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Weight loss medications (part 1)

weight loss Jul 06, 2022

At Real Life Medicine, we love lifestyle medicine. Lifestyle medicine is where you can use lifestyle interventions to not only prevent disease but also treat it.

But sometimes lifestyle isn’t enough.

This was evident recently when Dr Mary developed gestational diabetes, despite being on a low carb lifestyle. She needed to take some insulin overnight to manage her overnight blood glucose levels. This is not a failure.

Lifestyle changes and medications are not an either /or. They can work synergistically.

Using lifestyle intervention can mean that the dose of medication required is lower so less risk of side effects.

So, let’s discuss some of the medications that can be useful in weight management.

Ozempic (Semaglutide)

What is Ozempic?

Ozempic (Semaglutide) is a medication that is injected once per week.

It works by mimicking one of the gut hormones also called incretin hormones. The fancy name of this class of medications is a glucagon-like peptide 1 or GLP-1 analogue.

Using Ozempic causes your stomach to empty more slowly.

This makes you feel fuller.

It also lowers the insulin spike i.e. flattens the curve and as high insulin blocks fat break down, this is a good thing.

Ozempic also works at a brain level to reduce appetite, assist increase satiety and decrease food cravings.  

Who is Ozempic for?

Semaglutide is not currently registered for weight management in Australia so its use is considered “off label”. This does not mean that it is unsafe to use in weight management, just that it has not been approved by the TGA (Therapeutic Goods Administration) for this purpose. It is currently approved for use in diabetes only.  Another medication of the same drug class, liraglutide (Saxenda), which requires daily injection, is already used in Australia for weight management. Ozempic is used extensively overseas for weight management under the name Wegovy and at a higher dose.

As with all medications, there are potential side effects and these need to be taken into consideration. The majority of people who commence Ozempic will need to take it for a minimum of 5 years and possibly for life.

Ozempic is effective for people with;

  •    Obesity
  •    Type 2 diabetes
  •    Pre-diabetes
  •    Insulin resistance
  •    Metabolic syndrome
  •    PCOS
  •    Insulin resistance

Who should not use Ozempic

Important conditions to discuss with your doctor BEFORE starting Ozempic

  •    Pregnant, planning to become pregnant or breastfeeding. Ozempic is contraindicated here and must be ceased for 3 months before becoming pregnant
  •    Gallstones or gallbladder disease
  •    History of pancreatitis
  •    Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2) – either personally, or a family history

How long should you use Ozempic?

The studies indicate that people who lose weight using Ozempic are at high risk of weight regain once it is stopped. The NPS suggests a minimum of 5 years to allow for adjustment of the weight set point.  Not everyone will need this but it is an important consideration

How do you use it?

Semaglutide is injected once a week, on the same day each week, at any time of day, with or without meals. It is administered as a subcutaneous injection into the abdomen or thigh. The day of weekly administration can be changed if necessary as long as the time between two doses is at least 3 days (>72hours).  If you miss your dose by more than 5 days you should discuss it with your doctor. 

The starting dose is 0.25mg once a week. – this is continued for a minimum of 4 weeks. This is to avoid the side effects. Some people get weight loss with this dose but many don’t so don’t be too disappointed.

After 4 weeks it can be increased to 0.5mg once a week.

If required, after at least another 4 weeks, it can be increased to 1mg once a week.

There is no need to go up a dose if weight loss is occurring. As with all medications we are aiming for the lowest effective dose.

Do not increase the dose if you have significant side effects. Sometimes dose splitting can be done but this needs to be in consultation with your doctor.

*Tip for new users.

There are 2 caps on the needle. A big cap and then a smaller cap. It is not used in the same way as an EpiPen, more like insulin. You need to dial up your dose and then inject 

What are the common side effects? 

Common adverse effects are;

  •    nausea
  •    vomiting
  •    reflux
  •    diarrhoea
  •    constipation 

These symptoms vary in severity between patients but generally get better with continued use.

Other people have noticed headaches and lethargy.

*Tips for new users

  •    Do not be tempted to override your fullness by finishing your meal. This can result in severe vomiting or diarrhoea.
  •    Drink plenty of water to help with constipation. We have an article on constipation for low carb and keto which is also useful for Ozempic users. Read the article here.
  •    Prioritise your protein. As people have reduced appetite, they can become malnourished (I know seems weird). Weight loss needs to be done in a healthy way for your body and your body needs protein to function at every level. Learn more about your protein requirements here.

