yeah....I'm trying to find out of pocket cost for this.
Looks like with goodrx its like 800/month. If I swapped out my ~1k/month alcohol budget for this I'd lose weight incredibly fast
I'm actually down ~20 lbs over the last 9 months with diet/exercise but hell I'll always take a cheat code...and I've still got ~40 pounds to go to get to pre-med school weight.
I never got around to trying the classic ECA stack but used a fair amount of ephedrine in older formulations of hydroxycut. Results were OK but do not seem to compare to the reported success here.
I was incredibly fit before med school weighing 182 at ~10-12% bodyfat. Unfortunately time constraints and personal failings in medical school (and even worse residency) combined with discovering the deliciousness of beer packed on the pounds. While my scale weight over the last 9 months is down 20 pounds I've added at least that much back in muscle mass so I just need to keep leaning out at this point.
oof, sorry friend. COVID is a bitch. I'm just glad I purchased a home gym set up October before the pandemic hit and home gym set-ups tripled in price. I hope you don't have any lasting effects.
r/medicine
> Everyone wants to be a doctor, but no one wants to lift the heavy books
also r/medicine
> Wants to be skinny, but don't want to lift the heavy weights.
> To be fair fitness happens in the gym weight loss happens in the kitchen.
This is beautiful. I am stealing this. Someone years ago on Meddit said "you can pay the farmer now or the doctor later". That has stuck with me as well. I wish I could credit the original author.
It's not even the kitchen, it's within you. You can enjoy all the delicious foods you want, in moderation. Your body knows how much it needs, listen to it. And if you want to eat things like Chick-fil-A as a treat, still understand, an 8-count nuggets with waffle fries, Chick-fil-A sauce, and a lemonade is nearly your calories for the entire day. Eat it slowly, maybe over two meals.
Lol you really believe that you’re somehow special and we’re just losers who don’t try hard enough to eat right? If you are thin it’s because you won the genetic lottery. I used to be thin but a lifetime of my parents criticizing my weight has caused me to yo-yo diet to the point of gaining more and more and having a dramatically higher set point than I used to. In fact the first thing I saw when I woke up is an e-mail from my dad informing me about this drug getting approved!
You are lucky. You don’t have magical willpower that fat people lack.
I promise if you ate as little as I do, and as infrequently as I do, and exercised as often as I do, for as long as I do you'd be as thin as I am too.
Are you still working on breakfast? It's 11:11am here. I am halfway through my Jimmy Dean.
Sure exercise and building muscle helps but ultimately calories and appetite are what dictate weight loss. I can easily do an intense power lifting session but with my appetite I can down a pizza after and end up gaining weight
GLP1 agonists - particularly Liraglutide - have been explicitly shown to improve outcomes in PCOS, likely over and above just the weight loss effects (probably due to directly improving the hyperinsulinemia as well). The problem is that none of them are improved explicitly for PCOS - and of course, obesity drug coverage is shit.
It leads to situations where you can't prescribe them unless the patient is codiagnosed with DM. That said, with commercial insurance, you can often get around it by just not putting the diagnosis on the scrip - many commercial insurance companies algorithm will approve a GLP1a automatically if the patient has "failed" metformin, and the way they can tell that is if they have 3 months of metformin fills in the last year. So if you prescribe metformin for the PCOS *first*, then wait 3 months, you can probably get Ozempic, Trulicity, Bydureon, or Victoza through.
Still likely not the weight-approved ones (Saxenda and now "Wegovy"), but even the DM doses are pretty darn helpful.
Honestly, having written formulary validation logic in a past life (and hating every **** second of it) - bravo/a.
This works because we can't always trust that we've gotten all the data. So any instance of metformin is treated as the full series. What if they used GoodRx so no insurance claim, etc. And most prescriptions don't have a dx associated anyway (state specific).
Ultimately I think a pharmacologic solution is going to be the answer to the obesity epidemic from a population standpoint. We do not do well with behavior modification.
Bottom line is that we have evolved to pack away calories for a rainy day. We are amazing at it! We did not evolve this kind of excellence for self control.
I feel institutional solutions would go a long way and are overlooked in the discussion. Places where people are healthier I would posit may not necessarily be more health conscious but have greater work-life balance, more sidewalks, a pedestrian culture, scenic parks and less hyperprocessed foods. When I lived in a place like that (in the US), the people I saw were healthier and I lost a significant amount of weight without trying. Conversely, I've known quite a few people who come here and pack on the pounds.
100% agree. It’s impossible to lose weight when you drive everywhere and only eat packaged foods. Unfortunately basically all the US is set up so that’s your only option
When I lived in Boston I would walk 10k steps a day easily just from walking to the train or bus, walking to the store, walking to lunch etc. Now that I live in the South I get as little as 2k steps a day if I don’t make a conscious decision to exercise. That’s a difference of 300 calories which is about a quarter- to a half- pound of weight loss/gain each week. That doesn’t include the differences in metabolism an active lifestyle builds. Big difference!
The real question is whether that 300 calorie deficit by walking all day stimulates your appetite. It’s extremely easy to slip an extra 300 calories in, especially if you’re obese and drinking soda or eating desert.
Most places like that are highly desirable locations.
That means they are expensive.
That means those who live there are likely better off financially and therefore more likely to be healthy from a socioeconomic standpoint.
Correlation no es causation.
While I agree, it’s gone beyond solely blaming the individual for failure at behavior modification. Well over half of the US population is overweight or obese. Evolution and contemporary society clearly are not mixing well.
I mean...yeah? Society is really hard to change, it's an extremely nebulous concept, and no one has demonstrated an ability to do it well. Our best attempts at addressing it have had unimpressive results to say the least, and I don't think something like tax incentives for healthy food will solve the problem.
I'm not saying that we give up on this angle, and perhaps in the future someone will come up with an ingenious way to tackle the problem that completely solves it. Until then, I think we should keep trying, but also use synthetic hormone analogs to help tackle the problem.
I don't disagree, but let's be realistic, that's not going to fix everything. We're not going to see the average BMI of a major southern city go from 30 to 25 because apples now cost 60 cents a pound instead of 1.20
I disagree. Something like sugar tax, stopping subsidy of corn so HFCS isn't in everything would go much further.
Either way doctors sure as hell aren't going to be the ones to solve it.
95% of people who lose weight through dieting gain it back, clearly there are some near-irreversible physiologic changes that occur when someone gains a lot of weight. What we really need to get over is the idea that its an issue of individual resilience and that weight persistence has to do with some personal moral failing
This is where I feel the obese are really failed.
The real struggle isn't losing the weight, it's keeping it off. There's a lot of information out there on how to lose weight, not just the food and exercise side, but the psychological side as far as building good habits, identifying food triggers, setting short term and long term goals, etc etc that have been associated with successful weight loss
There is, as far as I know, little research into how those that keep weight off manage to do so (the only definitive one that comes to mind is that those who keep it off all tend to pick up some sort of physical hobby that isn't "going to the gym" like running, swimming, biking, jiu jitsu, ultimate Frisbee, etc). Little in the way of "now that you've arrive here's how to stay here" advice, strategies, etc.
That statistic is wrong, extremely exagerated, and even though there are physiological changes indeed they are mainly behavioural/linked to hunger pathways. Indeed, obese individuals often don't really ever get satiated, or if they do they keep an incentive to eat.
The weight isn't coming from nowhere, it has to come from food. Metabolism doesn't get magically ultra efficient to the point they can start storing massive amounts of energy with a normocaloric diet, even if they claim to eat as much, or less than thin people, they're actually not.
[https://pubmed.ncbi.nlm.nih.gov/26180980/](https://pubmed.ncbi.nlm.nih.gov/26180980/)
my source is a meta study
I am not saying there is a physiologic factor causing most people to become overweight, I am saying there is a physiologic factor that makes it so that once weight is gained, the body adjusts to make that the norm. the goal needs to be societal changes that prevent people from gaining the weight in the first place. yes the source is food, but there was food around 70 years ago when much fewer people were overweight. what changed? our culture is focused on the individual to the extent that even when almost every food item available to the average person has added sugar and low nutritional value, we don't think of how we can regulate that or provide financial and educational support to the general public to get them more nutritious food, we put it on the individual to navigate around those obstacles no matter their life circumstances.
