Nov. 28, 2023
Weight Loss Revolution: Ozempic & Friends
The use of Ozempic/Wegovy and similar medications such as Mounjaro for weight management is rapidly evolving. As they continue to be studied further and receive FDA approvals, including the approval of Zepbound this month, the question becomes whether they can be a meaningful substitute for bariatric surgery.
Ozempic has been used to treat type 2 diabetes since 2017. When used for weight loss, semaglutide is used at higher doses and marketed as Wegovy. Newer medications such as Mounjaro (tirzepatide) have entered the market for and will be marketed under the name Zepbound for the sole purpose of weight loss.
When combined with healthy lifestyle choices, people can lose 15-20% of body weight over a six month course on semaglutide and up to 25% on tirzepatide. Dr. Bass answers everyone’s biggest questions about the use of these medications for weight loss, including:
- Does insurance help cover the cost?
- Who is a candidate?
- Can these medications be a meaningful substitute for bariatric surgery?
- Does the weight rebound once you stop?
About Dr. Lawrence Bass
Innovator. Industry veteran. In-demand Park Avenue board certified plastic surgeon, Dr. Lawrence Bass is a true master of his craft, not only in the OR but as an industry pioneer in the development and evaluation of new aesthetic technologies. With locations in both Manhattan (on Park Avenue between 62nd and 63rd Streets) and in Great Neck, Long Island, Dr. Bass has earned his reputation as the plastic surgeon for the most discerning patients in NYC and beyond.
To learn more, visit the Bass Plastic Surgery website or follow the team on Instagram @drbassnyc
Subscribe to the Park Avenue Plastic Surgery Class newsletter to be notified of new episodes & receive exclusive invitations, offers, and information from Dr. Bass.
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Welcome to Park Avenue
Plastic Surgery Class,
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a podcast where we explore controversies
and breaking issues in plastic surgery.
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I'm your co-host, Doreen Wu,
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a clinical assistant at Bass
plastic surgery in New York City.
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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,
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educator and technology innovator.
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The title of today's episode
is Weight Loss Revolution:
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Ozempic and Friends. You've all heard
of Ozempic and its role in weight loss,
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but I'm a little light on the details.
If you'll pardon the pun. Fill me in,
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Dr. Bass, let's start
off with some background.
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There's group of medications which
stimulate glucagon-like peptide one
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receptors or glucose
dependent insulinotropic
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polypeptide receptors.
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So these receptors are
called GLP-1 and GIP for
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short. They're very fancy names,
but let me try to break it down.
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Glucagon along with insulin are the
main hormones in the body used to
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regulate the level of
glucose in the bloodstream.
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Glucagon-like peptides have
multiple metabolic effects including
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stimulating secretion of insulin,
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delaying gastric emptying
and inhibiting appetite.
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The medications are used to treat people
with type two diabetes as an injection
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performed at home.
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The effects also work to limit
caloric intake and have shown
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significant weight loss in these patients.
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What are the names of these medications?
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Ozempic and Wegovy are names for
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semaglutide, which is a GLP-1,
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receptor agonist or stimulator.
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Ozempic is the name of the medicine,
used to treat type two diabetes.
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Wegovy is the exact same
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medicine semaglutide that
is FDA approved to treat
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obesity. Mounjaro,
generically tirzepatide,
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is a newer medication that
stimulates both GLP-1 and
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GIP receptors. There are older
medications like Trulicity,
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Victoza, and Saxenda,
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which are self-administered
daily as an injection rather than
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weekly like Ozempic, Wegovy and Mounjaro.
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And what kind of weight loss
are we talking about here?
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On average 15% and with some
recent data with Mounjaro
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averaging 20% of body weight.
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So this means if you weigh 200
pounds you could slim down to 160
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pounds over a typical six
month course on the medicines.
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Dr. Bass,
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you said these medicines were used to
help diabetics control their blood glucose
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levels. What is the role for weight loss?
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Well,
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that's a great question and that's
really where things are evolving.
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But first, let's look at what's
going on in weight loss therapies,
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generally surgical weight loss,
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medical weight loss and so forth.
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Doctors typically characterize
people's weight based on body
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mass index or BMI.
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This is a calculation made by
inputting height and weight.
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It's an indicator rather than a
direct measurement. For example,
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people who have a lot of muscles
such as bodybuilder with very low
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body fat,
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they could weigh as much as someone who's
overweight and has very little muscle
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and a lot of body fat, but they
might both have the same BMI.
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So BMI is not absolute,
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but it's a good rule of
thumb that physicians use.