What are the serious side effects of using Semaglutide?

Malnutrition - This can occur when people don’t eat enough protein. If people have a lot of nausea, eating protein can be difficult. You may need a multivitamin and use a protein powder.

Pancreatitis - This causes severe central abdominal pain. Please seek immediate health care advice.

Gall stones - This can be as a result of rapid weight loss and also results in severe upper abdominal pain.

Hypoglycaemia (Low blood sugar) - This is most commonly seen in people taking medication for type 2 diabetes or insulin. Also, be mindful if you are taking Berberine with Ozempic as hypoglycemia has been reported here too.

 *Signs of low blood glucose include dizziness, lightheadedness, blurred vision, anxiety, irritability, mood changes, sweating, slurred speech, hunger, confusion, drowsiness, shakiness, weakness, headache, fast heartbeat and feeling jittery.

Dehydration - Diarrhoea, nausea and vomiting may cause a loss of fluids (dehydration). It is important to drink fluids to help reduce your chance of dehydration. If you have underlying kidney conditions this is even more important.

Changes in vision - Surprisingly there appears to be a risk of worsening diabetic retinopathy Discuss with your doctor if you have changes in vision during treatment.

Serious allergic reactions - Stop using Ozempic and seek urgent medical help if you have any symptoms of a serious allergic reaction, including swelling of your face, lips, tongue or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heartbeat.

Possible thyroid tumours, including cancer - Please discuss with your doctor if you develop a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath as these may be symptoms of thyroid cancer. In studies with rodents, Ozempic and medicines that work like Ozempic caused thyroid tumours, including thyroid cancer. It is not known if Ozempic will cause thyroid tumours or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.  

How much weight should you lose on Ozempic?

Below are some of the trial results. There are 3 things to consider with these results;

  1.  With any medications, we have people who are hyper-responders and non-responders. Hyper responders have results above the average result. Non-responders are people for whom the medication had no or negligible effect.
  2.  The lifestyle intervention is not a low carbohydrate intervention. We would expect to see a bigger weight loss in people who also adopt a low carb lifestyle
  3.  The dose used is 2.4mg, whereas the current dose available in Australia is 1mg 

Trial results

STEP 1 trial (2021) 1961 people (Semaglutide + lifestyle change vs lifestyle change alone) for weight reduction in patients without diabetes. Average BMI 38, average age 47, approx. 75% women

-   Participants received 2.4mg Semaglutide weekly for 68 weeks or placebo. 

-   Semaglutide recipients achieved 16.9% weight loss compared to 2.4% weight loss in the placebo group. 

-   86.4% of Semaglutide recipients achieved 5% weight loss compared to 31.5% in the placebo group.

STEP 8 trial (2022) compared Semaglutide with liraglutide (Saxenda) in weight management over 52 weeks - found significantly greater weight loss on Semaglutide vs Saxenda (average 15.3 kg vs 6.8 kg)-again noting the dose for Ozempic was 2.4mg

How much does Ozempic cost in Australia?

Ozempic is not on the PBS for weight loss. It is on the PBS for people with type 2 diabetes but under strict criteria. It is unlikely that any weight loss medications will be subsidised on the PBS. As mentioned the majority of people will need to be on Ozempic for 5 plus years so cost is an important consideration.

Ozempic 2mg in 1.5ml pen administers 0.25 and 0.5mg doses. $132 per pen

This gives you 8 doses at 0.25mg a week or 4 doses at 0.5mg

Ozempic 4mg in 3ml pen administers 1mg doses. $132 per pen

This will give you 4 doses of 1mg.

The future of Ozempic in Australia

At the writing of this article, there is an Australia-wide shortage of medication. The TGA has asked pharmacies to prioritise people with type 2 diabetes.

The shortage is causing much uncertainty for patients and it is hoped it will be resolved soon.

The TGA is likely to approve Semaglutide for weight loss under the label Wegovy. It means that higher doses like those used in the trial will be available. It will also cost more.

If you would like to discuss using Ozempic as part of your real health and weight loss journey, you can book an online appointment with Dr Lucy to discuss this here.

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