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What is the difference between Ozempic and Wegovy? What is GLP-1? Is weight loss medication covered by insurance? How to ask your doctor for weight loss injections?
Janese Laster, MD, a gastroenterologist and obesity medicine specialist, discusses types of weight loss drugs, their mechanisms, costs, insurance coverage, and the importance of lifestyle changes in conjunction with medications for weight loss.AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Janese Laster, MD, gastroenterologist and obesity medicine specialist
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about the most common questions patients have about weight loss drugs, and how physicians can answer them. We'll discuss the science behind these type of drugs, their benefits, side effects and more. Our guest today is Dr. Janese Laster, a gastroenterologist and obesity medicine specialist in Washington, D.C. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Laster, welcome.
Dr. Laster: Thank you so much for having me. Happy to be here.
Unger: Well, there's a lot of discussion out there about weight loss drugs, and so we're going to start with some general background about what the drugs are that are on the market right now and how these drugs work. Why don't we just start right there?
Dr. Laster: I love it. Let's jump right in. First of all, there are a lot of drugs that are out there. Some of them are newer, but a lot of them are old and have been around for forever. Two of them that are old and are oral agents are the brand name Qsymia, which is a make up of phentermine and topiramate.
Another medication, Contrave which is made up of bupropion and naltrexone. And then the two new ones that everybody's talking about is Wegovy—which is the sister drug to Ozempic, an injectable GLP-1 agonist, and the most recent one to hit the airwaves in FDA approval is Zepbound, which is the sister drug to Mounjaro, and that one's a GLP and GIP medication, but also an injectable.
Unger: Now patients obviously have a lot of questions about how these drugs compare to one another. Can you just kind of give us a brief overview about the key differences between them?
Dr. Laster: Yeah, so the first two are both oral. So that's the big thing that sets those apart. And they've been around for a very long time, both made up of a very old drugs that have been around for forever. And the one thing I tell patients is there's no one size fits all. I know the last two that have come out with the injectables have gotten a lot of hype, but sometimes the oldies and goodies work really well.
The Qsymia, which is phentermine and topiramate, that one works by increasing basal metabolic rate. It also helps with patients feeling more satiated. The other one, Contrave, which is an oral agent, which is again made up of naltrexone and bupropion. That one works on emotional eating. So that helps with a lot of binge eating or patients that have a lot of cravings.
The other two—the injectables—Wegovy, which is the sister drug to Ozempic again. That one works on GLP-1 agonist, which is a hormone that comes from your small bowel, and that hormone works on the hypothalamus, the arcuate nucleus of the brain. And that is what helps with energy expenditure, appetite suppression and it also slows gastric motility. So that's why people feel more satiated.
And then the other one, Tirzepatide or Zepbound, the sister drug to Mounjaro, which is for diabetes—works on those two gut hormones as well, GLP and GIP, again, working on that same pathway in the arcuate nucleus, again, working on—just now, we're affecting two different gut hormones rather than just one with Wegovy and Ozempic.
Unger: Why does it seem like we really didn't hear a lot about these drugs until the injectables came out?
Dr. Laster: I don't know. It's really incredible why these things were not talked about more. But I think it's because obesity really wasn't recognized as a disease. People thought of it as a moral failing, and people—patients didn't want to talk about it. It was one of those things that it's like, I just don't want to talk about it. It doesn't—nothing works. And physicians really—we weren't really doing a good job at bringing them up and identifying patients who were candidates for these medications and talking to them about the risk and benefits and what could be helpful.
Because actually, some of these injectables for diabetes have been out for a while, which is why we do have so much data on them, actually, because they've been out for a long time. But they were daily injectables, which is a hard sell for most patients. And now these things are weekly, so they've gotten—they've taken off because of, I think, now they're weekly and they're a little bit easier for patients to tolerate.
Unger: So let's say we have a patient who thinks a weight loss drug might be a good fit for them, and they're wondering what to do next. And they have questions like, do I need a prescription and where could I buy this specific drug? What's the basic that you need to tell patients?