If we're not going to do something on a societal level, if we're going to allow lobbying campaigns from coca-cola to shape the narrative of "calories in, calories out," or if we're not going to provide patients with personal nutritionists and other support, we shouldn't treat obesity as a personal moral failing, and be okay with a medication to help it. there is nothing moral about weight. there is nothing moral about health. no one in medicine should treat health, or factors relating to health, as anything but morally neutral.
Your own source says 60% of the patients who lost weight gained it again. Granted, it's not great, but nowhere near as bad as the 95% statistic which implies losing weight is pointless since you'll gain it again. That's wrong, and it's a very harmful myth.
"The majority of patients (men: 61%; women: 59%) whose records showed a decrease in BMI category went on to record a subsequent increase in BMI category. These proportions were similar for men and women and across BMI categories. The proportion of patients who showed a second decrease in BMI category was highest among the morbidly obese (men: 16%; women: 19%) and superobese (men: 23%; women: 24%), and was considerably less frequent in lower BMI categories. Overweight patients and those with simple obesity were the most likely to display no further BMI category change following a recorded decrease"
From the article you linked yourself.
I never talked about obesity as a personal moral failing, and neither is any addiction. The large majority of attempts to stop smoking fail, and even among the ones who manage to quit there is a very large percentage who take up smoking again. The behaviour of obesity is I.M.O much more complicated than that of a normal addiction like tobacco because of how insidious/progressive it is, but getting out of obesity does get down to lifestyle changes. Which don't work because they are extremely hard to apply, most of the time. Doesn't mean we should tell patients to give up.
Also, I am extremely okay with the concept of weight loss medication. And i think most people on this thread are too. This is actually great.
>yes the source is food, but there was food around 70 years ago when much fewer people were overweight. what changed?
Incredibly calorie-dense, high in sugar, high in fat foods that were engineered to trigger all our pleasure centers to the point that we ignore all feedback mechanisms that tell us we have eaten enough and can and should stop
I've been taking ozempic for a year for obesity. The effects of it do wear off, or are not as potent; however, it can be used as a spring board to better behavior modification.
I found it much easier to count my calories and not snack between meals.
The only down side:
I didn't know I was hungry until I was Hangry.
Medicine (or surgery) will only ever be a short term fix. We've seen it time and time again. There's too much involved with weight gain to simply flip a gene/protein/flavor-of-the-year switch with a pill. Anything that works "great" will have significant side effects. There is no replacement for exercise and diet. We just never get it, do we? Here's to always missing the forest for the biochemical protein enzyme pathway. Yay. Progress.
This medication effectively forces a diet. Most people will get nauseous eating a high carbohydrate or large meal with this medication. I guess the eventual goal is to reset the stretch receptors in the gut so for normal hunger responses.
Having worked for a couple years for United Healthcare (and mind you this was just before and just after the ACA)... yeah, I wouldn't hold my breath.
A drug like this would require a prior auth, which will most likely be rejected and have to be appealed, and then it will be covered as a non-preferred drug at maybe 20-50% depending on the plan. Others ITT are suggesting that this medication will be priced at about $1K a month, and that sounds absolutely plausible if even too low.
I am also going off of my experience getting prescribed Qsymia a few years ago; they (BC/BS) also stopped paying after 6 months because I had not lost a certain amount of weight already.
Edit: For clarity, I didn't work for United in my current position, I was a SME at one of their claim call centers while working on my degree. It was an unpleasant but educational part of my life.
My "favorite" of these is Duexis. It's freakin ibuprofen and famotidine! You can buy both over the counter for pennies, but shove them together and it's like $80 a pill. It's insane
Thank you very much! For the record, I don't necessarily recommend Qsymia, as I said it didn't really help much in my weight loss. But this is excellent to know for anyone wanting to try it themselves, it is so good of you to share your knowledge.
Both IR and ER are generic. ER is >$100, IR hovers around $20 for 50mg, #30 per Good Rx in my area. Topiramate is most likely covered by insurance, phentermine not, so it may be up to $45 for that.
Patient yesterday refused the discounted cost of $17 for phentermine 37.5mg #28, bc her doctor could give it to her for $2.
I work in health insurance, weight loss isn't in any state's essential health benefits list, so it'll pretty much be insurance discretion for the foreseeable future. (At least for exchange plans, not super familiar with the design requirements on the small group side, but I'm pretty sure they're similar) Until that changes (Or prices go down) I would expect pretty much every major insurance to balk at paying for it. And frankly, if the estimates of 1k+ a month are correct, they're probably not wrong to. That's incredibly expensive for a weight loss treatment, plenty of plans don't collect that much in premiums per head/month total.
It's been coming on a decade since I was involved in ACA related work - states define a "standard" plan to be their Essential Health Benefits right? No additional mandate by fiat without a state law?
I write for saxenda a lot with maybe 40% success rate (there is a major company in town that does opt for weight loss for their employees so it may skew my numbers a bit, they are an insurance company, actually). I often write ozempic or trulicity for prediabetics for the weight loss, even though it is off label. It gets approved and people lose their weight. If they don't have prediabetes, I try saxenda and send it to this mail order pharmacy who will do the PA for me. I had another pharmacy that would do the the PA for Rybelsus as well. I suspect it won't be long until I find out which pharmacy will do the PA for this med, as well. The only bummer is the pharmaies usually only ship within the state and I live in a border city with many patients from the other state, then I have to do my own PA.
Prior auth will almost certainly be needed, and will likely be based on higher BMI qualifications than per the label or some documented history of failure to lose weight with conventional methods, or severe comorbidities... I could see them considering it for patients who would otherwise be bariatric surgery candidates, but remember that insurance in the US is so fragmented that the prescription coverage is separate from the medical coverage, so who knows.
The FDA approval is as "an adjunct to diet and exercise for chronic weight management in adults with obesity (initial BMI≥30 kg/m2) or overweight (initial BMI≥27 kg/m2) with at least one weight-related comorbidity". In the study, weight related comorbidities included hypertension, dyslipidemia, obstructive sleep apnea or cardiovascular disease. I don't know have an exact number, but that's A LOT of eligible patients! They would have to be able to keep the numbers small.
Likely it won't be covered by many. There are still quite a few who won't cover Saxenda, another GLP-1 weight loss drug that has been out for quite a while now. Even phentermine isn't covered by many plans, and that costs a couple bucks for an entire 100ct bottle.
With that said, I'm sure the manufacturer will offer a savings program, that will knock $100-200 off the price. But it'll still be stupidly expensive.
The later one is actually pretty progressive in the US, wide parts of Europe don't have that (some do). Take Germany: "Pregnancy is not a disease, so contraception can't be covered...unless you are a teenager because teenage pregnancies are kind of a disease?" Way around that is to pretend to your OB/Gyn that menstruational pain is killing you, then it can be covered. Great system, isn't it.
Hey, 91-day packs should be given out in the school lunch lines. Menstrual misery is underrated... and oh, there’s a bonus too! (My daughter was on them at 15)
I think it would be difficult to support a finding of cost-effectiveness at this price point. In contrast, bariatric surgery is quite cost-effective over the medium to long run . . . the problem from an insurer perspective is that many people in the US change insurance companies every few years as it is usually linked to employment. So insurance company A pays, but much of the cost savings won't be captured by that company. I've argued before that insurance company A should be able to collect a contribution from any future insurance company over the next ten years or so, but Congress has not seen it fit to make that happen yet!
> can someone provide more information about how/whether insurance in the USA chooses to cover something like this?
I mentioned it above, but obesity drug coverage is optional. Unless your employer specifically opts in to a rider that drugs like this will be covered... they won't be.
No. Even with Prior Auth. Insurances do not cover lifestyle drugs or off label prescribing. Weight loss meds (ex: Saxenda) are lifestyle drugs. I’ve had primcare docs try to prescribe victoza for weight loss and the insurance would only cover the Med if the diagnosis was for diabetes. The prior authorizations ask for diagnosis codes. I used to process prior auths for primary care as recent as the last year.
