The Magic Fix for Weight Loss?
Over the past year, there has been a flurry of discussion on social media about the wonders of weight-loss drugs like Ozempic, Wegovy and Mounjaro.
Natasha Withers, DO, a primary care provider at The University of Vermont Health Network - Porter Medical Center in Middlebury, has been prescribing the weight-loss medication Wegovy for the past year. Nathan Lamberton, PharmD, the UVM Health Network Pharmacy Manager of Ambulatory Care and Population Health, has worked directly with primary care patients on the use of medication-assisted weight loss and chronic disease management for the last two years.
Both say they have “multiple conversations a week” with patients about weight-loss drugs. Here are their answers to some common questions.
What’s the story behind these medications?
While Ozempic (also known as Wegovy or its active medication, semaglutide) gets the most attention, it is part of a larger class of injectable medications that have been used for the last two decades to treat type 2 diabetes.
After their first decade of use, doctors realized that these medications also led to weight loss. In 2014, with the approval of the FDA, these drugs started to be remarketed specifically for obesity.
The newest medication in this class of drugs is called Mounjaro -- also known by its active ingredient name, tirzepatide. At the moment, it is only approved for the management of type 2 diabetes. But the manufacturer is currently compiling data from clinical trials and plans to submit its findings to the FDA later this year, so Mounjaro may then be approved for chronic weight management.
This would make Mounjaro the only single-brand medication with dual approvals for both type 2 diabetes and chronic weight management.
How do they work?
As we eat and our stomach fills, our bodies naturally produce a chemical called GLP-1. When that chemical is picked up by receptors in the brain, we get a signal to stop eating. Ozempic and Wegovy work by introducing a synthetic version of that chemical, which gives us the same feeling of satiety around the clock.
Patients taking these medications have a smaller appetite overall; they eat less frequently, or they eat smaller amounts, or a combination of both. “We find that patients’ appetite is suppressed about 50% with these medications,” reports Lamberton.
Mounjaro works in a similar manner, but because it adds a second synthetic hormone involved in digestion, it is more powerful. This means that patients may lose more weight, but experience more side effects, with Mounjaro than with other weight-loss injectable medications.
Are they effective?
Yes, say Lamberton and Dr. Withers, but it’s a long-term solution and may be a lifelong commitment.
On average, Lamberton reports, patients lose about 15% of their body weight over 8 to 12 months. Dr. Withers adds that, while patients will see weight loss even without exercise, they need to combine these medications with lifestyle changes to get the most benefit. She notes that all of the studies include both caloric restriction and physical activity.
Lamberton also adds that, in order to keep the weight off, patients need to keep taking the medication. “If patients discontinue the medication, even after making lifestyle changes, they usually gain back some or most of the weight they lost,” he says.
Dr. Withers summarizes things this way: “I’m all for it: These medications offer a bit of a boost, which helps with long-term motivation. But, much like weight-loss surgery, patients need to make lifestyle changes as well in order to have lasting results. We can’t think of these meds as a standalone cure-all.”
Are they safe?
Based on an abundance of available data, both Lamberton and Dr. Withers say yes.
“These drugs have a lot of evidence, and we’ve seen them work when other things haven’t,” says Dr. Withers, who admits she was initially skeptical. “I received my medical training during an era of very dangerous and detrimental weight-loss drugs, so I was initially wary. But in this case, we have an appropriate amount of data, so I’m very comfortable prescribing them. But I tell everyone, ‘this is what we know today;’ tomorrow there may be new data that changes the discussion.”
Lamberton adds that the newer medications labeled specifically for weight loss use the same active ingredient as the original diabetes medications, which have been around for 15 years. “In that period of time, we haven’t seen any unintended consequences,” he says.
Who’s a good candidate?
Generally, people with a Body Mass Index (BMI) of 30 kg/m2 or higher are good candidates for the medication. The cost may be partially covered by commercial insurance plans. In addition, people with a BMI of 27 to 30 kg/m2, along with one or more weight-related conditions (such as high blood pressure, high cholesterol, or diabetes) will also benefit and may qualify for insurance coverage, but it is best to contact your insurance provider for coverage details. (Need to figure out your BMI? Here's a calculator.)
What if I’m not medically obese, but want some help losing that “COVID-19”?
Dr. Withers says she’s open to talking about these medications with anyone, no matter how much (or how little) weight they have to lose, and the drugs would likely be helpful, even for modest weight loss. The problem, say both experts, is that insurance will likely only cover it in cases of clinical obesity – and without insurance coverage, the out-of-pocket costs are prohibitive for most people (i.e., thousands of dollars a month).
For many people with obesity, the excess body weight can make it painful to exercise, notes Lamberton. With these medications, many of those patients can generate the momentum to start getting active.
“It gets the ball rolling and helps them develop new behaviors,” Lamberton says.
Who’s not a good candidate – both medically, and in terms of insurance coverage?
Patients with a personal history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia (MEN) type 2, or who have a first-degree relative with either of those rare conditions, shouldn’t take them, because these medications can increase their cancer risk. In addition, says Lamberton, patients with chronic pancreatitis or a pathological slowing of the GI tract, called gastroparesis, may not be strong candidates.
And it’s worth noting again: Insurance companies have strict criteria about who qualifies for coverage. This is partially due to the fact that demand is currently outpacing supply -- which can make it difficult even for people with diabetes to get the medication. Insurance companies will only cover Wegovy for weight loss in cases of clinical obesity. They currently do not cover Ozempic or Mounjaro for weight loss. If patients do receive coverage for weight-loss medications, it’s generally only partial coverage; patients are still responsible for monthly copays, which can be $200 per month or more.
Finally, Dr. Withers adds that it’s only the commercial insurers that cover weight-loss medications; both in Vermont and in New York, Medicare and Medicaid patients are currently not eligible.
What are the side effects?
Four out of 10 weight-loss patients experience mild or moderate GI upset, Lamberton says. “These drugs also slow stomach emptying, so if you take these medications and you continue to eat large portions or eat quickly, you may feel uncomfortably full.” There can also be some more serious side effects associated with these drugs, so it is best to discuss them with your doctor.
What are the key takeaways?
These drugs offer new hope to patients and could reduce obesity-related health conditions and costs among the population.
But while both experts are very positive about medication-assisted weight loss, they also stress that everyone needs to have reasonable expectations. “Lots of people think they’ll take this medication for a few months and lose 50 pounds,” Lamberton says. “Unfortunately, the majority of weight-loss medications don’t work THAT well.” The average degree of weight loss is around 15% from their starting weight. This means that a 250-pound individual could expect to lose around 37 pounds, on average.
“Also, sometimes patients start looking for alternative ways to get it cheaper,” adds Dr. Withers, “and some pharmacies have taken advantage and are advertising these medications for online order at a substantial savings.” she says. But patients should be wary of compounding pharmacies -- or clinics that use them -- promoting weight-loss medications. “The manufacturers of these drugs do not sell them for compounding,” she explains. “So you have to wonder, are you getting a different drug, or a diluted version of the active ingredient? There’s no way to know.”
If you have weight to lose, definitely talk to your doctor, says Dr. Withers.
“There’s no judgment, and there’s no need to keep trying on your own. I really welcome people asking me about it, because that opens up a two-way conversation. That’s far better than my saying to them at their physical, ‘Your BMI is 35. Let’s talk.’ That’s not always well-received.”