gain needs to be established first. Treatment does not end with the first prescription. Over the following months, the doctor gradually increases the dose at follow-up appointments and checks whether the medicine is working and whether the patient tolerates it well.

In brief

• Eligibility depends on your BMI at the start of treatment: 30 or more, or 27 or more with at least one weight-related condition. Being overweight without such a condition is not enough.
• Before you get a prescription, talk to the doctor about pregnancy or plans for pregnancy, past pancreatitis and severe kidney, liver or heart disease, among other things. Someone taking naltrexone for alcohol dependence cannot take naltrexone/bupropion tablets.
• A doctor may refuse if your BMI and medical conditions do not meet the criteria, if the medicine would be dangerous or if the cause of the weight gain needs to be established first. In that case, ask what would need to change.
• An e-prescription from an online consultation is just as valid as a prescription from the clinic. The dose is increased gradually, and the doctor assesses whether the medicine is working only after several months. With semaglutide, this happens after 3 months on the 2.4 mg dose.

Who can be prescribed obesity medication?

A doctor may suggest medication to an adult with a BMI of at least 30, or with a BMI of 27 to 29.9 and at least one weight-related condition, if diet and physical activity have not been effective enough. Semaglutide, tirzepatide, liraglutide and naltrexone/bupropion are licensed for obesity only at or above these BMI thresholds (2, 3, 4, 5).

For someone 170 cm tall, a BMI of 30 means about 87 kg and a BMI of 27 about 78 kg. The doctor also measures your waist circumference, because it helps to identify abdominal obesity and to assess the risk of complications. However, it is BMI that determines whether medication is indicated.

Can you get obesity medication if you are only overweight?

No, being overweight alone is not enough. With a BMI of 25 to 26.9, a doctor will not prescribe obesity medication, because these medicines are licensed only for people with a BMI of 27 or more. With a BMI of 27 to 29.9, medication is an option only if you have a weight-related condition. The examples of such conditions differ slightly from one medicine to another.

Prediabetes and lipid disorders usually cause no symptoms and show up only in blood tests, so before deciding on medication the doctor orders tests and measures your blood pressure. Our article on tests before obesity treatment explains what is tested and why.

Do you have to try diet and exercise before obesity medication?

Usually yes, although it does not always have to last six months. Someone who has not yet tried treatment with diet and physical activity starts with that. If body weight has not fallen by at least 5% after 3-6 months, the doctor discusses medication with the patient. Medication can be considered straight away if the patient has already tried diet and physical activity without success, or has conditions that increase the risk of heart and blood vessel disease. With a BMI of 40 or more, the doctor considers both medication and bariatric surgery from the start (1). Before your appointment, write down your previous attempts to lose weight: which diets, for how long, how many kilograms you lost and when they came back.

Will the doctor stop the medicine once your BMI drops below 30?

No. A fall in BMI below 30 is not a reason to stop the medicine, because the BMI threshold applies only to starting treatment. The medicine is used for as long as it is needed, effective and well tolerated. Treatment shorter than 6 months is not recommended. The STEP 1 trial also looked at what happens after the medicine is stopped. People who ended semaglutide treatment and the lifestyle programme after 68 weeks regained, within a year, about two thirds of the weight they had lost (6). Our article on stopping obesity medication explains how to prepare for this.

Which doctor can prescribe obesity medication?

Obesity medication can be prescribed by a GP (family doctor), an internist, a diabetologist, an endocrinologist or a doctor who treats obesity. According to the Polish guidelines, a GP can plan and manage obesity treatment on their own, including medication (1). Our guide on where to start obesity treatment explains who to see and how to prepare for your first appointment.

The doctor prescribes only medicines licensed for treating obesity. Medicines licensed for other conditions, such as diabetes, should not be used for obesity. The doctor chooses the specific medicine together with the patient, taking into account coexisting conditions, contraindications, how the medicine is given and its cost. None of these medicines is reimbursed for obesity, so you pay the full price at the pharmacy no matter who wrote the prescription (7).

Is an e-prescription for obesity medication from an online consultation valid?

Yes, an e-prescription issued after an online consultation is just as valid as a prescription from the clinic. Under the Polish Act on the Professions of Physician and Dentist, a doctor can assess a patient's health not only by examining them in person, but also remotely or on the basis of medical records (8).

During an online consultation, the doctor relies on the test results and measurements sent by the patient. If something is missing or the results are unclear, the doctor may ask for additional tests or an appointment at the clinic.

Which contraindications must a doctor rule out before prescribing obesity medication?

Semaglutide, tirzepatide and liraglutide have only one contraindication: allergy to the medicine (2, 3, 4). There are, however, situations in which the medicine is not recommended or is given with caution. Naltrexone/bupropion has a much longer list of contraindications. Before starting any of these medicines, the doctor also checks whether it interacts with other medicines you take.

What will the doctor ask before prescribing semaglutide, tirzepatide or liraglutide injections?