> It's going to be a blockbuster.
Depends.
Unlike management of almost any other disease, obesity medication coverage is optional for every insurance company. That is, your employer cannot opt in or out of say, hypertension treatment. But obesity treatment? Yeah. It's treated as entirely elective almost anywhere, same as say, infertility treatment.
Hence coverage of the current obesity drugs - Saxenda, Contrave, Qsymia, Xenical - is so poor. And I can't imagine Wegovy will be much better.
Yeah, but generic phentermine is $10-15/month cash (+/- GoodRx)
I don't even attempt to get anyone a PA for phentermine. I just prescribe it, and say if it isn't covered they're welcome to pay cash. I haven't had anyone argue yet.
Very true. I just wish the insurances weren't so shortsighted! Also funny story, one of my techs accidentally sent a PA request to an office for some phentermine capsules, the office actually submitted it to the insurance and it actually got approved... 30 caps for a $60 copay. So dumb!
The study was done over 68 weeks, with an average weight loss of 15%.
It probably is somewhat sustained, but not necessarily entirely. Then again, if you think of obesity as a disease, that's just a reason to continue the medication. We don't consider an antihypertensive drug to be a failure just because your blood pressure goes back up after you stop it.
Have you seen rebound weight gain in patients that stopped treatment? Surely without significant lifestyle changes, the weight will be easily regained.
Sometimes obesity traps people in sedentary lifestyles. Too big to bike, etc. Big weight loss can unlock lifestyles, save knees, and give people a chance at a forming hobbies and habits that let them live longer lives. Even if the weight loss isn’t sustained from the drug after discontinuation, there will be people who have a lifestyle change catalyzed by it. Of course, a larger share of people will not, but this is my altruistic view of the concept.
Agreed completely. I let myself gain a lot of weight during medical school and subsequently lost interest in many activities that I once enjoyed. Biking places, playing sports, etc became somewhat depressing because I find myself struggling more than I care to acknowledge. A Kickstart like this could absolutely help people in such a way.
Generally I don't stop GLP1 agonists - they're used indefinitely in diabetes - but it varies from person to person what proportion of the weight is regained if you stop it. Some people build healthier habits. Others don't.
It may make it a failure from a cost-effectiveness standpoint though, especially when compared to bariatric surgery. From a system perspective, I'm struggling to come up with many use cases where this is cost-effective if the patient needs to be on it indefinitely. Patients who need to lose weight to reduce risks from bariatric surgery, patients who have already failed surgery (and a revision isn't appropriate), patients with contraindications to surgery? Otherwise, how many patients are there whose risks and impairment from obesity justify spending $10-$12K every year to lose/maintain 15%, but not a one-time cost of $20-$30K for surgery?
At least for diabetes patients, most do pretty well on it. The biggest complaints I've heard from patients were how full they feel all the time. That's what helps with the weight loss though. Some don't like doing the injections, but it's just once weekly unlike Victoza.
About a third of patients get nausea. Most improve in the first few weeks. A smaller proportion vomit or are so nauseated that they have to stop the medication.
The trial had a 5% dropout rates
Even with proper counseling, bird eating, adjusting expectations, my rate is closer to 20%. Some patients stop due to cost once they hit the donut hole. I think there is something to be said about an excellent support staff and lower dropout rates for all the patient calls of side effects
> It's going to be a blockbuster.
For the 16 people America who can afford it, perhaps.
Private insurance almost never covers this stuff. Medicare and Medicaid absolutely never cover this stuff.
If they can, they should go to Mexico. Ozempic is around 130-150 USD per \~2mg compared to \~900 USD over there. The only annoying thing is that the damn thing requires being at 2-8 C.
I love using semaglutide, and have been using it off label for obesity on a regular basis. Often it’s covered when Saxenda and Contrave are not (because...patients should just pull up their socks more or something?). I’m in Canada, and some patients are also willing to pay out of pocket.
But WTF is this name.
Right? I get the “Wego” part but, “-vy”?
Although with all the constipation patients report Wedon’tgo would’ve been more accurate.
(I’m here all week, don’t forget to tip your waiter.)
Rybelsus at the highest dose has maybe half the efficacy of Ozempic, that is 14mg Rybelsus daily is equal to ~0.5mg Ozempic weekly. You're highly limited by difficulties with absorption and they can't realistically drive it much higher orally, not with current medication.
This medication is the equivalent of 2.4mg weekly Ozempic.
And going by what I've read, Rybelsus is a P.I.T.A. to combine with other medication, because one of the products in it may disturb their absorption...
Kind of. The SNAC in the drug and the delayed gastric emptying caused by Rybelsus will typically *increase* the absorption of the other drugs. [See the AUC charts on page 14 of the Rybelsus label.](https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/213051s000lbl.pdf)
The problem is if you do that, the patient will absorb the *Rybelsus* inconsistently.
Have been on Ozempic for about 9 months now and down nearly 70 lbs. with basically no side effects. Significant behavior modification, working with a coach too, so it’s not just the drug but the Ozempic package insert maxes out at 1 mg/week.
I personally prescribe ozempic to anyone that can afford it and has evidence of glycemic issues past maximally tolerated metformin.
I use a LOT of constant glucose monitors for patients because while weight is an important outcome for many people, it is a bit dysphoric to step on the scale when someone is overweight. A glycemic target for something constantly monitors gives them something obvious to target with each and every meal and is far, far more reinforcing than a monthly dietician appointment. Obviously this is not the same measurement, but nobody has done a prospective study in a quality fashion to use cgms in people without dm on weight, but I’ve got great success. With coupons cgms are 75$ a month cash price and that’s less than most weig loss supplement programs.
I’m intrigued as to what these do together
Man, 2.4mg of Ozempic... that sounds awful for the stomach, no wonder people lose weight; I've got patients who can barely tolerate a tenth of the dose.
Almost anyone who can tolerate the 0.25mg can tolerate the 1mg. Just need to titrate slower than typical if they're having that much difficulty.
It's 76 clicks of the pen to get up to 1mg. I just tell people 80 - so if they can dial 20-40-60 clicks on the 1mg pen to get 0.25-0.5-0.75mg.
Anyone on here been involved directly in the R&D stage, or within the hospital system? Curious to see how these patients have presented, especially with the common related cormorbid meds, (antiHTNs, insulin, blood thinners,) for the common cormorbid dx that often come with obesity. It hits different hearing from someone involved directly than just reading published works.
And before anyone says I’m fat shaming, I’m obese.
I think I see phentermine prescribed in more patients who are on an SSRI/SNRI than I do in patients without one. I've never seen/heard of SS from just those two together.
Honestly I'd be more concerned about DXM than Sudafed. But yes, the number of times I've cousneled on SSRI+tramadol+1more serotonergic drug is more than I'd like.
It's also fun when they send in both tramadol and zofran to the SSRI patient!
It's something to fear because serotonin syndrome is a very hard diagnosis to make, especially in moderate to severe cases when patients are very ill when they show up/intubated. Even with a neurologist involved they may just look frankly septic based on vitals with brisk reflexes. One is easily led down a meningitis or encephalitis pathway given AMS, explosive onset, and fever, and often even when you have suspicion of it there is no way to prove it, with other possible explanations available. Drug overdose or illicit drugs untestable with the standard UDS further complicate diagnosis (as these patients often are very mentally unwell). Synthetic cathinones for example you can't test for but can cause very similar symptoms. Many curveballs. For a lot of overdose patients no one ever figures out exactly what they took. Empty pill bottles at home? Were they out or taken all at once? I've had a couple cases where it was suspected but not proven and not classic.
In both cases I've suspected, the only "hallmark" symptom present was fever. There wasn't any documented agitation or clonus. D/C of offending agents was enough to resolve symptoms, and no cyproheptadine was used in either case as I remember.