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And CDC has definitions for what BMI
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corresponds with what
state of your body weight.
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So currently if you're under
18.5 you're underweight.
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Now that used to be 20,
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but they decided we could be thinner
and still be a normal body weight.
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And between 18.5 and 25 is normal, weight
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between 25 and 30 is overweight
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and 30 or over is obese.
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So 30 to 35 is class one obesity,
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35 to 40 class two obesity
and greater than or
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equal to 40 is class three obesity,
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what used to be called morbid
obesity but now is termed extremely
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obese.
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So who in what ranges are candidates
for these new medications?
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Well, again,
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I'm going to back us up here and talk
a little bit about bariatric surgery.
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So that's kind of become the gold
standard for treating severe obesity.
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And the current standard
is people with a BMI
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over 35 are candidates
for bariatric surgery like
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gastric sleeve gastric bypass,
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people with a BMI over 30
with type two diabetes or
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who have failed attempts in more
conservative measures are candidates,
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but this is shifting sand.
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There was some revision
of the standards in 2022,
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but still these standards
overall are based on the
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previous standards,
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which came from 1991
and in 1991 most of the
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bariatric surgery was being
done open, big open incisions.
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Nowadays these procedures are
almost always done laparoscopically
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and that creates much less risk
and much less recovery time.
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So it's resulted in some revision,
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but still overall the surgery
is for the heaviest patients,
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those who are obese and
failing medical therapies.
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Now if we turn to these
medicines a little bit, Wegovy,
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which is semaglutide,
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the same medication as in
ozempic that has a specific FDA
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indication or approval to help
with weight loss in patients with
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a BMI greater than 30,
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so class one obesity or BMI greater than
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27 if the patient has hypertension,
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type two diabetes or
hyperlipidemia. In addition,
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and this is interesting,
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there's also a specific
approval for pediatric patients,
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which is a growing group
of overweight patients.
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So for patients 12 and over who
are above the 95th percentile of
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weight for their age and sex,
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they likewise can be treated with Wegovy
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for weight loss.
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Will insurance pay for the medication
and if not, how much does it cost?
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This is a huge issue in what's going
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on in this area right now. The list price,
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so to speak, of a month's
supply of Ozempic is
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$2,300
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and if you're a type two diabetic,
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your insurance will cover it according
to whatever the terms are of your
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prescription plan.
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For weight loss coverage
is much more variable
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and so six month course of
these medications adds up to
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quite a bit of money.
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People have looked at alternative
ways of getting their hands
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on semaglutide and other of
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these
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receptor block receptor agonists
and one way they've done that is by
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going to compounding
pharmacies and that becomes
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much less expensive,
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but you have to be sure that the pharmacy
has the adequate qualifications and
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experience the proper
sourcing to prepare the
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material to the standard
that the pharmaceutical
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material would be.
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What about adverse events?
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So there are a lot of minor GI
symptoms that patients experience,
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nausea, abdominal cramping,
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other things that are
largely GI in nature,
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gastrointestinal, particularly
when they start the medications,
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those often resolve
after a few weeks on the
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medication.
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But another issue is what happens
when you stop the medication.
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Most patients will be on the medication
six months to achieve their weight loss
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goals and then begin
weaning off the medication.
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So there have been different
studies with different
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information about how
much rebound, for example,
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with Wegovy when that's stopped after
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finishing a weight loss period of time.
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Recent study with Mounjaro
suggested a very small amount of
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rebound 5% in one year,
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but some of the experience with
Ozempic and Wegovy has been quite a bit
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more rebound than that,
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and that's similar to what happens
when we go on a diet and then stop
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usually your weight seesaw back
at least a little bit sometimes
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all the way back.
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This seems to be less than all the way
based on everything that's been in all of
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the studies, but it's still not zero.
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Dr. Bass, before we wrap
up our discussion today,
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can you give our listeners
some parting takeaways?
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So this is a rapidly evolving field
and we will circle back and update
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for our listeners as needed.
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All of the therapy options,
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both medical and surgical work
best with dietary counseling,
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exercise and support. It's
just like quitting smoking.
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It's really about lifestyle changes.
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The medications help with that,
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but support is really key to
have a program of weight loss
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not simply going on a medication.
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So if I look at what effect these
medications will have in the field of
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plastic surgery, I have a few thoughts.
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I don't think these medications are
really going to have a lot of impact on
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liposuction. Liposuction
is not for weight loss.
