'Victim of his own success': Ozempic's great flaw (2023)

Professor John Dixon, world leader in obesity medicine, questions the priority of treating diabetes over obesity. “Since Ozempic works better than anything else available, why would we consider its use in obesity problematic?

“We have had drugs to treat diabetes for decades, and there are several new drugs. We have seen dramatic improvements in the health and well-being of people living with diabetes. It was golden for them.

“But people with obesity, even the most severe forms of obesity, don't have access to any of the drugs listed on the PBS. The only thing they have is very little access to metabolic bariatric surgery in public hospitals.

“Today in Australia, 94% of these operations are performed in private hospitals. Therefore, access to people with clinically severe obesity is negligible. This means that effective treatment is negligible.

“Over a million Australians are clinically severely obese and would be eligible for priority bariatric surgery.The biggest problem we have in treating and preventing obesity is stigma.”

He says drug companies know they have a better chance of getting a drug approved to treat diabetes than to treat obesity. The same bias applies to government bodies that determine whether a drug should be subsidized.

"There has never been a drug to control obesity on the Australian PBS," says Dixon of the Iverson Health Innovation Research Institute at Victoria's Swinburne University.

He says people have a hard time accepting that obesity is a serious disease and not the result of personal indulgence. It affects the main organ systems, joints and mental health.

"But we ignore the risk of cancer, heart disease and physical disability in clinically obese people."

mechanism

Ozempic is a medicine without insulin intended to improve blood sugar levels in adults with T2 diabetes. Its main mechanism is significant weight reduction.

Its active ingredient, semaglutide, works to induce satiety. This feeling of satisfaction or "fullness" suppresses the appetite, leading to less food consumption and weight loss.

“Medications approved for obesity in the last decade are not as effective as semaglutide and have more side effects. But diabetics get the best option, while obese people are left out," says Dixon.

“The world loves these drugs, but the company that makes them simply doesn't have the capacity to produce what the world needs. Most of the stock went to the US, where they charge a higher price than here.”

On PBS, Ozempic costs Australians about $42 a month (four injections a week). On a private prescription, the price is around $132 per month.

According to the medical news website WebMD, Ozempic can cost uninsured Americans more than $1,000 a month, with many migrating to Canada to save $700 a month. The Danish multinational that makes the drug, Novo Nordisk, offers promotional prices on its website.

Demand for healthy people

Another factor influencing the offer is its use by healthy people who want to lose a few kilos to feel and look better. In addition to exacerbating shortages, experts say they can harm health.

"They don't know they could be putting their health at risk," says Gary Wittert, professor of medicine at the University of Adelaide and senior consultant endocrinologist at the Royal Adelaide Hospital. The drug is very effective in inducing fat loss, but people also lose lean tissue.

They are stealing from Peter to pay Paul. They will lose muscle and bone mass, and when they stop taking the drug, they will regain fat tissue and more, but not all the muscle and bone will come back,” he says. “It is a drug for people with serious health problems, and that is how it should be used.

The long-term consequences of this loss of muscle and bone mass are unknown. Clinical trials offer five years of data, and while registry data offers more, it remains to be seen what will happen 20 years from now.

“In terms of nutrition, if these people eat a suboptimal diet, they don't get the right nutrients. With the drug, they eat less and diet, which won't help them," Wittert says. "Conversely, if you drive a Maserati and you put an ethanol blend in your car and your car doesn't drive well, put less ethanol blend it won't help the situation.

"There just won't be enough of this drug in the world to treat everyone who thinks they are overweight," says Wittert.

"The drug is very well tolerated, but it can cause gastrointestinal side effects, including nausea, leaky gut, and reflux," he adds. “Because it delays gastric emptying, ingested food is not pushed forward at the same rate and can cause reflux.

However, when the drug is used to treat T2 diabetes or severe obesity, Wittert says the effects can be "life-changing."

It targets the relevant biology and lowers blood sugar, reduces weight, and controls food intake in people who cannot do it on their own.

"The bottom line is still optimizing basic health-related behaviors like normalizing sleep, eating smarter, and engaging in resistance exercise to preserve muscle mass," he says. “When you add medicine to this holistic approach, you solve intractable problems. If the basics aren't in place, you're just plugging the cracks."

Victim of his own success.

Professor Jerry Greenfield, head of endocrinology and director of diabetes at St Vincent's Hospital in Sydney, says semaglutide has become a victim of its own success due to its efficacy in inducing weight loss and improving diabetes control.

“The supply problems that led to the unavailability of semaglutide and then dulaglutide (another weekly injection) are due to the potency of this class of agents to induce appetite suppression and satiety in people with and without diabetes.

"Prior to the launch of these agents, therapeutic options for weight loss were very limited," he says. “It has been very difficult to get semaglutide for the last year. In recent months, there has been an increase in availability. Given supply issues, semaglutide prescriptions should be limited to people with T2 diabetes, particularly those who were treated before shortages became apparent.

"Some patients previously using semaglutide or dulaglutide had to start other diabetes therapies or switch to daily injections such as liraglutide, which is only available by private prescription without PBS subsidy."

He has seen shortages of other medicines from time to time, but he can't recall ever seeing a shortage of T2 diabetes medicines to such a degree.

But there are similar drugs on the way that should alleviate supply problems. One, called Mounjaro, represents a new class of diabetes drugs. Ozempic activates the hormone receptor; Mounjaro activates that same hormone receptor plus another related receptor.

It was approved for use by the TGA in December, but manufacturer Eli Lilly has yet to confirm when it will be launched and supplied in Australia. Triple agonists, which stimulate three receptors, are also being developed.

Oral versions of the drug are being developed, and the possibility that semaglutide might work inReward Circuits of the Brainand help reduce compulsive and addictive behavior.

As social media influencers continue to tout Ozempic as a weight loss miracle cure, the TGA continues to warn consumers about illegal substitutes as they wait for the shortage to end in July.