Overwhelmingly the price, and one study counted it directly: of 78 people offered liraglutide inside a supervised weight program, 57 declined and the paper names out-of-pocket cost as the reason [1]. That is nearly three quarters of the people a clinician had already judged suitable, refusing at the point where somebody was handing it to them. What the equivalent month costs on this market is set out in what a GLP-1 actually costs per month.
The study that measured the refusal
174 adults with obesity entered a twelve-week program of diet, activity and education. At week six, anyone who had lost less than 2.5% of their body weight was classed an early non-responder and offered liraglutide for the remaining six weeks. Seventy-eight people met that definition, twenty-one accepted the offer, and fifty-seven turned it down.
Between weeks six and twelve the treated group lost 3.5 kg, which is 3.2% of body weight, while the group that declined lost 1.3 kg, or 1.4%, at p < 0.001. With liraglutide use, baseline body mass index, sex, age and week-six weight change all entered the model, only the drug was significantly associated with what happened next. Tolerance was unremarkable, with four people reporting nausea and two upper abdominal pain.
The same refusal, at national scale
Seven years of the Medical Expenditure Panel Survey tracked who was actually getting these drugs as they went from rare to common [2]. Use rose from 0.42% to 4.45% of adults, and from 8.50% to 31.36% among adults with a condition the drugs are approved for. Spending per prescription rose by nearly half across the same stretch, which is what turns a growth story into an access story.
Privately insured, higher-income, college-educated white adults were the reference group. Against them, the odds of using one of these medications ran 0.53 for uninsured adults (95% CI 0.31–0.92) and 0.67 for adults with less than a high school education (0.53–0.85). They ran 0.73 for middle-income and low-income earners, 0.74 for Hispanic adults (0.58–0.94) and 0.78 for Black adults (0.62–0.99). Every one of those intervals sits below parity. The barriers people meet before the price question even arrives are collected in why a prescription is hard to get.
The prescribers say the same thing
A survey of primary care physicians across five Swedish regions collected 190 responses, of which 163 were analyzed [3]. Ninety-eight percent agreed the drugs are effective for treating obesity and 91% expected them to matter to obesity treatment going forward. The barriers they named were supply shortages at 86% and what the patient has to pay at 69%.
Clinical reluctance, in other words, was not what stood in the way where the question was asked directly. Two qualifications travel with that. The response rate was 28%, and physicians with an interest in these drugs are the ones most likely to answer a survey about them. Near-unanimous agreement among the people who replied says little about the ones who did not. Fieldwork ran in October 2024, during the documented shortage, so the 86% supply figure carries a date and should not be quoted without it.
What a refusal is actually measuring
A decline recorded in a clinic is a demand curve nobody usually publishes. It shows where the price sits relative to what people will pay when the drug is described to them by someone who thinks they should have it. That is a different measurement from a market share figure. Fifty-seven of seventy-eight is the number to keep. It points the same way as the coverage findings in the nineteen percent of employers who cover it: this market is rationed by who pays rather than by who benefits.
Two limits belong on the headline figure before anyone quotes it. The drug offered was liraglutide, the oldest molecule in the class, a daily injection, and weaker than what most people are now choosing between. A figure of 3.2% over six weeks does not read across to a newer molecule. And twenty-one people is a small treated arm, which fixes the direction rather than the size.
The people who accept and then stop are a separate group again, counted in why people stop taking a GLP-1. Turning the drug down at the counter and abandoning it three months in are different decisions, and only the second one leaves a refill record behind.