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Liposuction is designed to
take specific body shapes
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in particular ones that
don't diet and exercise well,
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so are not real weight loss
shapes and flatten those shapes
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off if they're made of fat.
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I also don't think that there'll be
a big impact with these medications.
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On body contouring procedures,
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a lot of the body contouring
procedures relate to skin as much as
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fat. In fact,
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in some ways we may see an increase in the
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need for body contouring,
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skin excisional procedures
like thigh lift,
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buttock lift and adominoplasty arm lift,
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breast lift and facelift,
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and all of these procedures
are typically needed in a good
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percentage of patients
after massive weight loss.
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I do think that these medications
will very likely supplant
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the existing medications that are FDA
approved to assist with weight loss
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due to the very high level of efficacy and
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for these already FDA
approved options like Wegovy
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and we're likely to get a few more
medications that are currently
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in late clinical trials
right now depending on how
the study data comes out and
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how FDA views it when they review it.
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Some of these newer medications,
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the amount of weight loss that's
being seen may be enough to
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reasonably supplant bariatric surgery,
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especially for patients with class one
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obesity, will likely have a growing
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role for overweight patients
in addition to obese
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patients taking these medications.
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That may be based on FDA approvals,
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it may be off-label use,
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use from compounding pharmacies
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by people who are just anxious
to get some means to assist them
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in their diet and exercise
program. Currently,
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insurance is limited in terms of
covering these medications for
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weight loss, especially if
you're overweight, not obese,
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but this will likely
slowly expand over time.
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I feel like the jury's still out on how
much rebound you get when you go off
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these medications,
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but I'm sure over the next few
years we'll see a lot of data to
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answer that question more definitively
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and honestly,
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rebound is something we see
after bariatric surgery so that
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there's no option that's
immune to rebound.
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At the end of the day,
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the other factor is the cost.
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I mean right now these
medications are the top several
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medications that are going to be
prescribed in all of the United States in
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2023. But making it
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affordable,
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particularly where it's not
insurance covered and making sure
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there's an adequate supply of the
medication is probably the current
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biggest challenge to their routine
use. Those are all very nice points.
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And now I have an update
for our listeners.
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Since we originally
recorded this episode on
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November 8th, 2023, the FDA approved the
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medication in Mounjaro
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for the indication of weight loss.
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The generic name of the
medication is tirzepatide
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just as Ozempic is for diabetes
and the same medicine for
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obesity cells under a different
brand name, Wegovy, tirzepatide
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for weight loss will be marketed under
the brand name Zepbound. Tirzepatide
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is a GLP-1 and GIP receptor
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stimulator.
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And this may account for why the
study data showed more weight loss
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00:15:30,771 --> 00:15:34,250
than Wegovy. In the study,
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00:15:34,340 --> 00:15:39,050
up to 25% of body mass was lost over
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00:15:39,060 --> 00:15:41,540
1.5 years at the highest dose.
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00:15:41,930 --> 00:15:46,580
So on average in the study
that was 48 pounds of
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00:15:46,640 --> 00:15:49,760
weight loss weight at a lower dose,
238
00:15:49,910 --> 00:15:53,540
an average of 34 pounds
of weight loss was seen.
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00:15:55,190 --> 00:15:59,720
This is more than seen for Wegovy
maybe because of the double
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00:15:59,721 --> 00:16:01,130
receptor effect.
241
00:16:02,030 --> 00:16:05,090
The indications are similar to Wegovy.
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00:16:05,720 --> 00:16:09,440
It's indicated for
people with a BMI over 30
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00:16:10,280 --> 00:16:15,260
or people with a BMI over 27 with
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00:16:15,530 --> 00:16:18,800
some kind of cardiac or
pulmonary risk factor,
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00:16:18,830 --> 00:16:22,610
hypertension type two
diabetes hyperlipidemia.
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00:16:23,660 --> 00:16:27,800
We're still waiting to hear about
the rebound when going off the
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00:16:27,801 --> 00:16:32,630
medication and the out-of-pocket
cost is expected to
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00:16:32,631 --> 00:16:36,170
be about a thousand
dollars a month, currently.
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How health insurance companies
will choose to cover the medication
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is evolving and we'll keep you posted.
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Thank you Dr. Bass for sharing
your insight and expertise with us.
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00:16:49,010 --> 00:16:51,170
as always.
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00:16:51,170 --> 00:16:53,930
Thank you for listening to the
Park Avenue Plastic Surgery Class
254
00:16:53,940 --> 00:16:56,510
podcast. Follow us on Apple Podcasts,
255
00:16:56,540 --> 00:16:58,610
write a review and share
the show with your friends.