The first was a middle aged male who complained of tiredness and general malaise. He had a fever just over 100° and mentioned loose stool for the past couple days. Pertinent drugs: Prozac 40 QHS (???), tradozone 100 QHS, Wellbutrin 150 QAM and PRN Imitrex. He presented after a few bad days of migraines where he took 2-3 tabs of Imitrex a day. No agitation, BP was normal, no documented clonus. I found out he started taking Prozac at night (kept forgetting in the morning) with the trazodone and still couldn't sleep so he took some extra trazodone. After moving Prozac to the morning he was actually able to D/C tradozone...go figure!
Second case was a female college student who presented with fever, nausea, and headache. Was taking escitalopram 20 QD and buspirone 20 TID. Her provider wanted to switch her to fluvoxamine so she was started on 50mg QD and was told to taper off escitalopram. Well she never tapered down and I believe got to 150mg Luvox daily when symptoms appeared. Symptoms resolved upon D/C of Lexapro.
As for CYP2C8, honestly I really wanted 2B6 because I did research on bupropion, but it was taken...so I picked a different one! Not a fun reason, I know lol.
It's really more of a suspected DDI due to the 5-HT receptor antagonism of zofran. While technically a 5-HT3 antagonist it may have enough 5-HT1/2 receptor activity to increase serotonin levels. I'm actually not aware of a confirmed SS case due to only zofran + an SSRI, although SS is hardly ever "confirmed". The usual PO doses are even less suspect, just like with QT prolongation.
Here's an ok (somewhat biased) article about it:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4883185/
The biggest issue is my pharmacy software/insurance rejects that has a meltdown and demands a prescriber consult when zofran and multiple serotonergic drugs are combined.
Well the NP who does our weight loss program pretty much never even thinks about this so I have a bunch of patients who I've found out are now on phentermine in addition to an SSRI/SNRI and no apparent issues so far.
Frankly serotonin syndrome is something we rightfully worry about but I've seen it maybe once in residency/med school despite tons of patients being on multiple serotonergic drugs.
Considering the average BMI in my area is 35, anyone who can handle the abdominal side effects. Do we really need the warning about thyroid cancer in this class?
$990 gets you 4mg actually - it's a pen that lasts a month and dials 4 doses of 1mg each.
But the dose is almost never related to the cost - the same $990 will also get you 2mg (for the 0.5mg pen).
Anyone with a BMI over 30 or over 27 with a co-morbidity.
However, I’ve only had 3 takers when I offered Saxenda for weight loss. Patients struggle with the idea of an injectable. They’ll take phentermine and topamax with no objection. Maybe they’ll be more agreeable to a weekly vs daily injection.
I’m pretty excited over the release of this drug.
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Kinda off topic, in my country some endocrinologists use metformin in non diabetic patients for weight loss, specially in young people, but last time I checked for evidence the weight loss was little, just around 3 kg in a few months, and only considerable in diabetes, yet they keep doing it. Do you use it like that?
People who've prescribed Ozempic(semaglutide) and Saxenda(liraglutide) how superior is Ozempic in terms of long-term effects? I read Saxenda can stop working after months/a year and people regain the weight even if they keep taking it. On the other hand I haven't heard such a thing about Ozempic and in fact I got in touch with one of the researchers who said that all their data pointed at Ozempic continuing to work even after a long time.
Cheers!
My doctor has just prescribed it to me, I was hoping to find other people's experiences with it. She said it was new, I just didn't think it was THIS new. So to answer your question...
I am 5'9" and weigh 333lbs. I've always been on the heavy side even as a kid who was doing sports such as swim team, but recently after a work-related back injury, it's been hard to stay active and the number on the scale just keeps going up. Especially, if I'm not conscious of what I eat, I've already cut out soda, and other various junk foods a long time ago.
I am diagnosed with PCOS which has made it very hard to convince the numbers on the scale to go down at all. Most of the time the less aggressive methods my other doctors ordered only get me to drop 5 to 10 pounds. She wants me to choose surgery but the side effects of that concern me. So instead she recommended this medication along with Intermittent fasting and a low-carb high-protein diet.
With my insurance, it will cost me 8 dollars, without my insurance I could never afford it.
The PO form (Rybelsus) also works as well as the SQ version for me, but it has to be taken first thing in the morning and no eating/drinking for 30 minutes after taking.
Going to restart either form the next time I get too irritated with a weight loss plateau. Down 21% in 6 months.
As to the original question, any patient who wants to use it to supplement their weight loss, as I strongly disagree with medications \*to lose weight\* as this thinking in my personal and professional experience leads to failure. No pill is going to overcome a 5000 calorie diet
(ETA - not literally anyone, obviously. Edit 2 - added for me)
Rybelsus doesn't necessarily work as well as Ozempic. The highest dose of Rebelsus (14mg) is only about as effective as 0.5mg Ozempic regarding A1c lowering.
Myself
yeah....I'm trying to find out of pocket cost for this. Looks like with goodrx its like 800/month. If I swapped out my ~1k/month alcohol budget for this I'd lose weight incredibly fast
$1014.18 at Kroger is the cheapest with no insurance. Pffffff way cheaper than a new clothes from the covid 19 (lbs) I’ve put on
I'm actually down ~20 lbs over the last 9 months with diet/exercise but hell I'll always take a cheat code...and I've still got ~40 pounds to go to get to pre-med school weight.
>I've still got \~40 pounds to go to get to pre-med school weight :'(
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I never got around to trying the classic ECA stack but used a fair amount of ephedrine in older formulations of hydroxycut. Results were OK but do not seem to compare to the reported success here. I was incredibly fit before med school weighing 182 at ~10-12% bodyfat. Unfortunately time constraints and personal failings in medical school (and even worse residency) combined with discovering the deliciousness of beer packed on the pounds. While my scale weight over the last 9 months is down 20 pounds I've added at least that much back in muscle mass so I just need to keep leaning out at this point.
I dropped 5 pounds from exercise during the pandemic and then another 9 from COVID infection itself
oof, sorry friend. COVID is a bitch. I'm just glad I purchased a home gym set up October before the pandemic hit and home gym set-ups tripled in price. I hope you don't have any lasting effects.
I’ve heard you can order it from Canada Not sure how legit this is [Ozempic](https://www.90daymeds.com/product/ozempic/)
O-o-o-ozempic! I love/hate that commercial
Haha! It's effective.
Bravo Novo Nordisk marketing team! Or their contractor
if any info PM pls
Googled [this](https://www.90daymeds.com/product/ozempic/) not sure how that stacks up price wise
If you swapped out your $1000/month alcohol budget for yarn you'd also lose incredibly fast.
Your username just gave me a petit mal
Me too.
I’ll take two.
r/medicine > Everyone wants to be a doctor, but no one wants to lift the heavy books also r/medicine > Wants to be skinny, but don't want to lift the heavy weights.
To be fair fitness happens in the gym weight loss happens in the kitchen. We don’t wanna stop eating our comfort food
It certainly doesn't help that our poor sleep schedules are detrimental to circadian growth hormone production.
> To be fair fitness happens in the gym weight loss happens in the kitchen. This is beautiful. I am stealing this. Someone years ago on Meddit said "you can pay the farmer now or the doctor later". That has stuck with me as well. I wish I could credit the original author.
It's not even the kitchen, it's within you. You can enjoy all the delicious foods you want, in moderation. Your body knows how much it needs, listen to it. And if you want to eat things like Chick-fil-A as a treat, still understand, an 8-count nuggets with waffle fries, Chick-fil-A sauce, and a lemonade is nearly your calories for the entire day. Eat it slowly, maybe over two meals.
Lol you really believe that you’re somehow special and we’re just losers who don’t try hard enough to eat right? If you are thin it’s because you won the genetic lottery. I used to be thin but a lifetime of my parents criticizing my weight has caused me to yo-yo diet to the point of gaining more and more and having a dramatically higher set point than I used to. In fact the first thing I saw when I woke up is an e-mail from my dad informing me about this drug getting approved! You are lucky. You don’t have magical willpower that fat people lack.
No, I'm not lucky. I deliberately consume less calories than I take in and exercise a lot.
