Ask the Pharmacist

Q)  I can’t seem to read the news or watch tv without seeing some mention of Ozempic.  I hear it’s very effective for weight loss.  What are your thoughts on it

 A)  Whether you get your information from Tik Tok, the CBC or print media, one cannot escape from the celebrity endorsements, controversies and all of the other hype that surrounds the drug Ozempic (semaglutide). In a welcome change, especially when it comes to weight loss treatments, the hype actually seems to match the reality.  

The first thing we should talk about is that Ozempic is actually not approved for weight loss.  It is an extremely effective diabetes medication and can lower A1C (a measure of a person’s average blood sugars over the last three months) by approximately 1.4 to 1.6%. 

Ozempic is also very effective at lowering the risks of major cardiovascular events such as stroke and heart attacks, both of which people with diabetes are at a much greater chance of having relative to the general population. 

It was during the clinical trials for Ozempic that researchers noticed a happy “side effect” in their diabetic patients; They lost significant amounts of weight.  As such, Novo Nordisk, the Danish manufacturer of Ozempic, promptly asked for approval of semaglutide under a different trade name, Wegovy for the indication to help nondiabetics lose weight.  The only major difference between the two is that Wegovy comes in a higher strength (2.4mg) than Ozempic (0.25/0.5mg, 1mg) does and has not been released in Canada yet. The overwhelming demand for it south of the border has caused Novo Nordisk to hit the “pause” button as they try to find a way to meet the demand.   

Semaglutide, by whatever name, is extremely effective as a weight loss agent.  In a 40 week trial, a third of the participants lost more than 10% of their body weight at the 1 mg weekly dose level and the 2.4mg weekly dose brought an average weight loss of 15% of body weight.  To put this into perspective, someone who weights 200 pounds would lose on average 30 pounds.  This compares extremely favourably with both past (amphetamine like drugs) and present (the dietary fat blocker orlistat) weight loss treatments both in terms of effectiveness and safety. 

Semaglutide is a once weekly subcutaneous (i.e. just into the underlayer of the skin) injection that is typically administered into the abdomen.  The drug basically mimics the actions of the hormone glucagon-like peptide (GLP-1) found in the gut which our bodies typically release after a meal.  GLP-1 causes the body to produce more insulin and less of another hormone called glucagon which collectively cause a number of effects. 

These include regulating the rise of insulin after a meal as well as slowing down the rate at which your stomach empties causing people to feel fuller.  The drug also has an effect on the hypothalamus, the part of the brain that controls hunger causing people to feel less hungry.  Lastly, it impacts the way our body deals with fat causing it to be more likely to break it down.  Hence, the drug deals with almost all of the components that go into obesity: hunger, metabolism and the sudden post-meal spike in insulin.  No wonder the drug is such a success.  

Unfortunately, there is no perfect drug and semaglutide does give cause for concern. 

First, as with all other medications, it does not work for everyone.  Second, if one stops taking the drug, the weight is likely to come back.  There are also possible side effects, some of them being fairly common although usually mild in nature such as nausea, stomach pain and vomiting.  It’s the main reason that doctors usually start patients on a low dose and slowly increase it over a month. 

There is also the possibility of acquiring what is being called Ozempic face.  This is technically not a side effect but is a result of the sudden and dramatic weight loss and the resultant sagging of the facial skin that occurs due to the reduction of fat and muscle under the skin.  This doesn’t occur in everyone who successfully loses weight with Ozempic but it can be embarrassing and the fix for it appears to be cosmetic surgery. 

As well, those with a personal or family history of pancreatic disorders or medullary thyroid carcinoma (a cancer that forms on the inside of the thyroid gland) might want to stay away from these drugs based on rare but reported cases or studies in animals.  There is also the concern that semaglutide is still very much a new drug so whether previously unreported adverse effects will show up as it is being used for longer and longer durations is a concern. 

Lastly, semaglutide is not cheap.  The Ontario government and many private insurance plans will only pay for Ozempic when it is prescribed to a person who has diabetes.  That leaves those looking for help with weight loss on the hook for the full cost which runs at about $260 a month. 

The potential side effects and the cost hopefully will cause those who do not have a significant weight problem not to use this drug but there are already multiple stories of Hollywood celebrities and Tik Tok influencers using the drug in their unending search for the perfect body shape.  This has led to a shortage of the drug in the U.S. and a growing business model of border pharmacies selling the drug to Americans at much lower prices (the drug costs $900-1000 USD) than they would pay back home perhaps putting our own supply of the drug in jeopardy.  We have already seem this impact in the pharmacy.   

There is also, unfortunately, controversy about using the drug for weight loss purposes.  There are suggestions by some that the drug should be reserved for those with diabetes.  This harkens back to the still much believed myth that obesity is some kind of moral failure and that anyone can achieve weight loss by simply eating less and exercising more.

Obesity is a complex and often misunderstood condition that is influenced by factors beyond any individual’s control such as genetics, a person’s medical history (are they able to safely exercise, do they have mental health problems that sap the energy to work out, do they take commonly prescribed prescription drugs that are known to promote weight gain…?) and the so-called obesigenic environment we live in such as sedentary jobs, housing sprawl that forces an over reliance on cars or public transport, easy to access and affordable calorie-packed processed foods.  They all play a role.  It’s no small wonder that nearly 30% of Canadians are obese (and many more overweight) and there are credible estimates that by 2035 over half of the world’s population over the age of five will be overweight or obese. 

Treating obesity safely and effectively will have a major impact on the lives who suffer from it.  Obesity is inextricably linked to having a much higher risk of diseases such as diabetes, heart disease, high blood pressure and multiple cancers along with the aches and pains that come with carrying a few extra pounds.  The social isolation related to the loss of self esteem should not be underestimated either. 

Doctors who prescribe the drug for weight related reasons report of patients seeing major boosts in the quality of life of their patients such as reduced joint pain, an increased ability to do everyday chores like vacuuming, increased socialization and better mental health.  There is also the financial costs associated with obesity.   A recent study suggested that reducing the numbers of obese/ overweight people by just five percentage points would bring annual worldwide savings of $429 billion by allowing the obese to both live longer and have more productive working lives. 

Soon, Ozempic will have competition here in Canada.  Eli Lilly has already marketed a new GLP-1 type drug in other countries and it is producing even better results when it comes to weight loss (20% of body weight on average). These drugs are very effective, seem to be relatively safe and their costs will come down over time as more competitors enter the marketplace and when eventually generic versions are legally allowed to be manufactured.  These drugs are clearly here to stay, and they are game changers. 

For more information about this or any other health related questions, contact your pharmacist.