256
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Be sure to join us next time to avoid
missing all the great content that's
257
00:17:02,121 --> 00:17:05,660
coming your way. If you want to
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258
00:17:05,690 --> 00:17:06,590
we'd love to hear from you.
259
00:17:07,070 --> 00:17:11,570
Send us an email at podcast@drbass.net
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260
00:17:12,120 --> 00:17:12,200
@drbassnyc.
00:00:00,660 --> 00:00:03,330
Welcome to Park Avenue
Plastic Surgery Class,
2
00:00:03,660 --> 00:00:07,800
a podcast where we explore controversies
and breaking issues in plastic surgery.
3
00:00:08,220 --> 00:00:09,720
I'm your co-host, Doreen Wu,
4
00:00:09,990 --> 00:00:13,170
a clinical assistant at Bass
plastic surgery in New York City.
5
00:00:13,620 --> 00:00:18,060
I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,
6
00:00:18,360 --> 00:00:20,490
educator and technology innovator.
7
00:00:21,270 --> 00:00:24,600
The title of today's episode
is Weight Loss Revolution:
8
00:00:24,630 --> 00:00:29,100
Ozempic and Friends. You've all heard
of Ozempic and its role in weight loss,
9
00:00:29,160 --> 00:00:31,830
but I'm a little light on the details.
If you'll pardon the pun. Fill me in,
10
00:00:32,940 --> 00:00:35,220
Dr. Bass, let's start
off with some background.
11
00:00:36,780 --> 00:00:41,670
There's group of medications which
stimulate glucagon-like peptide one
12
00:00:41,671 --> 00:00:46,320
receptors or glucose
dependent insulinotropic
13
00:00:46,380 --> 00:00:48,210
polypeptide receptors.
14
00:00:48,960 --> 00:00:53,880
So these receptors are
called GLP-1 and GIP for
15
00:00:53,881 --> 00:00:58,530
short. They're very fancy names,
but let me try to break it down.
16
00:00:59,340 --> 00:01:04,200
Glucagon along with insulin are the
main hormones in the body used to
17
00:01:04,201 --> 00:01:06,990
regulate the level of
glucose in the bloodstream.
18
00:01:07,740 --> 00:01:12,660
Glucagon-like peptides have
multiple metabolic effects including
19
00:01:12,661 --> 00:01:15,000
stimulating secretion of insulin,
20
00:01:15,570 --> 00:01:19,020
delaying gastric emptying
and inhibiting appetite.
21
00:01:19,920 --> 00:01:24,780
The medications are used to treat people
with type two diabetes as an injection
22
00:01:25,110 --> 00:01:26,370
performed at home.
23
00:01:27,120 --> 00:01:31,830
The effects also work to limit
caloric intake and have shown
24
00:01:31,831 --> 00:01:34,470
significant weight loss in these patients.
25
00:01:35,370 --> 00:01:37,200
What are the names of these medications?
26
00:01:38,250 --> 00:01:42,450
Ozempic and Wegovy are names for
27
00:01:42,510 --> 00:01:45,270
semaglutide, which is a GLP-1,
28
00:01:45,271 --> 00:01:48,060
receptor agonist or stimulator.
29
00:01:48,870 --> 00:01:53,490
Ozempic is the name of the medicine,
used to treat type two diabetes.
30
00:01:53,490 --> 00:01:56,430
Wegovy is the exact same
31
00:01:56,440 --> 00:02:01,290
medicine semaglutide that
is FDA approved to treat
32
00:02:01,291 --> 00:02:05,250
obesity. Mounjaro,
generically tirzepatide,
33
00:02:07,410 --> 00:02:12,120
is a newer medication that
stimulates both GLP-1 and
34
00:02:12,930 --> 00:02:17,850
GIP receptors. There are older
medications like Trulicity,
35
00:02:17,851 --> 00:02:20,280
Victoza, and Saxenda,
36
00:02:21,240 --> 00:02:25,650
which are self-administered
daily as an injection rather than
37
00:02:25,651 --> 00:02:29,880
weekly like Ozempic, Wegovy and Mounjaro.
38
00:02:31,650 --> 00:02:33,840
And what kind of weight loss
are we talking about here?
39
00:02:34,560 --> 00:02:39,540
On average 15% and with some
recent data with Mounjaro
40
00:02:41,100 --> 00:02:43,890
averaging 20% of body weight.
