Weight Loss Revolution: Ozempic & Friends

PA055 Ozempic & Friends.txt
Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, a podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu, a clinical assistant at Bass plastic surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is Weight Loss Revolution: Ozempic and Friends. You've all heard of Ozempic and its role in weight loss, but I'm a little light on the details. If you'll pardon the pun. Fill me in, Dr. Bass, let's start off with some background.

Dr. Lawrence Bass (00:36):
There's group of medications which stimulate glucagon-like peptide one receptors or glucose dependent insulinotropic polypeptide receptors. So these receptors are called GLP-1 and GIP for short. They're very fancy names, but let me try to break it down. Glucagon along with insulin are the main hormones in the body used to regulate the level of glucose in the bloodstream. Glucagon-like peptides have multiple metabolic effects including stimulating secretion of insulin, delaying gastric emptying and inhibiting appetite. The medications are used to treat people with type two diabetes as an injection performed at home. The effects also work to limit caloric intake and have shown significant weight loss in these patients.

Doreen Wu (01:35):
What are the names of these medications?

Dr. Lawrence Bass (01:38):
Ozempic and Wegovy are names for semaglutide, which is a GLP-1, receptor agonist or stimulator. Ozempic is the name of the medicine, used to treat type two diabetes. Wegovy is the exact same medicine semaglutide that is FDA approved to treat obesity. Mounjaro, generically tirzepatide, is a newer medication that stimulates both GLP-1 and GIP receptors. There are older medications like Trulicity, Victoza, and Saxenda, which are self-administered daily as an injection rather than weekly like Ozempic, Wegovy and Mounjaro.

Doreen Wu (02:31):
And what kind of weight loss are we talking about here?

Dr. Lawrence Bass (02:34):
On average 15% and with some recent data with Mounjaro averaging 20% of body weight. So this means if you weigh 200 pounds you could slim down to 160 pounds over a typical six month course on the medicines.

Doreen Wu (02:53):
Dr. Bass, you said these medicines were used to help diabetics control their blood glucose levels. What is the role for weight loss?

Dr. Lawrence Bass (03:01):
Well, that's a great question and that's really where things are evolving. But first, let's look at what's going on in weight loss therapies, generally surgical weight loss, medical weight loss and so forth. Doctors typically characterize people's weight based on body mass index or BMI. This is a calculation made by inputting height and weight. It's an indicator rather than a direct measurement. For example, people who have a lot of muscles such as bodybuilder with very low body fat, they could weigh as much as someone who's overweight and has very little muscle and a lot of body fat, but they might both have the same BMI. So BMI is not absolute, but it's a good rule of thumb that physicians use. And CDC has definitions for what BMI corresponds with what state of your body weight. So currently if you're under 18.5 you're underweight. Now that used to be 20, but they decided we could be thinner and still be a normal body weight. And between 18.5 and 25 is normal, weight between 25 and 30 is overweight and 30 or over is obese. So 30 to 35 is class one obesity, 35 to 40 class two obesity and greater than or equal to 40 is class three obesity, what used to be called morbid obesity but now is termed extremely obese.

Doreen Wu (04:48):
So who in what ranges are candidates for these new medications?

Dr. Lawrence Bass (04:53):
Well, again, I'm going to back us up here and talk a little bit about bariatric surgery. So that's kind of become the gold standard for treating severe obesity. And the current standard is people with a BMI over 35 are candidates for bariatric surgery like gastric sleeve gastric bypass, people with a BMI over 30 with type two diabetes or who have failed attempts in more conservative measures are candidates, but this is shifting sand. There was some revision of the standards in 2022, but still these standards overall are based on the previous standards, which came from 1991 and in 1991 most of the bariatric surgery was being done open, big open incisions. Nowadays these procedures are almost always done laparoscopically and that creates much less risk and much less recovery time. So it's resulted in some revision, but still overall the surgery is for the heaviest patients, those who are obese and failing medical therapies.

(06:11):
Now if we turn to these medicines a little bit, Wegovy, which is semaglutide, the same medication as in ozempic that has a specific FDA indication or approval to help with weight loss in patients with a BMI greater than 30, so class one obesity or BMI greater than 27 if the patient has hypertension, type two diabetes or hyperlipidemia. In addition, and this is interesting, there's also a specific approval for pediatric patients, which is a growing group of overweight patients. So for patients 12 and over who are above the 95th percentile of weight for their age and sex, they likewise can be treated with Wegovy for weight loss.

Doreen Wu (07:08):
Will insurance pay for the medication and if not, how much does it cost?

Dr. Lawrence Bass (07:13):
This is a huge issue in what's going on in this area right now. The list price, so to speak, of a month's supply of Ozempic is $2,300 and if you're a type two diabetic, your insurance will cover it according to whatever the terms are of your prescription plan. For weight loss coverage is much more variable and so six month course of these medications adds up to quite a bit of money. People have looked at alternative ways of getting their hands on semaglutide and other of these receptor block receptor agonists and one way they've done that is by going to compounding pharmacies and that becomes much less expensive, but you have to be sure that the pharmacy has the adequate qualifications and experience the proper sourcing to prepare the material to the standard that the pharmaceutical material would be.