Dr. Laster: The basic is to make sure you find somebody that is obesity specialist, somebody—or an endocrinologist at minimum, or a gastroenterologist, someone that can follow you through this process, somebody that's going to be able to do consistent follow-up.
Yes, you do need a prescription for these medications, and you should be consistently followed because there is a titration period where we're going up on the dose. Sometimes we have to go back down. We have to make sure we pay attention to symptoms and drug interactions, making sure patients are getting enough in to eat. They're not eating too little. They're getting weight-bearing activity.
So there's a lot of things that come along with these medications. They're not just some things that are inconsequential—you lose weight, the end. No, it takes a lot of lifestyle changes and things to be consistent in order for patients to maintain that weight loss.
Unger: Now, obviously, cost is a question on every patient's mind. Are these drugs typically covered by insurance, and how much do they cost if you don't have that?
Dr. Laster: Yes, that is something that we do a lot of advocacy work in to try to get this globally covered, or nationally covered. So not every insurer will cover them. It has gotten better over the last couple years, but it's not 100% at this point. And so some insurers will cover.
And so if we—when we think about cost, the oral agents, which are older, are less expensive. So Qsymia without insurance coverage is probably about $200 a month. And sometimes we can use coupons to take that down further to be about $100 a month. Contrave is about is similarly priced. And again, we use manufacturer coupons to bring that price down.
But then when we think of Wegovy—and the one thing I want to say between Ozempic and Wegovy—Ozempic, although that's the one that's been put out as the poster child, is FDA approved for diabetes. So it's off-label use when we're using it for weight loss.
So when we're trying to get it approved for somebody for a weight loss medication who does not have diabetes, we're ordering Wegovy. So Wegovy is, in most cases, about $1,500 to $2,000 a month without insurance. And right now, there's not a coupon from the manufacturer that's able to be used, so it's pretty expensive.
Ozempic sometimes is covered by insurance if someone has diabetes. But sometimes they'll make you jump through a few hoops to see if they've tried other medications first. And again, the same thing with Zepbound and tirzepatide—or Zepbound is for weight loss, whereas Mounjaro is for diabetes.
So Mounjaro sometimes is approved by insurance. If you have diabetes, Zepbound for weight loss. And right now, there is a coupon. So that one's also about $1,500 to $2,000 a month. Now there's a coupon that we use that takes it down to about $550.
And most recently, Eli Lilly has come out with information for separate vials so that the dose is a little bit less expensive for the 2.5 and the 5-milligram doses. So the 2.5, I think, is $399 and the 5-milligram dosage, which is the next dose up, is about $550. So a couple of things coming out, but still very expensive, even with coupons.
Unger: Well, a lot to contend with there in terms of the pricing, but obviously it can be pretty expensive. These drugs might be driving headlines, but we're still pretty early in our understanding of them. Patients are uncertain about how much weight they're going to lose and how long they need to be on these drugs and if they'll regain the weight once they're off them. What does the research tell us about that?
Dr. Laster: Very true. So the beautiful part about them getting so much attention is that it's driving so much research and so much data to be collected, so that I'm excited about. So there's all ends of the spectrum.
There are patients that don't have—don't see any weight loss with these medications, which can be devastating when you see all of these people online that are having this miraculous journeys. So there are some drugs that blood tests that have come out to allow us to understand which patients may be able to achieve success from these medications and which may not. So that's one thing I think is really helpful.
As far as who needs to be on it forever versus not, I tell patients, every patient is very different. I am able to get some patients off of these medications with being able to follow them for months and months and months and months, building those lifestyle changes, though.
So sometimes we're able to get them to their goals, and get them off the medications and watch them. And they continue to follow up, though. And we continue to work on as life happens, because when life happens, people regain their weight because they get off of those habits that we've created.
And then there are some patients that I'm able to take down to a lower dose, but I'm not able to, quote, "completely get them off," and we still need it at that dose. And I think there will be more research that's coming to let us know a little bit more about what those populations are, which I think will also be helpful for insurance companies. And I think that is some of the issues I have when I'm going to Congress doing advocacy work, is the thought that people have to be on this forever and that everybody will, when that's just not the case.