41
00:02:44,550 --> 00:02:49,170
So this means if you weigh 200
pounds you could slim down to 160
42
00:02:49,171 --> 00:02:52,980
pounds over a typical six
month course on the medicines.
43
00:02:53,940 --> 00:02:54,631
Dr. Bass,
44
00:02:54,631 --> 00:02:59,070
you said these medicines were used to
help diabetics control their blood glucose
45
00:02:59,080 --> 00:03:01,360
levels. What is the role for weight loss?
46
00:03:02,140 --> 00:03:02,410
Well,
47
00:03:02,410 --> 00:03:07,360
that's a great question and that's
really where things are evolving.
48
00:03:07,660 --> 00:03:11,260
But first, let's look at what's
going on in weight loss therapies,
49
00:03:11,410 --> 00:03:14,170
generally surgical weight loss,
50
00:03:14,171 --> 00:03:16,450
medical weight loss and so forth.
51
00:03:17,320 --> 00:03:22,090
Doctors typically characterize
people's weight based on body
52
00:03:22,091 --> 00:03:24,010
mass index or BMI.
53
00:03:24,040 --> 00:03:28,540
This is a calculation made by
inputting height and weight.
54
00:03:30,130 --> 00:03:34,510
It's an indicator rather than a
direct measurement. For example,
55
00:03:34,511 --> 00:03:39,280
people who have a lot of muscles
such as bodybuilder with very low
56
00:03:39,281 --> 00:03:40,210
body fat,
57
00:03:41,860 --> 00:03:46,540
they could weigh as much as someone who's
overweight and has very little muscle
58
00:03:46,541 --> 00:03:50,740
and a lot of body fat, but they
might both have the same BMI.
59
00:03:50,750 --> 00:03:53,020
So BMI is not absolute,
60
00:03:53,410 --> 00:03:56,920
but it's a good rule of
thumb that physicians use.
61
00:03:57,190 --> 00:04:01,090
And CDC has definitions for what BMI
62
00:04:01,420 --> 00:04:04,810
corresponds with what
state of your body weight.
63
00:04:05,770 --> 00:04:09,220
So currently if you're under
18.5 you're underweight.
64
00:04:09,640 --> 00:04:11,170
Now that used to be 20,
65
00:04:11,170 --> 00:04:15,190
but they decided we could be thinner
and still be a normal body weight.
66
00:04:16,240 --> 00:04:20,530
And between 18.5 and 25 is normal, weight
67
00:04:22,600 --> 00:04:26,110
between 25 and 30 is overweight
68
00:04:27,460 --> 00:04:30,700
and 30 or over is obese.
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00:04:30,701 --> 00:04:33,850
So 30 to 35 is class one obesity,
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00:04:34,390 --> 00:04:39,100
35 to 40 class two obesity
and greater than or
71
00:04:39,110 --> 00:04:42,040
equal to 40 is class three obesity,
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00:04:42,910 --> 00:04:47,170
what used to be called morbid
obesity but now is termed extremely
73
00:04:47,200 --> 00:04:48,033
obese.
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00:04:49,180 --> 00:04:52,630
So who in what ranges are candidates
for these new medications?
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00:04:53,200 --> 00:04:53,801
Well, again,
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00:04:53,801 --> 00:04:58,510
I'm going to back us up here and talk
a little bit about bariatric surgery.
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00:04:59,170 --> 00:05:04,000
So that's kind of become the gold
standard for treating severe obesity.
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00:05:04,990 --> 00:05:09,640
And the current standard
is people with a BMI
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00:05:09,670 --> 00:05:14,470
over 35 are candidates
for bariatric surgery like
80
00:05:14,480 --> 00:05:16,900
gastric sleeve gastric bypass,
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00:05:17,230 --> 00:05:22,060
people with a BMI over 30
with type two diabetes or
82
00:05:22,061 --> 00:05:26,880
who have failed attempts in more
conservative measures are candidates,
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00:05:27,330 --> 00:05:29,230
but this is shifting sand.
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00:05:30,100 --> 00:05:33,370
There was some revision
of the standards in 2022,
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00:05:33,670 --> 00:05:38,500
but still these standards
overall are based on the
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00:05:38,501 --> 00:05:39,730
previous standards,
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00:05:40,060 --> 00:05:44,680
which came from 1991
and in 1991 most of the
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00:05:44,681 --> 00:05:49,390
bariatric surgery was being
done open, big open incisions.
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00:05:50,170 --> 00:05:55,150
Nowadays these procedures are
almost always done laparoscopically
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00:05:55,420 --> 00:05:59,090
and that creates much less risk
and much less recovery time.