Before starting treatment, you need to discuss with the doctor the situations in which these medicines are not recommended or must be used with caution:

• Pregnancy, planning a pregnancy and breastfeeding. Semaglutide is stopped at least 2 months before a planned pregnancy, tirzepatide at least a month before, and liraglutide as soon as a pregnancy is being planned. Semaglutide and liraglutide are not used during breastfeeding, while the doctor may consider tirzepatide treatment during this time.
• Past pancreatitis. This is not a contraindication, but semaglutide and tirzepatide are then given with caution. If pancreatitis develops during treatment and is confirmed, the medicine is not restarted.
• Severe kidney, liver or heart failure. Semaglutide and liraglutide are not recommended in severe renal or hepatic impairment or in the most severe, class IV heart failure, because there are no data on their safety. Tirzepatide is given with caution in severe kidney and liver disease. Semaglutide is also not recommended in type 1 diabetes.
• Gastroparesis (delayed stomach emptying) and inflammatory bowel disease. Semaglutide is not recommended in severe gastroparesis, and liraglutide is not recommended in diabetic gastroparesis or inflammatory bowel disease. With tirzepatide, severe gastrointestinal disease calls for caution.
• Insulin or a sulfonylurea for diabetes. Taking them does not rule out obesity medication, but the doctor may lower their doses to reduce the risk of low blood sugar (hypoglycaemia). Semaglutide is not recommended in uncontrolled or unstable diabetic retinopathy.
• Another obesity medicine. Two obesity medicines should not be taken together.
• Age 75 or over and secondary obesity. Liraglutide is not recommended in people aged 75 or over, or when obesity is caused by a hormonal disease, an eating disorder or medicines that promote weight gain.

A woman of childbearing age who takes obesity medication should use effective contraception (1). The doctor may also ask whether you or anyone in your family has had medullary thyroid cancer. In the European Union this is not a contraindication, but in the USA this cancer and multiple endocrine neoplasia type 2 (MEN2), a hereditary syndrome of endocrine gland tumours, are listed among the contraindications to tirzepatide (9).

Who cannot take naltrexone/bupropion?

Naltrexone/bupropion (Mysimba) is a tablet that acts on the hunger and reward centres in the brain. Its contraindications differ from those of the injections. These tablets must not be taken in the following situations (5):

• Uncontrolled high blood pressure
• Epilepsy or a history of seizures, or a tumour of the central nervous system
• A history of bipolar disorder
• Bulimia or anorexia, now or in the past
• Opioid dependence, treatment with methadone or buprenorphine, or the period just after abruptly stopping opioids
• The period just after abruptly stopping alcohol or benzodiazepine sedatives in someone who is dependent on them
• Taking naltrexone or bupropion for another reason, such as naltrexone to treat alcohol dependence or bupropion to stop smoking
• Taking MAO inhibitors in the last 14 days
• Severe liver impairment or end-stage kidney failure
• Pregnancy, trying to conceive and breastfeeding

This means that someone taking naltrexone to treat alcohol dependence cannot take these tablets for obesity. The medicine is not recommended over the age of 75. In people who misuse alcohol, it is given with caution because their risk of seizures is higher. This list does not replace a doctor's assessment.

Why might a doctor refuse to prescribe obesity medication?

A doctor has to treat patients in line with current medical knowledge, so they will not write a prescription just because a patient asks for one. They may refuse in the following situations:

1. A BMI below the threshold, or a BMI of 27 to 29.9 without a weight-related condition. In this case, the doctor will not prescribe medication, even if the patient wants to lose weight faster.
2. No previous treatment with diet and physical activity. The doctor may suggest this treatment first.
3. A contraindication to the medicine or a situation in which it is not recommended, such as a planned pregnancy or severe kidney disease. The doctor will also not prescribe naltrexone/bupropion tablets to someone who takes naltrexone for alcohol dependence.
4. A request for a medicine that is not licensed for treating obesity, such as a diabetes medicine.
5. A suspicion that the weight gain has another cause. Before starting medication, the likely cause of obesity needs to be established, and stopping or switching medicines that promote weight gain should be considered. Our article on weight gain caused by medicines explains which medicines can make you put on weight.
6. Eating disorders. Binge eating, bulimia or anorexia need to be diagnosed and treated, and naltrexone/bupropion tablets are contraindicated in bulimia and anorexia. Read more in our article on binge eating.
7. Unwillingness to attend follow-up appointments. At follow-up appointments, the doctor assesses whether the medicine is working and whether it is safe. This is why the doctor may make the prescription conditional on the patient agreeing to these appointments.

What should you do if a doctor refuses to prescribe obesity medication?

• Ask about the reason: whether you do not meet the criteria, whether the medicine would be dangerous for you, or whether additional tests are needed first.
• Ask what would need to change. Test results, a description of your previous attempts to lose weight or treatment of another condition may affect the decision.
• You can ask another doctor for an opinion, but give them the same information. Leaving out a condition, a medicine or pregnancy plans when the doctor takes your history or in an online questionnaire does not reduce the risk; it only hides it from the doctor.
• Do not buy the medicine anywhere other than a pharmacy. A medicine from an unreliable source may not contain what the label says, so it cannot be used safely.