Doreen Wu (08:31):
What about adverse events?

Dr. Lawrence Bass (08:33):
So there are a lot of minor GI symptoms that patients experience, nausea, abdominal cramping, other things that are largely GI in nature, gastrointestinal, particularly when they start the medications, those often resolve after a few weeks on the medication. But another issue is what happens when you stop the medication. Most patients will be on the medication six months to achieve their weight loss goals and then begin weaning off the medication. So there have been different studies with different information about how much rebound, for example, with Wegovy when that's stopped after finishing a weight loss period of time. Recent study with Mounjaro suggested a very small amount of rebound 5% in one year, but some of the experience with Ozempic and Wegovy has been quite a bit more rebound than that, and that's similar to what happens when we go on a diet and then stop usually your weight seesaw back at least a little bit sometimes all the way back. This seems to be less than all the way based on everything that's been in all of the studies, but it's still not zero.

Doreen Wu (10:04):
Dr. Bass, before we wrap up our discussion today, can you give our listeners some parting takeaways?

Dr. Lawrence Bass (10:09):
So this is a rapidly evolving field and we will circle back and update for our listeners as needed. All of the therapy options, both medical and surgical work best with dietary counseling, exercise and support. It's just like quitting smoking. It's really about lifestyle changes. The medications help with that, but support is really key to have a program of weight loss not simply going on a medication. So if I look at what effect these medications will have in the field of plastic surgery, I have a few thoughts. I don't think these medications are really going to have a lot of impact on liposuction. Liposuction is not for weight loss. Liposuction is designed to take specific body shapes in particular ones that don't diet and exercise well, so are not real weight loss shapes and flatten those shapes off if they're made of fat. I also don't think that there'll be a big impact with these medications.

(11:24):
On body contouring procedures, a lot of the body contouring procedures relate to skin as much as fat. In fact, in some ways we may see an increase in the need for body contouring, skin excisional procedures like thigh lift, buttock lift and adominoplasty arm lift, breast lift and facelift, and all of these procedures are typically needed in a good percentage of patients after massive weight loss. I do think that these medications will very likely supplant the existing medications that are FDA approved to assist with weight loss due to the very high level of efficacy and for these already FDA approved options like Wegovy and we're likely to get a few more medications that are currently in late clinical trials right now depending on how the study data comes out and how FDA views it when they review it.

(12:39):
Some of these newer medications, the amount of weight loss that's being seen may be enough to reasonably supplant bariatric surgery, especially for patients with class one obesity, will likely have a growing role for overweight patients in addition to obese patients taking these medications. That may be based on FDA approvals, it may be off-label use, use from compounding pharmacies by people who are just anxious to get some means to assist them in their diet and exercise program. Currently, insurance is limited in terms of covering these medications for weight loss, especially if you're overweight, not obese, but this will likely slowly expand over time. I feel like the jury's still out on how much rebound you get when you go off these medications, but I'm sure over the next few years we'll see a lot of data to answer that question more definitively and honestly, rebound is something we see after bariatric surgery so that there's no option that's immune to rebound. At the end of the day, the other factor is the cost. I mean right now these medications are the top several medications that are going to be prescribed in all of the United States in 2023. But making it affordable, particularly where it's not insurance covered and making sure there's an adequate supply of the medication is probably the current biggest challenge to their routine use. Those are all very nice points. And now I have an update for our listeners. Since we originally recorded this episode on November 8th, 2023, the FDA approved the medication in Mounjaro for the indication of weight loss. The generic name of the medication is tirzepatide just as Ozempic is for diabetes and the same medicine for obesity cells under a different brand name, Wegovy, tirzepatide for weight loss will be marketed under the brand name Zepbound. Tirzepatide is a GLP-1 and GIP receptor stimulator. And this may account for why the study data showed more weight loss than Wegovy.

(15:33):
In the study, up to 25% of body mass was lost over 1.5 years at the highest dose. So on average in the study that was 48 pounds of weight loss weight at a lower dose, an average of 34 pounds of weight loss was seen. This is more than seen for Wegovy maybe because of the double receptor effect. The indications are similar to Wegovy. It's indicated for people with a BMI over 30 or people with a BMI over 27 with some kind of cardiac or pulmonary risk factor, hypertension type two diabetes hyperlipidemia. We're still waiting to hear about the rebound when going off the medication and the out-of-pocket cost is expected to be about a thousand dollars a month, currently. How health insurance companies will choose to cover the medication is evolving and we'll keep you posted.

Doreen Wu (16:46):
Thank you Dr. Bass for sharing your insight and expertise with us. as always. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram at @drbassnyc.