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00:05:59,480 --> 00:06:02,270
So it's resulted in some revision,
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00:06:02,600 --> 00:06:06,590
but still overall the surgery
is for the heaviest patients,
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00:06:07,130 --> 00:06:10,730
those who are obese and
failing medical therapies.
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00:06:11,840 --> 00:06:16,760
Now if we turn to these
medicines a little bit, Wegovy,
95
00:06:16,761 --> 00:06:18,200
which is semaglutide,
96
00:06:18,860 --> 00:06:23,810
the same medication as in
ozempic that has a specific FDA
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00:06:23,820 --> 00:06:28,490
indication or approval to help
with weight loss in patients with
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00:06:28,491 --> 00:06:30,620
a BMI greater than 30,
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00:06:30,830 --> 00:06:35,390
so class one obesity or BMI greater than
100
00:06:35,391 --> 00:06:39,050
27 if the patient has hypertension,
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00:06:39,051 --> 00:06:43,820
type two diabetes or
hyperlipidemia. In addition,
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00:06:43,821 --> 00:06:45,170
and this is interesting,
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00:06:45,650 --> 00:06:49,820
there's also a specific
approval for pediatric patients,
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00:06:50,570 --> 00:06:53,870
which is a growing group
of overweight patients.
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00:06:54,080 --> 00:06:58,940
So for patients 12 and over who
are above the 95th percentile of
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00:06:58,941 --> 00:07:01,100
weight for their age and sex,
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00:07:01,460 --> 00:07:04,790
they likewise can be treated with Wegovy
108
00:07:06,320 --> 00:07:07,790
for weight loss.
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00:07:08,360 --> 00:07:12,470
Will insurance pay for the medication
and if not, how much does it cost?
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00:07:13,670 --> 00:07:18,620
This is a huge issue in what's going
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00:07:18,621 --> 00:07:22,970
on in this area right now. The list price,
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00:07:22,980 --> 00:07:27,030
so to speak, of a month's
supply of Ozempic is
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00:07:27,950 --> 00:07:29,840
$2,300
114
00:07:31,580 --> 00:07:33,440
and if you're a type two diabetic,
115
00:07:34,130 --> 00:07:37,940
your insurance will cover it according
to whatever the terms are of your
116
00:07:37,941 --> 00:07:39,170
prescription plan.
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00:07:40,610 --> 00:07:44,990
For weight loss coverage
is much more variable
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00:07:45,620 --> 00:07:50,270
and so six month course of
these medications adds up to
119
00:07:50,271 --> 00:07:51,560
quite a bit of money.
120
00:07:52,610 --> 00:07:56,840
People have looked at alternative
ways of getting their hands
121
00:07:56,870 --> 00:08:01,520
on semaglutide and other of
122
00:08:01,521 --> 00:08:02,450
these
123
00:08:04,160 --> 00:08:08,810
receptor block receptor agonists
and one way they've done that is by
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00:08:08,811 --> 00:08:12,590
going to compounding
pharmacies and that becomes
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00:08:13,610 --> 00:08:15,350
much less expensive,
126
00:08:15,470 --> 00:08:20,420
but you have to be sure that the pharmacy
has the adequate qualifications and
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00:08:20,421 --> 00:08:24,740
experience the proper
sourcing to prepare the
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00:08:24,741 --> 00:08:29,690
material to the standard
that the pharmaceutical
129
00:08:29,691 --> 00:08:30,980
material would be.
130
00:08:31,610 --> 00:08:33,140
What about adverse events?
131
00:08:33,860 --> 00:08:38,420
So there are a lot of minor GI
symptoms that patients experience,
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00:08:38,480 --> 00:08:40,610
nausea, abdominal cramping,
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00:08:40,611 --> 00:08:45,290
other things that are
largely GI in nature,
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00:08:45,291 --> 00:08:49,970
gastrointestinal, particularly
when they start the medications,
135
00:08:50,360 --> 00:08:54,620
those often resolve
after a few weeks on the
136
00:08:54,630 --> 00:08:55,620
medication.
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00:08:56,340 --> 00:09:01,020
But another issue is what happens
when you stop the medication.
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00:09:02,400 --> 00:09:07,110
Most patients will be on the medication
six months to achieve their weight loss
139
00:09:07,111 --> 00:09:10,920
goals and then begin
weaning off the medication.