Unger: Interesting. And you mentioned—in that diet and lifestyle changes, or lifestyle changes, is that diet and exercise or what—obviously, people's relationship with food is complicated, and everybody's different, like you pointed out. What is that prospect for people while they're on drugs like this to move—to complement that with other changes?
Dr. Laster: Yeah. So I think one thing that's super important is making sure patients have that consistent follow-up. So in our practice, we are understanding what your day-to-day life is like. How can we make changes in patients lives'?
If it's somebody that hates cooking, is busy, is on the go, I have to create a plan for you that's going to work within your life. I can't tell you to go chop up onions every day. It's not going to work. So giving you a meal delivery service, making sure you understand what options are available for you, and giving patients practical things to do is what we really, really have to do. We have to give people brains. We have to make it easy for patients.
And teaching patients what these nutrition labels mean, because I think it's gotten so confusing about what you should eat, what you shouldn't eat, what's healthy, what's not. All of these labels look like everything is healthy.
But I teach patients to flip that around. That's all marketing. Ignore that part. Flip it around. Let's see what's on the back. And people are shocked when I'm explaining what's actually in these foods that taught to be, oh, I'm so healthy. And when we talk about it, they're like, oh my God, that has no fiber. That has no protein. Look at all the sodium. I'm like, exactly.
So I think we have to do a better job of teaching patients what those labels mean, what they should be looking for, what their goals in the day should be, and taking away this idea that, oh, I can't eat carbs or some of these old school things that are still sort of around in this diet culture and getting people back to just eating real food again and creating things that are reasonable and sustainable.
Unger: Sounds like—
Dr. Laster: So they can keep it up.
Unger: --it's a great idea. Last question is about side effects. And we've been reading about these in the press. People are uncertain about what might happen in terms of side effects. What does the research show so far about that?
Dr. Laster: Yeah. That's another good one, and which is also why I tell patients it's very, very important not to get these medications from random places. And you really need to be seeing somebody that's obesity board-certified or an endocrinologist or a gastroenterologist—someone who understands how these medications work.
And so that's number one. So I have a patient that comes in—I'm assessing all of those things during their initial visit with a review of systems. I am trying to determine if they have a history of insomnia or uncontrolled blood pressure or vision changes or GI symptoms, because I'm going to work on those things first, or I'm not going to prescribe them that medication.
So some of the things that we're seeing that people go into the hospital for—I look at it—I'm like, that patient should have never had that medication in the first place. If somebody has gastroparesis, which is slowing, slowing of the GI tract which some patients have, which is easily tested, then why would I start them on the medication like a GLP just because they ask for it, which slows the GI tract further, and so that's how the mechanism of action is reducing gastric emptying? That makes no sense.
So you have to be with somebody who understands the mechanism of action of the medication, how these medications work, the side effects of these medications to be able to counsel patients. Just because the patient wants it doesn't mean they know what's best for them. They have to understand, 'Oh, crap, I do have gastroparesis. You're correct. This medication would make me worse.'
And so I think a large part of that is physicians or prescribers making sure they understand—that they have knowledge of these medications before prescribing, and you take the time to understand that each patient is different. You don't just give every patient the same medication. And you talk to them in detail about what to expect as well.
So sometimes if some certain side effects are there, my patients will know to reach out to me if something happens, even if it's months after they've started it. They'll say, I never had this symptom, but I remember you telling me something about X. And we stop it. So I don't have patients that have complications of pancreatitis and some of these things because they know what to look for because I've given them explicit instructions.
Unger: I think that's so important in your point earlier, and that is, they do seem to be available at lots of different places that may or may not have a physician involved. And so, what great advice for patients out there—make sure you talk to a physician, and those with obesity medicine training—very, very important.
Dr. Laster, thank you so much for being here today. There are so many people that want to have this information. I'm sure it's very valuable to them. And if you want to support more programming like this, please consider becoming an AMA member at ama-assn.org/join. That wraps up today's episode, and we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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