It’s amazing to me how quickly a drug that has helped so many people lose weight, keep it off and reverse their diabetes (yes, I said reverse) became an enemy of the state. I tell my students and colleagues who I train and my own children quite frankly, to question everything you see in the media. What’s the angle? Who wrote it? Who stands to benefit (financially) from this opinion?
As a private practice physician with no ties to big pharma, and no mandates on pathways I must take from any hospital system, I am writing this article to set the record straight on the myths and truths about Ozempic.
Myth #1 – Ozempic is being prescribed off-label. That is dangerous!
As mentioned in our previous article, Wegovy and Ozempic are both brand names for the drug Semaglutide. Wegovy is generally prescribed for obesity at a maximum dose is 2.4 mg and Ozempic for diabetes at a maximum dose of 2.0 mg. Since it’s the same drug, how can it possibly be considered off-label use when prescribed for one condition versus the other? The difference is the brand name, not the formulation. Therefore, it is a branding issue, NOT a “safety” issue.
Myth #2 – Ozempic should be reserved for diabetics, not patients with obesity.
As mentioned above, Ozempic is the brand name for Semaglutide, a drug also branded as Wegovy for weight loss. It’s the same drug! Why is diabetes a more important disease than obesity? In fact, I would argue that the opposite is true. Since at least 90% of type II diabetics are overweight or obese1, it would make more sense to prescribe this medicine for obesity, since weight loss can reverse type II diabetes altogether. Plus, obesity is associated with over 200 diseases2, not just one. This is not a “disease hierarchy” issue.
Myth #3 – Ozempic is very dangerous and causes crippling nausea and bowel obstructions!
Any doctor experienced in writing this class of drugs (GLP-1s) will tell you that you must start low and go slow! You must never go faster than the suggested titration rates when stepping up to the next dose, and sometimes should proceed slower if a patient is struggling. These are nuances learned over time with experience, that a doc-in-a-box flippantly prescribing Ozempic may not know.
In my practice, I will never increase a dose until the patient is free of nausea and constipation. If you do this, the above side effects are minimal. I have never seen “crippling nausea” and have never written an anti-nausea drug with Ozempic. It is not necessary. I have also never had a patient in the hospital with a bowel obstruction cause by this drug.
Myth #4 – If you stop Ozempic, you WILL gain the weight back.
This is a question I get frequently from patients on anti-obesity medications, so I tell them the following:
“If you are on a medicine for blood pressure, do you stop it when you reach your goal of 120/80?” If the answer is no, why would you stop an anti-obesity medication when you reach your weight goal?
Additionally, in the last ten years, we have learned that a process called “metabolic adaptation” causes our hunger hormones to rise, fullness hormones to decrease, and metabolism to decrease with weight loss, pushing us back to our “set point” weight.3 Because of this, it is very hard to maintain significant weight loss if you stop medications that counter that process, such as those that control hunger or increase metabolism.
The National Weight Control Registry, however, has shown that it can be accomplished if you exercise 1-1.5 hours per day, document your food, get good sleep, use meal replacements, and incorporate other behavioral measures consistently. These are great tools, but the exercise piece is hard for many of my patients to maintain for a variety of reasons. Anti-obesity medications help patients keep weight off long term, and if started should be continued.
Using Ozempic in a Busy Medical Weight Loss Practice
Ozempic was FDA-approved in December 2017 for type II diabetes. However, due to excellent cardiovascular prevention data, most insurance companies will now cover Semaglutide for pre-diabetes as well. Ozempic is started at a dose of 0.25 mg for 4 weeks, then 0.5 mg for 4 weeks, titrating to 1 mg weekly for 4 weeks.
Earlier this year, a 2 mg dose was approved which has been a game changer, nearly doubling the 6.1% body weight loss seen on the 1 mg dose in clinical trials (resulting in 10-12% weight loss in our patients). As mentioned above, side effects are decreased by taking the time needed for a patient to adjust to each dose before titrating up, even if it requires a slower titration process.
As with many medications, we have been seeing supply chain issues with Ozempic that are off and on for different doses. At the time of writing of this blog, the 2 mg dose is not available, so I’ve had to move many patients down to 1 mg or hold them there. I have not noticed weight gain when I do this, but the loss is not as pronounced on the lower dose. We are seeing the same issue with Wegovy, and now Mounjaro, which is made within the United States due to supply chain issues. To improve the situation, compounding pharmacies have received approval to manufacture Semaglutide, but it is still quite costly (several hundred dollars) and may not be covered by insurance.
References:
1 National Diabetes Statistics Report 2020 https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
2 Obesity as a Disease: The Obesity Society 2018 Position Statement. Obesity (2019) 27, 7-9. Doi: 10.1002/oby22378
3 Obesity 2016. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Aug;24(8):1612-9. doi: 10.1002/oby.21538. Epub 2016 May 2.