140
00:09:12,480 --> 00:09:15,060
So there have been different
studies with different
141
00:09:16,560 --> 00:09:20,010
information about how
much rebound, for example,
142
00:09:20,020 --> 00:09:24,540
with Wegovy when that's stopped after
143
00:09:24,541 --> 00:09:27,960
finishing a weight loss period of time.
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00:09:29,910 --> 00:09:34,350
Recent study with Mounjaro
suggested a very small amount of
145
00:09:34,351 --> 00:09:36,600
rebound 5% in one year,
146
00:09:36,601 --> 00:09:41,100
but some of the experience with
Ozempic and Wegovy has been quite a bit
147
00:09:41,110 --> 00:09:43,050
more rebound than that,
148
00:09:43,620 --> 00:09:47,310
and that's similar to what happens
when we go on a diet and then stop
149
00:09:48,300 --> 00:09:53,010
usually your weight seesaw back
at least a little bit sometimes
150
00:09:53,070 --> 00:09:54,240
all the way back.
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00:09:55,620 --> 00:10:00,330
This seems to be less than all the way
based on everything that's been in all of
152
00:10:00,331 --> 00:10:03,150
the studies, but it's still not zero.
153
00:10:04,110 --> 00:10:06,510
Dr. Bass, before we wrap
up our discussion today,
154
00:10:06,511 --> 00:10:08,880
can you give our listeners
some parting takeaways?
155
00:10:09,960 --> 00:10:14,880
So this is a rapidly evolving field
and we will circle back and update
156
00:10:14,881 --> 00:10:16,830
for our listeners as needed.
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00:10:18,060 --> 00:10:19,950
All of the therapy options,
158
00:10:19,951 --> 00:10:24,120
both medical and surgical work
best with dietary counseling,
159
00:10:24,240 --> 00:10:28,350
exercise and support. It's
just like quitting smoking.
160
00:10:28,351 --> 00:10:31,080
It's really about lifestyle changes.
161
00:10:31,980 --> 00:10:33,750
The medications help with that,
162
00:10:34,170 --> 00:10:39,030
but support is really key to
have a program of weight loss
163
00:10:39,031 --> 00:10:41,040
not simply going on a medication.
164
00:10:42,810 --> 00:10:47,790
So if I look at what effect these
medications will have in the field of
165
00:10:47,791 --> 00:10:52,110
plastic surgery, I have a few thoughts.
166
00:10:54,990 --> 00:10:58,650
I don't think these medications are
really going to have a lot of impact on
167
00:10:58,660 --> 00:11:02,070
liposuction. Liposuction
is not for weight loss.
168
00:11:03,690 --> 00:11:08,370
Liposuction is designed to
take specific body shapes
169
00:11:08,460 --> 00:11:12,270
in particular ones that
don't diet and exercise well,
170
00:11:12,690 --> 00:11:17,550
so are not real weight loss
shapes and flatten those shapes
171
00:11:17,551 --> 00:11:18,930
off if they're made of fat.
172
00:11:19,710 --> 00:11:24,360
I also don't think that there'll be
a big impact with these medications.
173
00:11:24,360 --> 00:11:26,760
On body contouring procedures,
174
00:11:28,800 --> 00:11:33,360
a lot of the body contouring
procedures relate to skin as much as
175
00:11:33,361 --> 00:11:35,430
fat. In fact,
176
00:11:35,431 --> 00:11:40,350
in some ways we may see an increase in the
177
00:11:40,351 --> 00:11:42,180
need for body contouring,
178
00:11:43,020 --> 00:11:46,830
skin excisional procedures
like thigh lift,
179
00:11:46,831 --> 00:11:51,240
buttock lift and adominoplasty arm lift,
180
00:11:52,350 --> 00:11:55,180
breast lift and facelift,
181
00:11:55,270 --> 00:11:59,950
and all of these procedures
are typically needed in a good
182
00:11:59,951 --> 00:12:03,250
percentage of patients
after massive weight loss.
183
00:12:04,960 --> 00:12:09,730
I do think that these medications
will very likely supplant
184
00:12:09,820 --> 00:12:14,710
the existing medications that are FDA
approved to assist with weight loss
185
00:12:14,980 --> 00:12:19,840
due to the very high level of efficacy and
186
00:12:20,110 --> 00:12:23,950
for these already FDA
approved options like Wegovy
187
00:12:25,000 --> 00:12:29,860
and we're likely to get a few more
medications that are currently
188
00:12:29,861 --> 00:12:34,390
in late clinical trials
right now depending on how
the study data comes out and
189
00:12:34,391 --> 00:12:37,330
how FDA views it when they review it.
