I was tasked last week with giving Grand Rounds at my hospital: a lecture given to my peers (other attending physicians) to educate them on a topic they might not be up to speed on. I find that the vast majority of consults I get from other physicians is for patients who want to start an anti-obesity medication, and the referring provider doesn’t feel comfortable prescribing it so they send the patient to me for more help. So I thought that the highest yield topic for my Grand Rounds lecture would be a review of the currently-available anti-obesity meds.
In reviewing the scientific papers published about each medication in preparation for my talk, I was struck by the efficacy of the newest medication approved by the FDA to treat obesity: semaglutide, or trade name Wegovy. This is a once weekly injection made by NovoNordisk that has been on the market for years at lower doses under the trade name Ozempic (used to treat people with type 2 diabetes), with multiple papers having been published about it in top medical journals like the Lancet and the New England Journal of Medicine. I favor it over all the other meds for my own patients, so I thought I’d come here and tell you guys a little bit about it.
For anyone with a BMI of 30 or higher, or 27-29.9 or with another weight related condition that would be expected to improve with weight loss (such as prediabetes or type 2 diabetes, hypertension, fatty liver disease, or obstructive sleep apnea) who has been unable to lose weight or maintain weight loss successfully using lifestyle changes alone, adding in a medication to help is the next step to consider (or, of course, barbaric surgery). For those who aren’t quite ready to take the leap to weight loss surgery, meds may be the answer. The one thing to remember, of course, is that you have to view the medication as a long-term solution. It’s not something you can take for 6 months to lose weight, and then expect to keep that weight off if you discontinue the drug. That would be akin to thinking you could take an antihypertensive medication to treat high blood pressure for 6 months and then expect to have magically low blood pressure for the rest of your life after stopping it: no one ever thinks that way! Of course you expect your blood pressure to rise again if you stop the med, and so too should you expect weight regain if you stop an anti-obesity med. (You might be able to cycle on and off with a medication to maintain weight loss over the long run, and certainly some weight loss maintenance may occur if other healthy lifestyle changes are kept, but in the end, the weight loss attributable to the drug itself will likely be lost if you stop the drug.)
Semaglutide at its maximum dose of 2.4 mg weekly (trade name Wegovy) is by far the most effective (as far as weight loss) of the currently available anti-obesity meds, and for that reason it’s my go-to for my overweight patients who want to add in a medication. It is a glucagon-like peptide 1 (GLP-1) agonist, meaning it mimics the effects of GLP-1 in the body. This hormone acts to delay gastric emptying and gut motility (making you feel full faster on less food) and suppresses appetite by directly affecting the brain, promoting satiety even when you aren’t eating. Even the lower dose of 1.0 mg weekly (available as both Ozempic and as Wegovy) is more effective than other anti-obesity meds, and discontinuation rates of semaglutide due to adverse effects is reasonable and lower than several of the other available meds. To give you a sense of semaglutide’s weight loss effect, in the NEJM paper published about it last summer, people taking it at a dose of 2.4 mg weekly lost, on average, more than 16% of their bodyweight after being on this dose for a year when it was combined with changes to diet and exercise, and over 1/3 of people lost more than 20% of their bodyweight. For a 250 pound woman, a 20% weight loss is 50 pounds. Nothing to sniff at.
There are adverse effects, like any medication. Most are GI-related, like nausea, diarrhea or constipation, dyspepsia, acid reflux… and tend to improve over time. Some are more serious, like rare cases of acute pancreatitis or the development of gallstones, worsening of retinopathy (eye disease) in patients who have type 2 diabetes, and even very rare reports of suicidal thoughts. There was an increased risk of medullary type thyroid cancer in rodents, though no statistically significantly increased risk of any type of cancer has been found to date in humans. Talking to your doctor about potential side effects and watching out for them is important if you’re considering using semaglutide….
And then there’s the cost. It can be tough for some people to get their insurance to cover it, and preauthorizations and other jumping through hoops is sometimes required. I have been lurking on the semaglutide discussion pages on Reddit to get a sense of what real world users are saying, and a lot of people suggest buying it from a Canadian pharmacy (where it costs more like $325 out of pocket than the almost $2000 it costs in the U.S. without insurance), or from Mexico (though you apparently have to be personally present to buy it in Mexico, so this is an option only for people close to the border). Ozempic, the lower 1.0 mg dose, is apparently easier for many people to get approved by their insurance than Wegovy is, so using that is an option for some people (and the amount of weight loss on the 1.0 mg weekly dose is still impressive, ranging between 9.8%-13.7% after less than a year of being on the maintenance dose, according to the initial phase 2 clinical trial published in the Lancet in 2018). I couldn’t be luckier to work for the Department of Veterans Affairs, where it’s covered for any veteran who meets the appropriate medical criteria for getting it and costs the patient under $10 out of pocket!
Not everyone needs medications to help them lose weight — there are plenty of overweight healthy bodies that are fine just the way they are. But if you have harmful health conditions that are weight-related and have struggled to lose weight to improve your health with changes to diet and activity alone, considering a medication isn’t unreasonable. After all, if your blood pressure were high and you weren’t able to lower it by eating less salt and exercising more, wouldn’t you consider taking a blood pressure med? Just my two cents.
And a quick update on Project 135: still trucking along! My weight is down again this week, though I’m not making any promises for next week because my birthday is on Tuesday, and I WILL be eating cake. 🙂
Until next weekend, with love-
Project 135 (resurrected) stats:
week 0 (Jan 1, 2022): 164.4 lbs
week 1: 162.2
week 2: 160.8
week 3: 159.2
Total weight loss: 5.2 lbs (3.2%)