What We Get Wrong About Drugs Like Ozempic

8 minute read
Updated: | Originally published:
Freedhoff MD is an Associate Professor of Family Medicine at the University of Ottawa and the medical director of the Bariatric Medical Institute. He has received a clinical grant from Novo Nordisk

Imagine a new medication was developed that not only provided meaningful improvement for the debilitating chronic condition it’s prescribed, but also helps to treat and prevent a myriad of other serious diseases. Imagine this same drug markedly improved a person’s quality of life with noted reductions in pain and improvements in mobility along with increases in confidence and mood. Now imagine that the media and medical coverage of its release are almost uniformly negative or sensationalistic.

This is precisely what has happened with the new generation of anti-obesity medications, that began with Wegovy/Ozempic and with many more rapidly on their way. Currently approved medications lead people with obesity to lose on average 15% of their body weight which in turn has dramatic benefits for multiple weight responsive medical conditions, including diabetes, high blood pressure, sleep apnea, GERD, fatty liver disease, and more. Clinical trials of newer molecules demonstrate even greater losses with the most recent, for Retatrutide, demonstrating a 24% body weight loss after 48 weeks of use and where weight in those participants appeared to still be dropping. Sustained weight loss has been shown to decrease the risk of developing those same conditions as well as some of our most common cancers including breast, uterine, and colon.

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We also know that sustained weight losses help to reduce mechanical joint pain, increase mobility, improve quality of life, and for many, improve self-esteem and self-worth when it comes to internalized biases around weight, food, and body image—all issues poisoned by society’s hateful obsession with weight and with the notion that if you just want to lose weight badly enough, you’ll find a way. The corollary of which is that if you don’t, it’s because you’re lazy, or gluttonous, or both.

And yet, the media hasn’t focused enough on the huge potential upside of these drugs. Instead, they’ve amplified them as a punchline of celebrity jokes and promoted unfounded fear about these drugs effects.

Many flawed arguments have been aired, here are ten of the most common—debunked:

1. You need to take them long term and if you stop, you’ll regain the weight that you’ve lost.

Yes, that’s how treatments for chronic conditions work and aside from weight, that notion doesn’t seem to bother anyone. For instance, if you have high blood pressure, and you start taking a medication that effectively treats your high blood pressure, you still have high blood pressure, and if you stop treatment, it’ll come back.

2. They aren’t by themselves likely to lead everyone to lose all their excess weight.

While this is true, we don’t seem to worry about that with other chronic medical conditions. Using high blood pressure again as an example, a large percentage of people with high blood pressure require multiple medications to keep it under control and sometimes even then it never reaches “normal” levels. This partial reduction in blood pressure reduces its conferred risk, just as does a partial reduction in weight.

3. There are side effects.

Having written at least 1,000 prescriptions for these new medications I can say yes, there are. But not appreciably more than with other medications used to treat various chronic conditions where the benefits they provide are sufficient to warrant their prescriptions being sustained. The good news with antiobesity medications is that generally their side effects dissipate with ongoing use, but even if they didn’t, that the vast majority of people choose to remain on these medications, and their doctors continue to prescribe them, speaks to the risk benefit calculations being performed by both individuals and clinicians. Individuals who sustain medications despite side effects have decided that the benefits and impact of those medications out shadow the impact of their side effects. Clinicians who continue to prescribe them have performed their own calculus, or, more likely, know that the media’s depiction of these drugs’ side effects is not representative of their frequency or their severity.

4. They don’t treat obesity’s root causes.

How many drugs treat root causes? Do asthma drugs treat air quality? Do cholesterol lowering medications regulate trans-fat in our food supply? Do pain relievers prevent injury?

5. They’re expensive.

Most new drugs are. Research, development, and clinical trials are not cheap – especially when it comes to drugs for obesity as the regulatory hurdles set for them are systematically more rigorous than for most categories of medication. That said, in the United States, the average cost for the most prescribed of these medications, semaglutide, is approximately $13,600 annually, a significant cost but not out of line with other new drugs in the U.S. To that point, have you heard that the annual cost of abrocitinibet, a drug approved this year for eczema is $60,000 or that the median annual price of the 17 novel drugs the U.S. Food and Drug Administration approved since July 2022 is over 10x that of semaglutide at $193,900.

6. Too many people will benefit.

No, really, people have been arguing against the use of these medications because they will benefit too many people. . An op-ed was even published in the New England Journal of Medicine where economists opined that their coverage could bankrupt Medicare because so many people would qualify for their use. Meanwhile their main argument was based off of the Institute for Clinical and Economic Review (ICER)’s cost benefit anaylsis on semaglutide whereby in order to reach their conclusion that they were not cost effective they explicitly report choosing to ignore the drug’s many benefits, “ “The long-term benefits of preventing other comorbidities including cancer, chronic kidney disease, osteoarthritis, and sleep apnea were not explicitly modeled in the base case.”

7. People will use them inappropriately.

The prescription of medications requires a person meet the medical criteria set by the FDA or their country’s medical regulators for its prescription. No doubt, given the drug’s efficacy, there will be people who don’t meet medical need criteria for its prescription trying to find ways to take it. But if people who don’t meet medical criteria are taking this medication, that’s a problem with their prescribers, not with the medication.

8. We are medicalizing healthy people by diagnosing them with a disease and offering them treatment.

As with many chronic diseases, diagnosis is a matter of statistical risk associated with exceeding the level of an associated biomarker. For instance a blood sugar or blood pressure level where we see risks accrue sufficiently to recommend treatment, and where there’s no guarantee that not treating would lead to any long-term complications, leads to the diagnosis of diabetes or hypertension. While risks are not guarantees, there’s no public agonizing over conferring the diagnoses and treating high blood pressure or type 2 diabetes before they lead to problems – preventing their associated problems is in fact a good thing.. There is only outrage here because society considers obesity to be a disease of personal responsibility.

9. Lifestyle alone is sufficient.

That is true for a small percentage of people. But for the rest, sustained significant weight loss through lifestyle alone requires wide ranging privilege and even then, there are dozens if not hundreds of factors affecting our weights beyond our direct control – from genetics, to medical challenges, to our social determinants of health. Moreover, the vast majority of chronic non-communicable diseases are modifiable by way of lifestyle, yet it’s only with obesity where this false dichotomy about behavior as the only solution is pushed hard and therefore that it’s a failure to offer medications.

10. Their use will cause eating disorders.

Which do you think is more likely to lead to disordered eating? Highly restrictive dieting that leaves a person battling hunger, cutting out their favourite foods or entire food groups, and involves a constant mental battle replete with perseverant and maladaptive thinking around one of life’s seminal pleasures which society claims should be doable if you just want it badly enough, or a medication that decreases your hunger, your cravings, and makes you feel full faster?

We need to move beyond the double standards and demonization of anti-obesity medications. They are what happens when centuries of teaching and a poor understanding of this disease have led the world to believe obesity is a disease of choice and a reflection of individual weakness. Paradoxically it will likely be these and improved future anti-obesity medications that will finally begin to erode these explicit and implicit biases as their efficacies will undermine the notion that people are choosing not to address their obesity.

The efficacy and safety of these drugs, especially as they improve, will demonstrate that obesity can be managed by primary care providers just as high blood pressure is, with a quick office visit coupled with discussion of lifestyle changes and the offer of medications to help.

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