New Weight-Loss Drugs

By Mary Carpenter

TWO DRUGS—Wegovy, FDA-approved for weight loss in those who are obese or overweight with health problems; and Ozempic, FDA-approved for Type 2 diabetes—are different formulations of the same hormone-imitator semaglutide. As a result, when Wegovy supplies ran short recently due to high demand and a manufacturing snafu, people trying to lose weight turned to off-label use of Ozempic, which in turn created a shortage for those with Type 2 diabetes who depend on the drug.

“Ozempic Runs Low for Diabetes Patients as Weight-Loss Use Surges” was the headline on a “most popular” Wall Street Journal story last week. Elon Musk, celebrities and many others touting weight loss from both drugs have fueled more than 700 million views of Ozempic-related hashtags on TikTok.

While insurance covers Ozempic for patients with a Type 2 diabetes diagnosis, most insurance doesn’t cover any weight-loss drug. Patients taking either of the semaglutide drugs for weight loss must pay full price, which for a month of treatment via weekly injections, comes to about $892 for Ozempic and about $1,350 for Wegovy.

“I’m middle class and a good example of someone who needs to lose weight but cannot afford these drugs,” says local foundation executive R.D. Critics decry the failure of most health plans serving older adults and low-income families, often the people who most urgently need medical help for overweight or obesity—to cover weight loss drugs, although Medicare pays for bariatric surgery.

“These anti-obesity medications are the best we’ve ever seen,” said Tulane obesity specialist Shauna Levy. “Patients I see want their knees to feel better, their hips to feel better, their blood pressure to get better, their diabetes to get better,” Levy said. “But when they come in, I have to tell them, ‘I’m sorry, I’d prescribe this for you, but it’s going to be $1,200 a month because your insurance doesn’t cover it.’ It’s sad.”

Being overweight and having “pre-diabetes” (blood sugar levels just below those for a Type 2 diabetes diagnosis) are the top two risk factors listed by the CDC for Type 2 diabetes. In both Type 1 and Type 2, though for different reasons, insulin is no longer doing its job of processing glucose, which then circulates at high levels in the bloodstream. Persistent hyperglycemia can impair the body’s ability to fight off infections—putting diabetics at higher risk for infections in the urinary tract, lungs, skin and elsewhere—as well as damaging blood vessels throughout the body with serious health consequences.

Proponents of the semaglutide drugs’ use for weight loss emphasize the need to take them in conjunction with improving diet and regular exercise—without which beneficial effects may not endure. Likewise, among reasons given by insurers for their refusal to cover any weight-loss drug is the drugs’ failure to insure weight loss once a patient stops taking them, along with limited evidence of lasting benefits in reducing risk of diabetes or cardiovascular disease.

Serious health complications can arise for Type 2 diabetes sufferers who are unable to fill their Ozempic prescriptions. “When people suddenly stop semaglutide, the amount of glucose in their blood can surge,” as American Diabetes Association medical advisor Robert Gabby told the New York Times. “Patients with diabetes may experience blurry vision, fatigue and excessive thirst and urination…end up in the emergency room from exhaustion.”

Diabetes patients unable to locate semaglutide medication also face higher risk of heart failure, the most common cardiovascular disease in patients with Type 2 diabetes. In small studies of patients with both Type 2 diabetes and obesity, these drugs reduced ER visits and hospitalizations due to heart failure.

Semaglutide drugs work by mimicking hormones called incretins, which delay gastric emptying and activate satiety centers in the brain, creating a sensation of fullness that helps suppress appetite. At the same time, the drugs boost insulin production in the pancreas to help control blood glucose levels after eating. A newer drug, Mounjaro, employs a different chemical—tirzepatide— which also mimics incretins but acts on two different kinds of receptors, rather than just the one affected by semaglutide. Mounjaro, expected to receive FDA approval for weight loss, will cost about $975 a month.

Side effects of incretin-mimicking weight-loss drugs include feelings of nausea, vomiting, constipation and abdominal pain. Another unwanted effect is gauntness and sagging facial skin, common with weight loss for any reason but for people taking these drugs known as “Ozempic face.”

A different drug, Metformin, is often the first one prescribed for Type 2 diabetes patients but is also used off-label for weight-loss. Taken in a twice-daily pill, Metformin works by decreasing sugar absorption from the intestines, lowering the amount of glucose produced by the liver and improving insulin sensitivity. And the drug has received recent attention for its potential to stave off effects of aging —by creating greater resilience, especially against severe disease.

Plenity is an absorbent hydrogel pill available by prescription and designed solely for weight loss. Dubbed a “bloating drug,” Plenity—taken before meals with 16 ounces of water—creates feelings of fullness by decreasing the stomach’s volume by about 25%.  Side effects include abdominal distension as well as bloating. In research, participants taking Plenity have lost an average 10% of body weight in six months; those taking Wegovy achieved weight loss closer to 15-20% of their body weight, which is comparable to that of bariatric surgery.

Among an array of OTC options, L-glutamine supplements work by altering composition of the gut microbiome and may improve blood sugar control. Studies on these drugs’ effects on insulin as well as their success in achieving long-term weight loss has produced unclear results. Glutamine also occurs naturally in foods, including eggs, beef and tofu.

Some people struggling to control their weight, however, are not satisfied by feelings of fullness or helped by blood sugar control—as evidenced by those who have bariatric surgery to reduce stomach size but continue to overeat despite serious health complications. In some cases, people eat compulsively for emotional reasons, for example, trying to combat depression or feelings of emptiness.

And some 13% of the over-50 population who overeat sugary or salty foods have symptoms of addiction that include intense cravings. They attempt unsuccessfully to cut back on consumption and experience symptoms of withdrawal, such as irritability and headaches.

My worst experience of gaining too much weight, about 60 pounds in a month, came during an emotional crisis that led to me dropping out of college. The foods I couldn’t stop eating, way past feelings of fullness, were mostly very sugary and salty. After about nine months, I returned to college and started losing weight—with a new understanding and sympathy for anyone who has trouble resisting such intense cravings.

—Mary Carpenter regularly reports on need-to-know topics in health and medicine.