190
00:12:39,580 --> 00:12:41,380
Some of these newer medications,
191
00:12:41,381 --> 00:12:45,580
the amount of weight loss that's
being seen may be enough to
192
00:12:45,581 --> 00:12:48,910
reasonably supplant bariatric surgery,
193
00:12:49,360 --> 00:12:51,940
especially for patients with class one
194
00:12:51,941 --> 00:12:56,320
obesity, will likely have a growing
195
00:12:56,321 --> 00:13:00,970
role for overweight patients
in addition to obese
196
00:13:00,980 --> 00:13:04,090
patients taking these medications.
197
00:13:05,050 --> 00:13:07,360
That may be based on FDA approvals,
198
00:13:07,780 --> 00:13:11,110
it may be off-label use,
199
00:13:11,110 --> 00:13:13,540
use from compounding pharmacies
200
00:13:15,940 --> 00:13:20,230
by people who are just anxious
to get some means to assist them
201
00:13:20,760 --> 00:13:24,820
in their diet and exercise
program. Currently,
202
00:13:24,830 --> 00:13:29,560
insurance is limited in terms of
covering these medications for
203
00:13:29,561 --> 00:13:33,190
weight loss, especially if
you're overweight, not obese,
204
00:13:33,730 --> 00:13:37,810
but this will likely
slowly expand over time.
205
00:13:38,950 --> 00:13:43,390
I feel like the jury's still out on how
much rebound you get when you go off
206
00:13:43,391 --> 00:13:44,620
these medications,
207
00:13:44,621 --> 00:13:49,450
but I'm sure over the next few
years we'll see a lot of data to
208
00:13:49,510 --> 00:13:52,000
answer that question more definitively
209
00:13:53,980 --> 00:13:55,090
and honestly,
210
00:13:55,100 --> 00:14:00,040
rebound is something we see
after bariatric surgery so that
211
00:14:00,190 --> 00:14:04,750
there's no option that's
immune to rebound.
212
00:14:04,750 --> 00:14:05,740
At the end of the day,
213
00:14:05,740 --> 00:14:07,630
the other factor is the cost.
214
00:14:07,690 --> 00:14:12,370
I mean right now these
medications are the top several
215
00:14:12,371 --> 00:14:17,320
medications that are going to be
prescribed in all of the United States in
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00:14:17,321 --> 00:14:22,210
2023. But making it
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affordable,
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particularly where it's not
insurance covered and making sure
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there's an adequate supply of the
medication is probably the current
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biggest challenge to their routine
use. Those are all very nice points.
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And now I have an update
for our listeners.
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Since we originally
recorded this episode on
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November 8th, 2023, the FDA approved the
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medication in Mounjaro
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for the indication of weight loss.
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The generic name of the
medication is tirzepatide
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just as Ozempic is for diabetes
and the same medicine for
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obesity cells under a different
brand name, Wegovy, tirzepatide
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for weight loss will be marketed under
the brand name Zepbound. Tirzepatide
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is a GLP-1 and GIP receptor
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stimulator.
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And this may account for why the
study data showed more weight loss
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than Wegovy. In the study,
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up to 25% of body mass was lost over
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1.5 years at the highest dose.
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So on average in the study
that was 48 pounds of
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weight loss weight at a lower dose,
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an average of 34 pounds
of weight loss was seen.
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This is more than seen for Wegovy
maybe because of the double
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receptor effect.
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The indications are similar to Wegovy.
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It's indicated for
people with a BMI over 30
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or people with a BMI over 27 with
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some kind of cardiac or
pulmonary risk factor,
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hypertension type two
diabetes hyperlipidemia.
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We're still waiting to hear about
the rebound when going off the
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medication and the out-of-pocket
cost is expected to
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be about a thousand
dollars a month, currently.
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How health insurance companies
will choose to cover the medication
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is evolving and we'll keep you posted.
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Thank you Dr. Bass for sharing
your insight and expertise with us.
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as always.
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00:16:51,170 --> 00:16:53,930
Thank you for listening to the
Park Avenue Plastic Surgery Class
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00:16:53,940 --> 00:16:56,510
podcast. Follow us on Apple Podcasts,
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00:16:56,540 --> 00:16:58,610
write a review and share
the show with your friends.
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00:16:59,030 --> 00:17:02,120
Be sure to join us next time to avoid
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coming your way. If you want to
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00:17:05,690 --> 00:17:06,590
we'd love to hear from you.
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00:17:07,070 --> 00:17:11,570
Send us an email at podcast@drbass.net
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