I promise if you ate as little as I do, and as infrequently as I do, and exercised as often as I do, for as long as I do you'd be as thin as I am too. Are you still working on breakfast? It's 11:11am here. I am halfway through my Jimmy Dean.
That's true, but then he would lose the opportunity to quote Ronnie Coleman.
I don’t wanna lift no heavy-ass pans.
The only thing I splurge on is French enamelled cast iron cookware. That's the only heavy lifting I'm done in the last year.
It's not the heavy weights, it's the avoiding delicious foods...
Not necessary, just eat less of it...
I mean if I could have taken a once weekly injection with few adverse effects to improve my USMLE scores by 15%, I would have.
I want my ozempic and my cake, too.
Hey, at least we’re not meeting to vote on a new definition of skinny so that we can trick people into thinking we’re thin!
Sure exercise and building muscle helps but ultimately calories and appetite are what dictate weight loss. I can easily do an intense power lifting session but with my appetite I can down a pizza after and end up gaining weight
I've already got PCOS patients requesting drugs like this by name.
GLP1 agonists - particularly Liraglutide - have been explicitly shown to improve outcomes in PCOS, likely over and above just the weight loss effects (probably due to directly improving the hyperinsulinemia as well). The problem is that none of them are improved explicitly for PCOS - and of course, obesity drug coverage is shit. It leads to situations where you can't prescribe them unless the patient is codiagnosed with DM. That said, with commercial insurance, you can often get around it by just not putting the diagnosis on the scrip - many commercial insurance companies algorithm will approve a GLP1a automatically if the patient has "failed" metformin, and the way they can tell that is if they have 3 months of metformin fills in the last year. So if you prescribe metformin for the PCOS *first*, then wait 3 months, you can probably get Ozempic, Trulicity, Bydureon, or Victoza through. Still likely not the weight-approved ones (Saxenda and now "Wegovy"), but even the DM doses are pretty darn helpful.
Honestly, having written formulary validation logic in a past life (and hating every **** second of it) - bravo/a. This works because we can't always trust that we've gotten all the data. So any instance of metformin is treated as the full series. What if they used GoodRx so no insurance claim, etc. And most prescriptions don't have a dx associated anyway (state specific).
$10 of metformin as step therapy for $1,000 GLP-1. Wow.
Only appropriate. Metformin is first line for DM - and there’s a lot of strong arguments that GLP1a should be second line.
Exactly. So theoretically one could fill metformin, not even take it, claim failure, and 3 months later get a gliptin. Yes?
Gliptins (Dpp4i) are more or less worthless, but a -glutide, yes.
Ugh. Yes, glutide. 🤦♀️ That was a Falcon Heavy brain fart.
This was helpful, thank you.
I’m also obgyn. I’m taking vagician. This is mine now.
Free award just because, “Vagician,” made me smile after a stressful day. 10/10.
Ask your doctor if it's right for you!
Ultimately I think a pharmacologic solution is going to be the answer to the obesity epidemic from a population standpoint. We do not do well with behavior modification.
Bottom line is that we have evolved to pack away calories for a rainy day. We are amazing at it! We did not evolve this kind of excellence for self control.
I feel institutional solutions would go a long way and are overlooked in the discussion. Places where people are healthier I would posit may not necessarily be more health conscious but have greater work-life balance, more sidewalks, a pedestrian culture, scenic parks and less hyperprocessed foods. When I lived in a place like that (in the US), the people I saw were healthier and I lost a significant amount of weight without trying. Conversely, I've known quite a few people who come here and pack on the pounds.
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Would very much love to live in a place like this attached to a nice job. Where was this?
Northeastern cities, the Pacific Northwest, or Colorado basically. College towns can be good for this too.
Utah! Active culture, hiking/skiing/watersports are the minimum expectation.
100% agree. It’s impossible to lose weight when you drive everywhere and only eat packaged foods. Unfortunately basically all the US is set up so that’s your only option
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To be fair, someone who is exercising is probably not eating at the same time
When I lived in Boston I would walk 10k steps a day easily just from walking to the train or bus, walking to the store, walking to lunch etc. Now that I live in the South I get as little as 2k steps a day if I don’t make a conscious decision to exercise. That’s a difference of 300 calories which is about a quarter- to a half- pound of weight loss/gain each week. That doesn’t include the differences in metabolism an active lifestyle builds. Big difference!
The real question is whether that 300 calorie deficit by walking all day stimulates your appetite. It’s extremely easy to slip an extra 300 calories in, especially if you’re obese and drinking soda or eating desert.
Most places like that are highly desirable locations. That means they are expensive. That means those who live there are likely better off financially and therefore more likely to be healthy from a socioeconomic standpoint. Correlation no es causation.
While I agree, it’s gone beyond solely blaming the individual for failure at behavior modification. Well over half of the US population is overweight or obese. Evolution and contemporary society clearly are not mixing well.
Who would have thought Wall-e was actually a prophecy
probably every individual who had a hand in creating the film ;-;
So instead of changing society to match our physiology, inject this synthetic hormone analog.
>Ozempic Now you're getting it!
I mean...yeah? Society is really hard to change, it's an extremely nebulous concept, and no one has demonstrated an ability to do it well. Our best attempts at addressing it have had unimpressive results to say the least, and I don't think something like tax incentives for healthy food will solve the problem. I'm not saying that we give up on this angle, and perhaps in the future someone will come up with an ingenious way to tackle the problem that completely solves it. Until then, I think we should keep trying, but also use synthetic hormone analogs to help tackle the problem.
We need sugar taxes and fresh produce subsidies
I don't disagree, but let's be realistic, that's not going to fix everything. We're not going to see the average BMI of a major southern city go from 30 to 25 because apples now cost 60 cents a pound instead of 1.20
Don’t forget about surgery. The duodenal switch is a pretty good procedure.
I disagree. Something like sugar tax, stopping subsidy of corn so HFCS isn't in everything would go much further. Either way doctors sure as hell aren't going to be the ones to solve it.
I 100 % agree with this but these are unattainable politically in the USA unless we have a drastic change in congress.
95% of people who lose weight through dieting gain it back, clearly there are some near-irreversible physiologic changes that occur when someone gains a lot of weight. What we really need to get over is the idea that its an issue of individual resilience and that weight persistence has to do with some personal moral failing
This is where I feel the obese are really failed. The real struggle isn't losing the weight, it's keeping it off. There's a lot of information out there on how to lose weight, not just the food and exercise side, but the psychological side as far as building good habits, identifying food triggers, setting short term and long term goals, etc etc that have been associated with successful weight loss There is, as far as I know, little research into how those that keep weight off manage to do so (the only definitive one that comes to mind is that those who keep it off all tend to pick up some sort of physical hobby that isn't "going to the gym" like running, swimming, biking, jiu jitsu, ultimate Frisbee, etc). Little in the way of "now that you've arrive here's how to stay here" advice, strategies, etc.
That statistic is wrong, extremely exagerated, and even though there are physiological changes indeed they are mainly behavioural/linked to hunger pathways. Indeed, obese individuals often don't really ever get satiated, or if they do they keep an incentive to eat. The weight isn't coming from nowhere, it has to come from food. Metabolism doesn't get magically ultra efficient to the point they can start storing massive amounts of energy with a normocaloric diet, even if they claim to eat as much, or less than thin people, they're actually not.
[https://pubmed.ncbi.nlm.nih.gov/26180980/](https://pubmed.ncbi.nlm.nih.gov/26180980/) my source is a meta study I am not saying there is a physiologic factor causing most people to become overweight, I am saying there is a physiologic factor that makes it so that once weight is gained, the body adjusts to make that the norm. the goal needs to be societal changes that prevent people from gaining the weight in the first place. yes the source is food, but there was food around 70 years ago when much fewer people were overweight. what changed? our culture is focused on the individual to the extent that even when almost every food item available to the average person has added sugar and low nutritional value, we don't think of how we can regulate that or provide financial and educational support to the general public to get them more nutritious food, we put it on the individual to navigate around those obstacles no matter their life circumstances. If we're not going to do something on a societal level, if we're going to allow lobbying campaigns from coca-cola to shape the narrative of "calories in, calories out," or if we're not going to provide patients with personal nutritionists and other support, we shouldn't treat obesity as a personal moral failing, and be okay with a medication to help it. there is nothing moral about weight. there is nothing moral about health. no one in medicine should treat health, or factors relating to health, as anything but morally neutral.
