One in eight Americans had taken a weight loss injectable medication as of May 2024 as reported in an article by CNN. The article reports that about half of them were currently using a prescription, which was about 15 million people. Many times during an appointment or consultation, people will report they are either doing something they read online or using information they read online in their own decisions for their own health. People also say they will be out and about and will be asked which medication they are on, such as when placing a coffee order, and the barista will make a suggestion for a coffee based on that (sugar free so it causes less nausea). I have no idea what all of this will mean for our society five, ten, or twenty years from now, but I thought I would try to provide a source of information that may be helpful. This is a blog on some of the most common questions, concerns, and pitfalls I see and hear as people use these medications, and the current situation in accessing them.
This is for general information only and is not medical advice. That needs to come “one on one” with a licensed healthcare provider with whom you have a physician- patient relationship. As you can imagine, individual factors cause variations and that is why these are prescriptions! I recommend obtaining these after an individual visit with a licensed provider with training and experience in these medications and then using them with ongoing medical supervision. You may be able to access them very easily but that may not result in the best outcome for you.
These medications are used for both Type 2 Diabetes and chronic weight management as an adjunct to diet and exercise. Semaglutide works on one receptor, the GLP 1. Tirzepatide works on two receptors, both GLP 1 and GIP. This may be why tirzepatide shows a little more weight loss on average and may have fewer side effects. Of course, it is also harder to get for many right now. While the drugs vary somewhat in dosing schedules and how well they work, they both work, in practice, in pretty much the same way, so this information applies to them both, in general. Again, for more complete information, refer to your pharmacy insert.
These medications work on the “incretin” system. This is a system of hormones that affects many organs throughout the body to regulate energy metabolism, hunger, and fullness. Like most weight management medications, it has both a behavioral and metabolic component. It leads to decreased calorie intake and a change in how the food is metabolized. The relative importance of each of these varies with each person. While you do not have to take them forever, they are studied to be sure they are safe and effective to take them long term. This is beneficial because many people find they help maintain a healthier weight and prevent weight regain in combination with a nutrition and exercise plan. It is recommended that if you want to stop the medication, the dose is decreased and there is monitoring, as weight regain can happen. This is true no matter how a person loses weight. If you have medical conditions associated with overweight/obesity, your medications for these may need to be adjusted if your weight changes. For example, if your blood pressure medication was stopped when your weight went down, and then you stop the injection and your weight goes back up, you may need to go back on your blood pressure. There is nothing specific about these medications that make you more likely to gain weight back if you lose it compared to other weight management medications or even weight loss with diet and exercise. This is why follow up and long term monitoring is recommended.
These medications are started at a low dose, and increased as needed and tolerated. The initial dose is not intended to be therapeutic, so do not be alarmed if it seems like it is not working. On the other hand, you may feel it right away. In either case, the goal is to take the medication safely and follow up, so we can find the right dose for you over time. I typically will increase the dose if it is well tolerated. Kidney injury is listed as a risk for these medications. This does not come from the drug itself, the risk comes if someone gets dehydrated or low blood pressure. This is most common if someone gets vomiting, diarrhea, or is not eating and drinking, especially if they are on other medications. As always, people on medications for things like high blood pressure and blood sugar may need to have the doses of their medications reduced as they lose weight. Monitor your blood pressure if you are on medication. These medications, when used alone, should not cause low blood sugar, but you may be on other medications that may, most commonly insulin.
These medications are stored in the refrigerator. They can be out for a short time if needed, such as for travel. Refer to the information from the pharmacy for details. They are injections under the skin. They are small needles. While semaglutide is available orally, it is once daily, has more nausea and less side effects and is not yet FDA approved for weight loss, so it is rarely used unless a person has a needle phobia that can not be managed. Victoza and Saxenda are daily injections. The others are weekly injections. It does not matter what time of day you give it.
When you start these medications or increase the dose, you may have more side effects for the first 3 weeks. If they are manageable, continue the dose and see if they improve. I typically see people every 4 weeks during the dose titration period for this reason. MANY OF THE SIDE EFFECTS ARE RELATED TO WHAT IS EATEN AND HOW MUCH ON THESE MEDICATIONS. This is because they can have a very powerful effect on the motility and function of the stomach. If you are getting side effects, the first thing to do is look closely at what you are eating. I tell people to be prepared for significantly altered GI function for a few weeks each time you start or increase the dose. Some people simply can not digest “typical” American food. Heavier meals, especially greasy meals or those with fat, can cause more side effects. Many people use protein based meal replacements as part of a comprehensive plan for weight loss. This may be an excellent option to improve the tolerability of these medications as you adjust to them, to preserve skeletal muscle mass as you lose weight, to stabilize blood sugar, and to achieve more weight loss. A common approach is to use a protein based meal replacement for breakfast and lunch, then eat a “lean and green” dinner of protein and vegetables. Be sure to be aware of your protein requirement for the day, which is typically about 1.1 to 1.4 grams per kilogram of goal weight. This may increase if you exercise more than an hour a day and may decrease if you have kidney or liver issues. We have registered dietitians available for consultation.
