"These medications are useful but they’re not for everybody," UCI Health weight-management specialist Dr. Bavani Nadeswaran says of Wegovy and other GLP-1 weight-loss drugs.
With nearly two out of three U.S. adults considered overweight or obese, it’s no wonder that the weight-loss drug Wegovy has created a stampede of patients seeking prescriptions.
It’s not just about looking good. People living with obesity — an estimated 42% of American adults — are at greater risk for numerous chronic health conditions, including diabetes, heart disease, stroke, many types of cancer and more.
Ozempic — which contains semaglutide, a glucagon-like peptide-1 (GLP-1) agonist — has been used to successfully manage type 2 diabetes since 2017 by helping patients improve diabetes control and lose weight. Wegovy, a higher dose version of Ozempic, was later approved by the U.S. Food and Drug Administration (FDA) for weight loss in people with a body mass index (BMI) of 30 or above and for some individuals with a BMI of 27 who have existing health conditions. Saxenda, another GLP-1 anti-obesity medication, was approved in 2014.
GLP-1 drugs work by slowing gastric emptying. They have proven highly effective at controlling blood sugar levels and increasing the sensation of fullness, leading to significant weight loss. Recently however, physicians have raised concerns about serious side effects, especially delayed gastric emptying, which can result in life-threatening stomach paralysis, called gastroparesis.
Live Well asked Dr. Bavani Nadeswaran, a UCI Health weight management specialist and professor of internal medicine at the UCI School of Medicine, to describe patients who are good candidates for these anti-obesity medications and what people should know before taking them.
Q.: Who is a candidate for a GLP-1 drug?
If a patient has been trying for quite some time to lose weight and made the maximum beneficial changes in diet and lifestyle, but still hasn’t seen results or the weight keeps coming back, these are reasons to look at alternative treatments.
If I see that a patient with multiple health risks and comorbidities, I will give them options, including bariatric surgery and these medications.
Q.: What are the first steps before prescribing them?
When I see a patient who is overweight or has obesity, I ask their permission to talk about it. The first part of the conversation is discovering who they are as a person by discussing diet and lifestyle, including:
- Physical activity levels
- What they do for fun
- Work life — Is it sedentary, stressful?
- Hours of sleep
- Mental health
Next, we look at their blood tests and other lab work together and discuss any pre-existing health conditions, such as heart disease, diabetes or high blood pressure. We then determine their optimal weight and how we can implement simple lifestyle changes to facilitate weight loss.
For instance, avoiding liquid calories like sodas and alcohol, ways to get more steps worked into their daily routine and how to reduce calories while boosting nutrition by making good food choices.
We also go into detail about what they’ve tried in the past to lose weight, what was successful, what barriers they encountered and what are they willing to try moving forward.
Based on that discussion, in addition to lifestyle changes, we look at options such as bariatric surgery, weight-loss medications or a combination of the two.
Q.: What are the benefits of these drugs?
The good news is that we have a significant amount of data on GLP-1 medications. They’ve been available to manage diabetes since 2017 and have been proven to be safe for most people.
I’ve seen many patients successfully lose the extra weight and maintain their weight loss. Beyond that, I’ve seen reversals in fatty liver disease and improved diabetes control. Many people have been able to come off blood pressure medicine.
I’ve had patients come to me in a wheelchair, in tears, people who could barely walk because of arthritis in their knee. They couldn’t get a knee replacement until their BMI was less than 35. They were able to successfully lose the weight on this medication and get their surgery. Now they are active again and enjoying life.
Q.: What are the side effects?
The most common side effects of GLP-1 drugs are nausea, vomiting, diarrhea or constipation. Some people can feel dizzy because it drops their blood pressure too quickly.
I tell my patients that hydration is also extremely important. The same brain signaling that causes reduced food intake also leads to reduced fluid intake because they won't feel thirsty.
I tell them, you might not have the urge, but you still need to drink at least 2.5 to 3 liters of water per day, minimum.
Q.: Are there more serious risks?
These medications slow down the stomach’s emptying process. Because foods stay in the stomach longer, you feel full quicker and don’t feel hungry between meals. More serious conditions can develop with prolonged use of the drugs, including stomach paralysis.
In some instances, the condition is severe and does not go away even when medication is stopped. Diabetics and patients who have had previous bariatric surgery are at higher risk for gastroparesis because there may already be nerve damage.
There also have been reports of acute kidney injury, in part because of dehydration. These medications also increase the risk of inflammation of the pancreas, known as pancreatitis and gall stone disease.
I tell patients to be aware of the symptoms — persistent severe nausea, vomiting, diarrhea and abdominal pain. I advise them to stop the medicine immediately and go to the nearest emergency room for treatment if any of those symptoms persist.
Q.: How do patients take the drugs?
The GLP-1 drug Wegovy is given as a self-administered weekly injection, with the dose increasing gradually. We always start at .25mg and the highest dose is 2.4mg.
Treatment is individualized and you don’t have to take the maximum dose. I’ve had patients do really well at .5mg and I can maintain them at that dosage.
We closely monitor patients, especially at the beginning when most side effects occur, like vomiting and nausea. We might need to reduce the dose to prevent dehydration. We also track kidney function.
At the start of the treatment, we see the patient back within one to two months, either in person or in a telemedicine visit, to make sure they are doing well. Of course, they can speak to us sooner if they are having any issues.
Q.: How much do the drugs cost?
These medications are expensive. The list price for Wegovy is $1369 per package for a month. With insurance coverage, it can range from your copay only to upwards of $500 to $700 a month — the cost varies depending on the insurance plan.
More than 50% of my patients are Medicare patients and nearly 42% of adults ages 65 and older struggle with obesity. Unfortunately, Medicare is not covering weight-loss medications at this time. However, MediCal (California’s Medicaid program) is covering them.
We are also now seeing some employers adding bariatric exclusion clauses to insurance coverage in order to contain costs for both bariatric surgery and the GLP-1 drugs.
Some patients have turned to compounding pharmacies but I don’t recommend that. I agree with the FDA, which has warned people against obtaining Wegovy at compounding pharmacies because we can’t be sure of the active ingredients.
Q.: Do people need to stay on the medication for life?
Yes, you're put on a maintenance dose once you achieve your optimal weight. Studies show that the majority of patients eventually gain the weight back within one to five years of stopping the medicine.
I tell patients they have to look at it as long-term, chronic disease management, like taking medication for high blood pressure or diabetes, and make sure they are okay with that.
We can’t beat the long-term data that we have on bariatric surgery, which has been available for decades, whereas these medications have been used for five to seven years. However, I do see them as another valuable weight management tool, and they are effective in reducing future cardiovascular risk.
But patients need to be carefully screened to ensure they are appropriate candidates for the medication. And they will need close monitoring and support when on the treatment.
Q.: Any final words for people considering these GLP-1 drugs?
These medications are useful but they’re not for everybody. More than anything else, extremely close monitoring is essential for anyone who takes them. It’s not something you prescribe and see the patient in a year’s time.
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