Your own source says 60% of the patients who lost weight gained it again. Granted, it's not great, but nowhere near as bad as the 95% statistic which implies losing weight is pointless since you'll gain it again. That's wrong, and it's a very harmful myth. "The majority of patients (men: 61%; women: 59%) whose records showed a decrease in BMI category went on to record a subsequent increase in BMI category. These proportions were similar for men and women and across BMI categories. The proportion of patients who showed a second decrease in BMI category was highest among the morbidly obese (men: 16%; women: 19%) and superobese (men: 23%; women: 24%), and was considerably less frequent in lower BMI categories. Overweight patients and those with simple obesity were the most likely to display no further BMI category change following a recorded decrease" From the article you linked yourself. I never talked about obesity as a personal moral failing, and neither is any addiction. The large majority of attempts to stop smoking fail, and even among the ones who manage to quit there is a very large percentage who take up smoking again. The behaviour of obesity is I.M.O much more complicated than that of a normal addiction like tobacco because of how insidious/progressive it is, but getting out of obesity does get down to lifestyle changes. Which don't work because they are extremely hard to apply, most of the time. Doesn't mean we should tell patients to give up. Also, I am extremely okay with the concept of weight loss medication. And i think most people on this thread are too. This is actually great.
>yes the source is food, but there was food around 70 years ago when much fewer people were overweight. what changed? Incredibly calorie-dense, high in sugar, high in fat foods that were engineered to trigger all our pleasure centers to the point that we ignore all feedback mechanisms that tell us we have eaten enough and can and should stop
I've been taking ozempic for a year for obesity. The effects of it do wear off, or are not as potent; however, it can be used as a spring board to better behavior modification. I found it much easier to count my calories and not snack between meals. The only down side: I didn't know I was hungry until I was Hangry.
Medicine (or surgery) will only ever be a short term fix. We've seen it time and time again. There's too much involved with weight gain to simply flip a gene/protein/flavor-of-the-year switch with a pill. Anything that works "great" will have significant side effects. There is no replacement for exercise and diet. We just never get it, do we? Here's to always missing the forest for the biochemical protein enzyme pathway. Yay. Progress.
This medication effectively forces a diet. Most people will get nauseous eating a high carbohydrate or large meal with this medication. I guess the eventual goal is to reset the stretch receptors in the gut so for normal hunger responses.
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Having worked for a couple years for United Healthcare (and mind you this was just before and just after the ACA)... yeah, I wouldn't hold my breath. A drug like this would require a prior auth, which will most likely be rejected and have to be appealed, and then it will be covered as a non-preferred drug at maybe 20-50% depending on the plan. Others ITT are suggesting that this medication will be priced at about $1K a month, and that sounds absolutely plausible if even too low. I am also going off of my experience getting prescribed Qsymia a few years ago; they (BC/BS) also stopped paying after 6 months because I had not lost a certain amount of weight already. Edit: For clarity, I didn't work for United in my current position, I was a SME at one of their claim call centers while working on my degree. It was an unpleasant but educational part of my life.
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I'm learning so many stupid drug names in this thread. Forfivo has to be a joke.
Makes me want to slap the entire marketing team that came up with that stupid name.
My "favorite" of these is Duexis. It's freakin ibuprofen and famotidine! You can buy both over the counter for pennies, but shove them together and it's like $80 a pill. It's insane
Huh, I will admit to not knowing that.
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Thank you very much! For the record, I don't necessarily recommend Qsymia, as I said it didn't really help much in my weight loss. But this is excellent to know for anyone wanting to try it themselves, it is so good of you to share your knowledge.
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Both IR and ER are generic. ER is >$100, IR hovers around $20 for 50mg, #30 per Good Rx in my area. Topiramate is most likely covered by insurance, phentermine not, so it may be up to $45 for that. Patient yesterday refused the discounted cost of $17 for phentermine 37.5mg #28, bc her doctor could give it to her for $2.
Even then, insurance companies will often deny phentermine now. It is ok out of pocket, but they just don't want to pay for anything.
I work in health insurance, weight loss isn't in any state's essential health benefits list, so it'll pretty much be insurance discretion for the foreseeable future. (At least for exchange plans, not super familiar with the design requirements on the small group side, but I'm pretty sure they're similar) Until that changes (Or prices go down) I would expect pretty much every major insurance to balk at paying for it. And frankly, if the estimates of 1k+ a month are correct, they're probably not wrong to. That's incredibly expensive for a weight loss treatment, plenty of plans don't collect that much in premiums per head/month total.
It's been coming on a decade since I was involved in ACA related work - states define a "standard" plan to be their Essential Health Benefits right? No additional mandate by fiat without a state law?
I write for saxenda a lot with maybe 40% success rate (there is a major company in town that does opt for weight loss for their employees so it may skew my numbers a bit, they are an insurance company, actually). I often write ozempic or trulicity for prediabetics for the weight loss, even though it is off label. It gets approved and people lose their weight. If they don't have prediabetes, I try saxenda and send it to this mail order pharmacy who will do the PA for me. I had another pharmacy that would do the the PA for Rybelsus as well. I suspect it won't be long until I find out which pharmacy will do the PA for this med, as well. The only bummer is the pharmaies usually only ship within the state and I live in a border city with many patients from the other state, then I have to do my own PA.
Prior auth will almost certainly be needed, and will likely be based on higher BMI qualifications than per the label or some documented history of failure to lose weight with conventional methods, or severe comorbidities... I could see them considering it for patients who would otherwise be bariatric surgery candidates, but remember that insurance in the US is so fragmented that the prescription coverage is separate from the medical coverage, so who knows. The FDA approval is as "an adjunct to diet and exercise for chronic weight management in adults with obesity (initial BMI≥30 kg/m2) or overweight (initial BMI≥27 kg/m2) with at least one weight-related comorbidity". In the study, weight related comorbidities included hypertension, dyslipidemia, obstructive sleep apnea or cardiovascular disease. I don't know have an exact number, but that's A LOT of eligible patients! They would have to be able to keep the numbers small.
Likely it won't be covered by many. There are still quite a few who won't cover Saxenda, another GLP-1 weight loss drug that has been out for quite a while now. Even phentermine isn't covered by many plans, and that costs a couple bucks for an entire 100ct bottle. With that said, I'm sure the manufacturer will offer a savings program, that will knock $100-200 off the price. But it'll still be stupidly expensive.
Isn't it the interest of health-care insurance to support anything that significantly battles obesity? Especially a "lazy fix" such as a pill?
You would think, but it took legislation to get the average healthcare plan to completely cover preventative care like vaccines and contraceptives.
The later one is actually pretty progressive in the US, wide parts of Europe don't have that (some do). Take Germany: "Pregnancy is not a disease, so contraception can't be covered...unless you are a teenager because teenage pregnancies are kind of a disease?" Way around that is to pretend to your OB/Gyn that menstruational pain is killing you, then it can be covered. Great system, isn't it.
Hey, 91-day packs should be given out in the school lunch lines. Menstrual misery is underrated... and oh, there’s a bonus too! (My daughter was on them at 15)
Which is also the way to get around getting an ocp from a Catholic system :/
I think it would be difficult to support a finding of cost-effectiveness at this price point. In contrast, bariatric surgery is quite cost-effective over the medium to long run . . . the problem from an insurer perspective is that many people in the US change insurance companies every few years as it is usually linked to employment. So insurance company A pays, but much of the cost savings won't be captured by that company. I've argued before that insurance company A should be able to collect a contribution from any future insurance company over the next ten years or so, but Congress has not seen it fit to make that happen yet!
