Weight loss drugs are frequently in the news these days. Some new medications are specifically approved by the Food and Drug Administration (FDA) for diabetes, and others are specifically approved by the FDA for weight loss. You may have seen them advertised on TV.
In many cases, these drugs are part of an overall weight loss plan that may also include diet, exercise, and lifestyle changes, and they may often be a last resort for those who have tried other alternatives.
In this Q&A, Sophie A. Chrisomalis-Culver, MD, a specialist in internal medicine, explains who can benefit from these drugs and the experiences of her patients. She sees patients ranging in age from their 20s to those in their 80s for weight loss through Mount Sinai Virtual Primary Care.
Who is eligible for treatment with weight loss drugs such as Ozempic® and Wegovy®?
A lot of my patients have been trying to lose weight the good old-fashioned way with diet and exercise, but just can’t. To be a candidate for these drugs, you must have a Body Mass Index (BMI) over 27, along with other health issues such as hypertension, high cholesterol, diabetes, pre-diabetes, or you must have a BMI of 30 and above. You also must have tried a calorie-restricted diet, meaning under 1,200 calories per a day, and exercise 150 minutes of cardio per week for at least three to six months without success. We see many patients for consults about weight loss who have not yet reached this point, and others who have been at this point for most of their adult lives. We also consider patients who have an increased body fat percentage which their BMI may not reflect, but does impact their cardiovascular disease risk. Therefore, the BMI is simply a guide to determining eligibility for these medications and is ultimately patient dependent.
Sophie A. Chrisomalis-Culver, MD
Most of my patients are in their 30s or 40s. But I do have some in their 20s, and many over 50. Many of my patients are women who are post menopause and have trouble losing weight after they turned 50. And there are many women who have not been able lose weight they gained in pregnancy, though before they became pregnant their weight was normal.
Are the medications the primary therapy?
In addition to the medications, diet, exercise, and lifestyle are the foundational components of healthy living. We refer all our patients to a nutritionist and work towards more active lifestyles, but the medications are the key factor in how they are losing the weight. Most of the patients I see have tried everything to lose weight without success—but with these drugs, they are seeing success.
What are the different medications available, and how do they work?
The medications are a bit different. Ozempic and Wegovy are brand names for the generic drug, semaglutide. Ozempic is an FDA-approved injectable drug for diabetes, while Wegovy is approved for weight loss in patients who are not diabetic. These are called GLP-1 drugs because they mimic the action of a hormone called GLP-1 that controls blood sugar levels while decreasing appetite and slowing the digestive process.
Mounjaro® and Zepbound® are brand names for tirzepatide, which is a GLP-2 drug which means that it works on two receptors that stimulate two separate hormones that control blood sugar levels and curb appetite. Zepbound is FDA-approved for weight loss, while Mounjaro is approved for diabetes.
All of these brand names come in different formulations and strengths, which is why one brand name may be used for diabetes and another for weight loss. Ozempic is the drug that is most often in the news because it was the first to be used for weight loss. While it’s not FDA-approved for weight loss, physicians can prescribe it if a doctor determines it’s the best course of action for you. Most of our patients are taking Zepbound now due to shortages of the other formulations.
Are there risks to these weight loss medications?
With any medication, there are some risks. While taking into account each patients individual history, we also follow a specific set of clinical guidelines developed in collaboration with Mount Sinai’s Division of Endocrinology, Diabetes and Bone Disease to make sure that there are no contraindications for individual patients. The biggest ones are a personal or family history of pancreatitis, thyroid cancer, multiple endocrine neoplasia (MEN) syndromes, or endocrine cancers. If you are pregnant, planning on becoming pregnant, or breastfeeding, we would either pause or not prescribe these medications at that time.
In terms of side effects, the most common are gastrointestinal (such as nausea, vomiting, diarrhea constipation). We start patients off at the lowest effective dose and follow them closely throughout their weight loss journey. Side effects are usually tolerated at the lower dosages. Several of these medications work by slowing the digestive system so you feel full longer, and constipation can go along with that. Some patients may experience a change in bowel movement from a baseline of going every day to going four times a week instead. We encourage hydration, a high fiber diet, fiber supplements such as Metamucil®, and exercise to keep the gut moving. If patients are not having at least three bowel movements a week, we stop the medication or lower the dosage. Otherwise, a patient could be at risk for problems with their colon.
How often do you see patients for follow-up?
Initially, we see patients every four weeks, or sooner if they experience any side effects. We start at the lowest effective dose and then titrate up every four weeks until they reach a dose where they’re losing as much as one to two pounds a week. Some patients are able to lose weight on the lowest dose. Some patients plateau after two or three months, and we increase the dose. Others don’t lose any weight at all until they hit the higher dosages. Once we feel good about their treatment program, we may have a follow up visit every three months. But we need to follow up with everybody to make sure they are not losing too much weight or losing it too fast.
How do patients take these weight loss medications?
Most of these medications are a self injection. It’s a pen with a tiny needle, and all you feel is a pin-prick. Usually, you inject it in your belly or the lateral side of your upper leg, wherever you have more fat. The medication comes with an instruction manual with pictures, and it’s pretty self-explanatory. But we do have clinical pharmacists who offer video visits to walk patients through how to do it if they need assistance.
What results have you seen?
I’ve seen tremendous success with my patients. Not only from a physical standpoint, but also from an emotional and mental health perspective. It’s been life-changing for patients. Some of my patients were immobile, burdened with arthritis, and very uncomfortable in their day-to-day life. Many had sleep problems and were at high risk of cardiovascular disease due to conditions that come with obesity, such as high blood pressure, high cholesterol, or pre-diabetes.
Many had other issues with their health related to their obesity. It’s a slow process because the goal is one to two pounds a week, so it takes years to get the necessary weight off for some patients. Overall, it’s been amazing to watch their progress and see the transformation in so many facets of their lives. We are so grateful to finally have a tool that works to help treat obesity in the primary care setting, as much of preventative health is founded upon healthy habits, including maintaining a healthy weight or BMI.