How is a one-off prescription for obesity medication different from ongoing treatment?

Treatment with obesity medication lasts for months and requires further decisions by the doctor, so a single prescription is only the beginning. Semaglutide injections and tirzepatide are first taken at a starting dose for 4 weeks. After that, the doctor checks every few weeks how you are tolerating the medicine, decides whether to increase the dose and issues further prescriptions. When the doctor judges whether the medicine is working depends on the medicine and the dose.

At every appointment, the doctor should also remind you about changing how you eat and being more active. In the recommendation that opens the Polish guidelines, Poland's national consultant in family medicine (the Ministry of Health's chief adviser for the specialty) writes that obesity treatment cannot be limited to writing a prescription (1). In a large US study of more than 125,000 adults with overweight or obesity, almost two thirds of people without diabetes stopped taking the medicine within a year. People with more severe gastrointestinal symptoms were more likely to stop treatment, and those who lost more weight were less likely to do so (11). The study did not assess how often patients attended follow-up appointments.

How long does it take to increase the dose of obesity medication?

The dose is increased gradually to reduce nausea and other gastrointestinal symptoms. Semaglutide injections are started at 0.25 mg once a week, and the dose is increased every 4 weeks, so that after 16 weeks the patient reaches 2.4 mg (2). Tirzepatide is started at 2.5 mg; after 4 weeks the dose is increased to 5 mg, and each further increase of 2.5 mg is possible after at least 4 weeks on the current dose (3). Each step is the doctor's decision and usually means a prescription for a pen of a different strength. Read more in our article on the first months of obesity treatment with medication.

The doctor can issue the next prescription needed to continue treatment without examining you again, if your current health is documented in your medical records (8). If there are no records of previous treatment, the doctor has to assess you from scratch.

When does the doctor decide whether to continue obesity medication?

The Polish guidelines consider a medicine to be working if body weight has fallen by at least 5%. For semaglutide injections, the doctor assesses this after 3 months on the 2.4 mg dose, which is around the 7th month of treatment with standard dose escalation (1). For tirzepatide, there is no set point at which the medicine is stopped because of insufficient weight loss. The maintenance dose is 5, 10 or 15 mg, and the doctor decides when to review it and how to continue treatment. Liraglutide is stopped if body weight has fallen by less than 5% after 12 weeks on the 3 mg dose (4), and naltrexone/bupropion if the weight loss after 16 weeks is less than 5% (5). Our article on weight loss stalling on obesity medication describes what the doctor checks before deciding that a medicine is not working.

What should you ask before an online consultation about obesity medication?

• Will the doctor see my test results, list of medicines and measurements before issuing a prescription?
• Who will decide on a higher dose and issue the next prescription, and when?
• Who should I contact if I develop severe vomiting or severe abdominal pain?
• When and on what basis will the doctor assess whether the medicine is working?
• Who will help me change how I eat and become more active?
• How long will treatment last, and what happens after it ends?

In the 6-month obesity treatment programme at Nasz Gabinet, the doctor checks, in line with the Polish guidelines, whether medication is indicated for the patient, and after each subsequent medical review decides on the next e-prescription. The programme includes video consultations with a doctor and a psychologist, as well as monthly medical check-ups based on data from the app: a weekly weigh-in and monthly body measurements. The patient buys the medicine at a pharmacy, because it is not included in the price of the programme.

Frequently asked questions

Will a doctor prescribe obesity medication with a BMI of 28 and no other conditions?

Only if you have a weight-related condition, such as prediabetes, high blood pressure, lipid disorders or obstructive sleep apnoea. Some of these conditions are detected only in blood tests, so the doctor starts with tests and a blood pressure measurement. With a BMI of 28 and no such condition, treatment is based on changes to diet, physical activity and psychological support.

Will a doctor prescribe Ozempic if I can't lose weight?

Ozempic is licensed only for treating type 2 diabetes (10). For someone without diabetes, the doctor will prescribe a medicine licensed for treating obesity, such as Wegovy, which contains the same active substance at different doses. Being unable to lose weight is not enough on its own: what matters is your BMI, coexisting conditions and the absence of contraindications. Our article on what to do when you can't lose weight explains why your weight may not go down despite dieting.

Can someone being treated for alcohol dependence take obesity medication?

Yes, but the doctor needs to know about all of their treatment. Naltrexone/bupropion is contraindicated in someone taking naltrexone for alcohol dependence and in the period just after abruptly stopping alcohol. At Nasz Gabinet, we refer people whose drinking is hazardous to our addiction treatment clinic alongside obesity treatment. A separate article on obesity medication and alcohol describes how alcohol interacts with each of these medicines.

Sources

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