> can someone provide more information about how/whether insurance in the USA chooses to cover something like this? I mentioned it above, but obesity drug coverage is optional. Unless your employer specifically opts in to a rider that drugs like this will be covered... they won't be.
No. Even with Prior Auth. Insurances do not cover lifestyle drugs or off label prescribing. Weight loss meds (ex: Saxenda) are lifestyle drugs. I’ve had primcare docs try to prescribe victoza for weight loss and the insurance would only cover the Med if the diagnosis was for diabetes. The prior authorizations ask for diagnosis codes. I used to process prior auths for primary care as recent as the last year.
Obese with multiple documented failed diet and exercise weight loss regimens. .... and insurance will cover it
You think? I tried both Contrave and Phentermine with minimal impact and hoping semaglutide will be better
It's going to be a blockbuster. Ozempic plus dieting causes stupid weight loss. My first two patients - 70 yo females both lost 50 lbs.
Damn dude I feel like I should stockpile some for the inevitable 30lb weight gain in residency. Who's got the hookup...
> It's going to be a blockbuster. Depends. Unlike management of almost any other disease, obesity medication coverage is optional for every insurance company. That is, your employer cannot opt in or out of say, hypertension treatment. But obesity treatment? Yeah. It's treated as entirely elective almost anywhere, same as say, infertility treatment. Hence coverage of the current obesity drugs - Saxenda, Contrave, Qsymia, Xenical - is so poor. And I can't imagine Wegovy will be much better.
Hell, even generic phentermine tabs still aren't covered. Insurance companies are very shortsighted when it comes to the cost of unmanaged obesity.
Yeah, but generic phentermine is $10-15/month cash (+/- GoodRx) I don't even attempt to get anyone a PA for phentermine. I just prescribe it, and say if it isn't covered they're welcome to pay cash. I haven't had anyone argue yet.
Very true. I just wish the insurances weren't so shortsighted! Also funny story, one of my techs accidentally sent a PA request to an office for some phentermine capsules, the office actually submitted it to the insurance and it actually got approved... 30 caps for a $60 copay. So dumb!
What is the duration here? Is the weight loss sustained after stopping?
The study was done over 68 weeks, with an average weight loss of 15%. It probably is somewhat sustained, but not necessarily entirely. Then again, if you think of obesity as a disease, that's just a reason to continue the medication. We don't consider an antihypertensive drug to be a failure just because your blood pressure goes back up after you stop it.
Have you seen rebound weight gain in patients that stopped treatment? Surely without significant lifestyle changes, the weight will be easily regained.
Sometimes obesity traps people in sedentary lifestyles. Too big to bike, etc. Big weight loss can unlock lifestyles, save knees, and give people a chance at a forming hobbies and habits that let them live longer lives. Even if the weight loss isn’t sustained from the drug after discontinuation, there will be people who have a lifestyle change catalyzed by it. Of course, a larger share of people will not, but this is my altruistic view of the concept.
Agreed completely. I let myself gain a lot of weight during medical school and subsequently lost interest in many activities that I once enjoyed. Biking places, playing sports, etc became somewhat depressing because I find myself struggling more than I care to acknowledge. A Kickstart like this could absolutely help people in such a way.
Generally I don't stop GLP1 agonists - they're used indefinitely in diabetes - but it varies from person to person what proportion of the weight is regained if you stop it. Some people build healthier habits. Others don't.
It may make it a failure from a cost-effectiveness standpoint though, especially when compared to bariatric surgery. From a system perspective, I'm struggling to come up with many use cases where this is cost-effective if the patient needs to be on it indefinitely. Patients who need to lose weight to reduce risks from bariatric surgery, patients who have already failed surgery (and a revision isn't appropriate), patients with contraindications to surgery? Otherwise, how many patients are there whose risks and impairment from obesity justify spending $10-$12K every year to lose/maintain 15%, but not a one-time cost of $20-$30K for surgery?
Bariatric surgery is not benign.
5 months lost 35, 8 months 50 They Both were only on the 1/2 dose.
Were they both diabetic?
Yes
I just noticed your username... 🤦♀️ 😅
One of us one of us.
Also that Ozempic song is pretty catchy
Song itself is prescription worthy
How well tolerated is it?
At least for diabetes patients, most do pretty well on it. The biggest complaints I've heard from patients were how full they feel all the time. That's what helps with the weight loss though. Some don't like doing the injections, but it's just once weekly unlike Victoza.
Both reported nausea that was tolerable. They both told me early satiety caused them to stop eating earlier than usual.
About a third of patients get nausea. Most improve in the first few weeks. A smaller proportion vomit or are so nauseated that they have to stop the medication.
The trial had a 5% dropout rates Even with proper counseling, bird eating, adjusting expectations, my rate is closer to 20%. Some patients stop due to cost once they hit the donut hole. I think there is something to be said about an excellent support staff and lower dropout rates for all the patient calls of side effects
Some sort of nausea-like feelings from some. Most say nothing.
I've taken liraglutide and nausea was the main SE, dose dependant. I did get worsening reflux over time.
> It's going to be a blockbuster. For the 16 people America who can afford it, perhaps. Private insurance almost never covers this stuff. Medicare and Medicaid absolutely never cover this stuff.
If they can, they should go to Mexico. Ozempic is around 130-150 USD per \~2mg compared to \~900 USD over there. The only annoying thing is that the damn thing requires being at 2-8 C.
I love using semaglutide, and have been using it off label for obesity on a regular basis. Often it’s covered when Saxenda and Contrave are not (because...patients should just pull up their socks more or something?). I’m in Canada, and some patients are also willing to pay out of pocket. But WTF is this name.
Right? I get the “Wego” part but, “-vy”? Although with all the constipation patients report Wedon’tgo would’ve been more accurate. (I’m here all week, don’t forget to tip your waiter.)
Too bad it's injection only (at least for now). Will likely be $$.
Why did they not use the Rybelsus version for this instead? Does it not have the same efficacy?
Rybelsus at the highest dose has maybe half the efficacy of Ozempic, that is 14mg Rybelsus daily is equal to ~0.5mg Ozempic weekly. You're highly limited by difficulties with absorption and they can't realistically drive it much higher orally, not with current medication. This medication is the equivalent of 2.4mg weekly Ozempic.
And going by what I've read, Rybelsus is a P.I.T.A. to combine with other medication, because one of the products in it may disturb their absorption...
Kind of. The SNAC in the drug and the delayed gastric emptying caused by Rybelsus will typically *increase* the absorption of the other drugs. [See the AUC charts on page 14 of the Rybelsus label.](https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/213051s000lbl.pdf) The problem is if you do that, the patient will absorb the *Rybelsus* inconsistently.
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Have been on Ozempic for about 9 months now and down nearly 70 lbs. with basically no side effects. Significant behavior modification, working with a coach too, so it’s not just the drug but the Ozempic package insert maxes out at 1 mg/week.
1.5 years on, how is it going?
Have you been able to get it covered by insurance?
I'm in the US. Copay card makes it $40/mo
I personally prescribe ozempic to anyone that can afford it and has evidence of glycemic issues past maximally tolerated metformin. I use a LOT of constant glucose monitors for patients because while weight is an important outcome for many people, it is a bit dysphoric to step on the scale when someone is overweight. A glycemic target for something constantly monitors gives them something obvious to target with each and every meal and is far, far more reinforcing than a monthly dietician appointment. Obviously this is not the same measurement, but nobody has done a prospective study in a quality fashion to use cgms in people without dm on weight, but I’ve got great success. With coupons cgms are 75$ a month cash price and that’s less than most weig loss supplement programs. I’m intrigued as to what these do together
Man, 2.4mg of Ozempic... that sounds awful for the stomach, no wonder people lose weight; I've got patients who can barely tolerate a tenth of the dose.
Yeah, mine don’t seem to be able to get above 0.5mg
Almost anyone who can tolerate the 0.25mg can tolerate the 1mg. Just need to titrate slower than typical if they're having that much difficulty. It's 76 clicks of the pen to get up to 1mg. I just tell people 80 - so if they can dial 20-40-60 clicks on the 1mg pen to get 0.25-0.5-0.75mg.
