On Patient Safety: Managing the Risks of Telehealth Prescribing

The growth of consumer-first online platforms for prescriptions is booming. More than 100 telehealth sites now offer prescription medications at low prices for conditions ranging from baldness to sexual health to weight loss [8]. Revenue at Hims and Hers Health, a leading telehealth company, grew from USD 526 million in 2022 to USD 1.48 billion in 2024 [1], thanks to both domestic and international growth [3]. Anyone who has waited in a long line at a local pharmacy understands why: Online medication providers offer low drug costs and consumer convenience. Pharmaceuticals are delivered right to patients’ doors, saving them the time and expense of visiting first a doctor and then a pharmacy in order to obtain an often highly priced medication.

Since our patients are increasingly turning to online platforms for health and lifestyle needs, we should be aware of the prescriptions they obtain through these sites and help them safely use them. While these online companies provide medication-safety information and claim that they have medical professionals reviewing every patient’s medical information, no phone or video medical appointment typically is required to obtain a prescription [7]. In my experience, this seems to be fine with patients using these online portals—they have come to the website knowing what they want and they are seeking one result, which is to obtain that medication at the lowest price.

While streamlining the patient experience should be patient-centered, this type of prescribing raises a serious safety concern: No clinician is following these patients and their prescriptions over time to address potential risks of the medication. Ordering online may be convenient and less expensive for patients, but these telehealth providers are selling prescription drugs in the same way that Amazon sells books or toasters. Medications are inherently risky, and providing them without regular medical care visits is a safety risk.

To illustrate this risk, we can look at what is playing out in real time with glucagon-like peptide-1 receptor agonists (GLP-1RAs). Their use is exploding: 1 in 8 Americans have now used a GLP-1, with about 40% using it for weight loss [6]. Because of potential health risks, 67% of primary care physicians report being concerned about their patients obtaining these drugs from third-party telehealth companies [7] at the same time that sales of GLP-1RAs through telehealth companies are accelerating to keep up with rapidly growing demand [4, 9]. This issue is especially relevant to us, as GLP-1RAs can directly affect one’s bone health.

Early studies on GLP-1RAs were promising. A small study that primarily focused on patients with diabetes taking lower doses of GLP-1RA (such as liraglutide at a dose of 1.2 to 1.8 mg daily) did not demonstrate increased bone resorption or fracture risk [2], and these results correlated with animal studies that found no association between GLP-1RAs and loss of bone mineral density [10]. However, a recent and large randomized clinical trial [5] on GLP-1RA used as a treatment for weight loss calls these early findings into question: Researchers in Denmark found a moderate decrease in both hip and spine bone mineral density compared to placebo after 1 year of treatment on 3.0 mg of daily liraglutide—a higher dose than what earlier studies used. Importantly, these researchers [5] also found a regular, structured, vigorous exercise program that aims for an average sustained intensity of 80% maximal heart rate or higher to be effective in mitigating bone loss (in adults without diabetes, aged 18 to 65 years, with BMIs from 32 to 43 kg/m²).

I find these results concerning for several reasons. First, in my experience, patients using online platforms to obtain GLP-1RAs for weight loss typically are healthy and therefore interact infrequently with the medical system. Furthermore, the effect of their weight loss on their self-esteem is profound—many patients view these drugs as nothing short of “magic.” I expect they will take these drugs for considerable periods of time, and likely will not be interested in changing their lifestyle to include the vigorous exercise needed to mitigate bone loss. More importantly, without periodic contact with a physician who can routinely check their bone mineral density or exhort them on the need for vigorous exercise while on these medications, patients taking GLP-1RAs are at risk of sustained, clinically important bone loss. We may find ourselves flooded with hip and other fragility fractures over time, as patients age on these drugs while flying under the radar of regular medical care.

While orthopaedic surgeons are not the ones writing GLP-1RA prescriptions, our patients’ bone health is our primary concern. Since all medications carry safety risks, I do not believe any medication can be safely prescribed when no meaningful relationship exists between prescriber and patient. Individuals who obtain prescriptions from telehealth providers are consumers to those companies; when they come to us, they are patients seeking medical care. It is our duty to address any potential safety risks from the medications they are taking, including the risk of ordering from a telehealth company that does not require its prescribing physicians to meet each patient.

Upon intake, we should ascertain whether our patients are taking any medications prescribed by a telehealth company and arrange appropriate referral to primary care physicians for those who are taking medications without physician involvement. We should make clear to our patients that medications are not magic pills; they have risks that must be properly attended to, even if those patients are healthy. In addition to providing a referral for patients taking any drugs prescribed online, have that conversation with your patient on a GLP-1RA about the need for regular follow-up, vigorous exercise, and appropriately scheduled DEXA scans to mitigate bone loss. Be explicit and say these things out loud—“your medication has safety risks” does not convey the sense of importance and urgency to patients as saying “you need to schedule a DEXA scan” does. These are simple changes we can make to offer appropriate care for online prescriptions in general, and specifically for those that might affect our patients’ bone health, especially when no other physician is involved in monitoring that medication.