These medications can cause changes in bowel movements in either direction, meaning constipation or diarrhea. Constipation may be managed with typical over the counter remedies (read and follow all package instructions). Diarrhea may or may not be related to fat in the diet. Some people are taking metformin which can cause diarrhea also. As always, consult your healthcare provider for anything more than mild or anything that persists.
As with any means of weight loss, it is important to use this medication in combination with a nutrition and exercise program. When you lose weight, your body will be breaking down tissue for energy. The goal is to “keep” healthy tissue and target unhealthy tissue. If you do not use with a nutrition and exercise plan (this varies widely for each person, so talk to your provider as accommodations are common), you may lose a large amount of skeletal muscle. This has health risks, such as osteoporosis and sarcopenia. It is very hard to build back muscle once it is lost, and many people are starting with lower muscle mass because of chronic medical conditions, aging, or a history of weight loss surgery or weight cycling. Remember, when you lose weight, you are “putting down” 15 to 25% of your body weight. Imagine picking that up and doing everything with it? This illustrates why you may lose a lot of muscle with weight loss if you do not actively prevent it. For this reason, we monitor body composition during weight loss. This is typically done at baseline and then every 3 months. Be sure to schedule in person appointments specifically for this right before a provider visit so it can be used to adjust your program if needed.
There are three usual ways to access these medications, either through insurance or paying out of pocket.
Type 2 Diabetes- if you have a diagnosis of Type 2 Diabetes supported by laboratory evidence of a HA1c of 6.5 or higher within the last year, your insurance may cover Ozempic, Mounjaro, Victoza, Trulicity, or Bydureon. Your insurance may require you to try and fail, or have contraindications to, metformin and another oral medication for diabetes.
Medicare does not cover medications for weight management, but they do cover for if you have had a heart attack, stroke, or peripheral arterial disease and a BMI of 27 or higher.
Tricare does tend to cover these medications.
Certain employers have opted in to cover these medications for weight management. Currently, they are excluded unless a payor opts in. This is different from other medical conditions, which tend to be covered unless employers opt out. People can have fantastic benefits in other areas, and still have these excluded. The administrator of the health plan does not determine the coverage.
Chronic Weight Management- Unfortunately, many insurance plans exclude chronic weight management medications. Currently, with the exception of a heart attack, stroke or PAD in Medicare beneficiaries, the presence of other comorbid conditions such as PCOS, Metabolic Associated Liver Disease, Arthritis, Sleep Apnea or others, are not FDA approved indications and do not tend to be considered.
Paying out of Pocket
If you are paying out of pocket, you have the option of buying either the brand name version, or a compounded version. Compounded medications are “copies” of the brand name medication formulated in a different laboratory. They are not the same as generic medications, which are still made in a highly regulated fashion. Compounded medications are controversial, many recognized entities caution against using them, and you need to make an informed decision before using them. Here is the FDA resource on the topic of Human Drug Compounding. I will prescribe and manage compounded semaglutide and tirzepatide but only to a limited number of pharmacies, not always the least expensive.
We have current details on some current sources and approximate costs. In general, semaglutide cost for compounded version is $200-$350 a month depending on the pharmacy and dose and tirzepatide is $335 to $525 depending on pharmacy and dose. Of course, things change and so does supply!
I hope this has been helpful. We are here to guide you and individualize recommendations, so be sure to bring your questions to us!
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Valerie Hope-Slocum Sutherland, MD
Nice article, well done. A small point of clarification regarding "Tricare does tend to cover these medications."
If dispensed from a civilian/commercial pharmacy, there is a $76.00 co-pay. If able to be ordered through an MTF (military treatment facility) and picked up at said MTF there is usually no co-pay.
Additionally, your individualized treatment, with its attendant plan tailored to the patient’s condition is quite unique, in that I have encountered other providers who strictly adhere to FDA regulations and if a specific therapy/drug is not approved for weight loss, they won’t go anywhere near it. Moreover, many of them will no longer treat/prescribe weight loss programs after one moves from obese to overweight to target/goal/healthy weight (going…