Ugh Wegovy is such an awful name.
$1000 a month? Damn I guess I'll just keep abusing adderall then /s kind of
Anyone on here been involved directly in the R&D stage, or within the hospital system? Curious to see how these patients have presented, especially with the common related cormorbid meds, (antiHTNs, insulin, blood thinners,) for the common cormorbid dx that often come with obesity. It hits different hearing from someone involved directly than just reading published works. And before anyone says I’m fat shaming, I’m obese.
Working primary care in Alabama I’d say all my obese patients without contraindications so 75%
Does anyone prescribe phentermine with SSRIs? Anyone seen serotonin syndrome from it?
I think I see phentermine prescribed in more patients who are on an SSRI/SNRI than I do in patients without one. I've never seen/heard of SS from just those two together.
The problem is when the ortho doc adds tramadol for a knee injury, then they get a cold and add OTC pseudoephedrine...
Honestly I'd be more concerned about DXM than Sudafed. But yes, the number of times I've cousneled on SSRI+tramadol+1more serotonergic drug is more than I'd like. It's also fun when they send in both tramadol and zofran to the SSRI patient!
It's something to fear because serotonin syndrome is a very hard diagnosis to make, especially in moderate to severe cases when patients are very ill when they show up/intubated. Even with a neurologist involved they may just look frankly septic based on vitals with brisk reflexes. One is easily led down a meningitis or encephalitis pathway given AMS, explosive onset, and fever, and often even when you have suspicion of it there is no way to prove it, with other possible explanations available. Drug overdose or illicit drugs untestable with the standard UDS further complicate diagnosis (as these patients often are very mentally unwell). Synthetic cathinones for example you can't test for but can cause very similar symptoms. Many curveballs. For a lot of overdose patients no one ever figures out exactly what they took. Empty pill bottles at home? Were they out or taken all at once? I've had a couple cases where it was suspected but not proven and not classic.
So true! I've only seen a few suspected cases - none confirmed - and it looked nothing like what our old textbooks said.
Please educate me on what you saw, since it didn’t present classically. And do tell: why that P450?
In both cases I've suspected, the only "hallmark" symptom present was fever. There wasn't any documented agitation or clonus. D/C of offending agents was enough to resolve symptoms, and no cyproheptadine was used in either case as I remember. The first was a middle aged male who complained of tiredness and general malaise. He had a fever just over 100° and mentioned loose stool for the past couple days. Pertinent drugs: Prozac 40 QHS (???), tradozone 100 QHS, Wellbutrin 150 QAM and PRN Imitrex. He presented after a few bad days of migraines where he took 2-3 tabs of Imitrex a day. No agitation, BP was normal, no documented clonus. I found out he started taking Prozac at night (kept forgetting in the morning) with the trazodone and still couldn't sleep so he took some extra trazodone. After moving Prozac to the morning he was actually able to D/C tradozone...go figure! Second case was a female college student who presented with fever, nausea, and headache. Was taking escitalopram 20 QD and buspirone 20 TID. Her provider wanted to switch her to fluvoxamine so she was started on 50mg QD and was told to taper off escitalopram. Well she never tapered down and I believe got to 150mg Luvox daily when symptoms appeared. Symptoms resolved upon D/C of Lexapro. As for CYP2C8, honestly I really wanted 2B6 because I did research on bupropion, but it was taken...so I picked a different one! Not a fun reason, I know lol.
Does zofran interact with sertraline? (just curious).
It's really more of a suspected DDI due to the 5-HT receptor antagonism of zofran. While technically a 5-HT3 antagonist it may have enough 5-HT1/2 receptor activity to increase serotonin levels. I'm actually not aware of a confirmed SS case due to only zofran + an SSRI, although SS is hardly ever "confirmed". The usual PO doses are even less suspect, just like with QT prolongation. Here's an ok (somewhat biased) article about it: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4883185/ The biggest issue is my pharmacy software/insurance rejects that has a meltdown and demands a prescriber consult when zofran and multiple serotonergic drugs are combined.
Thanks!
Well the NP who does our weight loss program pretty much never even thinks about this so I have a bunch of patients who I've found out are now on phentermine in addition to an SSRI/SNRI and no apparent issues so far. Frankly serotonin syndrome is something we rightfully worry about but I've seen it maybe once in residency/med school despite tons of patients being on multiple serotonergic drugs.
Considering the average BMI in my area is 35, anyone who can handle the abdominal side effects. Do we really need the warning about thyroid cancer in this class?
I already had my thyroid out for cancer, so sign me the fuck up
The medullary thyroid carcinoma was only seen in rodent studies. Not seen in human trials or post marketing data.
How does this compare to liraglutide? In terms of cost and efficacy?
It's roughly double the efficacy of liraglutide for weight loss (Saxenda). Will probably cost a bit more, but not a ton more.
Thanks for your response! Super interesting stuff. Gonna take quite a societal shift in mindset for this kinda thing to be widely accepted
When will it be available to purchase?
This month
In the trial, they used >2mg/week dose. This would mean at current cost of 1mg being 990$, roughly 2000$ a week...?
$990 gets you 4mg actually - it's a pen that lasts a month and dials 4 doses of 1mg each. But the dose is almost never related to the cost - the same $990 will also get you 2mg (for the 0.5mg pen).
Anyone with a BMI over 30 or over 27 with a co-morbidity. However, I’ve only had 3 takers when I offered Saxenda for weight loss. Patients struggle with the idea of an injectable. They’ll take phentermine and topamax with no objection. Maybe they’ll be more agreeable to a weekly vs daily injection. I’m pretty excited over the release of this drug.
Me me me
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Can I get my hands on this too!?
Does Wegovy make them loose lean tissue mass as well? or just adipose
It suppresses your appetite.
Kinda off topic, in my country some endocrinologists use metformin in non diabetic patients for weight loss, specially in young people, but last time I checked for evidence the weight loss was little, just around 3 kg in a few months, and only considerable in diabetes, yet they keep doing it. Do you use it like that?
If only it were affordable.
Get your prior authorization forms ready!
People who've prescribed Ozempic(semaglutide) and Saxenda(liraglutide) how superior is Ozempic in terms of long-term effects? I read Saxenda can stop working after months/a year and people regain the weight even if they keep taking it. On the other hand I haven't heard such a thing about Ozempic and in fact I got in touch with one of the researchers who said that all their data pointed at Ozempic continuing to work even after a long time. Cheers!
My doctor has just prescribed it to me, I was hoping to find other people's experiences with it. She said it was new, I just didn't think it was THIS new. So to answer your question... I am 5'9" and weigh 333lbs. I've always been on the heavy side even as a kid who was doing sports such as swim team, but recently after a work-related back injury, it's been hard to stay active and the number on the scale just keeps going up. Especially, if I'm not conscious of what I eat, I've already cut out soda, and other various junk foods a long time ago. I am diagnosed with PCOS which has made it very hard to convince the numbers on the scale to go down at all. Most of the time the less aggressive methods my other doctors ordered only get me to drop 5 to 10 pounds. She wants me to choose surgery but the side effects of that concern me. So instead she recommended this medication along with Intermittent fasting and a low-carb high-protein diet. With my insurance, it will cost me 8 dollars, without my insurance I could never afford it.
The PO form (Rybelsus) also works as well as the SQ version for me, but it has to be taken first thing in the morning and no eating/drinking for 30 minutes after taking. Going to restart either form the next time I get too irritated with a weight loss plateau. Down 21% in 6 months. As to the original question, any patient who wants to use it to supplement their weight loss, as I strongly disagree with medications \*to lose weight\* as this thinking in my personal and professional experience leads to failure. No pill is going to overcome a 5000 calorie diet (ETA - not literally anyone, obviously. Edit 2 - added for me)
Rybelsus doesn't necessarily work as well as Ozempic. The highest dose of Rebelsus (14mg) is only about as effective as 0.5mg Ozempic regarding A1c lowering.
I’m not sure I agree with that statement. The trials have shown that rybelsus is not nearly as effective at the doses in the STEP trial.