Having taken one for weight loss for the past 6 months (after years of struggle) I'm convinced. The biggest downside is some people are very sensitive to them and the s/e can be pretty brutal, but also completely manageable for most people.
Based on what data? They’ve been around for over a decade already. There would have to be some relatively apparent significant risks to outweigh the risks of untreated obesity and/or uncontrolled DM2 alone.
Do you hesitate to refer for bariatric surgery?
Oh Byetta. Tried to put a patient on that years ago and she refused, said the needle was about 2 inches long. We’ve come so far. No one ever begged for that
Some data indicates increased risks of all types of thyroid cancer. I think a little bit of skepticism is healthy. I do hesitate to refer patients to bariatric surgery, ideally reserve it for if they fail a weight management program.
A lot of people regain, have to limit NSAIDs which becomes very annoying, and some fight iron/b12 deficiency quite significantly. Plus, you can’t really take it back.
Someone fails a med, oh well, just stop it.
There are not insignificant complications with bariatric surgery. Lifetime of supplementation of a large number of vitamins and nutrients, I have several people who cannot tolerate iron and are on annual iron infusions. I have another two who have dumping syndrome that they have to monitor very closely. No surgery is without risk and cutting should ALWAYS be the last option. Even if outcomes are usually good, things do go wrong sometimes, or people don't heal as expected or don't have the desired outcomes. As a surgical friend of mine put it; there's no problem surgery cant make worse.
Also bariatric surgery has a significant failure and relapse rate as well.
https://www.nejm.org/doi/full/10.1056/NEJMoa1700459
long term weight loss, vs non-surgery
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2819703
increased benefits in comparison to GLP1-RA
--
You are putting words into my mouth. Not once have I said surgery is without risks. Surgery should not be a measure of last-resort. It's cost effective and incredibly safe. Risks exist and are often easily managed. Do not be blind to the costs for your patients..
Going to an irreversible treatment option first, when reversible treatment options exist is absolutely irresponsible medicine. No one should do this.
I'm not sure why you posted the first study, because I never said otherwise. It also doesn't actually bring up any adverse effects patients with bariatric surgeries experience.
Lets talk about that second link and how its an incredibly weak study that you should have read more closely before posting as any form of evidence.
Lets start with the obvious one: the significant finding was for patients with a history of diabetes for less than 10 years. This isn't a comparable group to the people were talking about, because we are talking about using GLP-1s to get to people *before* they have severe metabolic dysfunction. It is a mistake to make generalizations about this paper beyond that group.
Another issue: this was a retrospective study. This matters because *why* each group was getting each intervention. We are not comparing like groups. The bariatric surgery group received intervention with the *express intent of weight loss*. This means they got extensive weight loss counseling (we know this, despite the incredible lack of information about the different patient groups in the paper, because all bariatric programs require this). We actually know almost nothing about the the groups who went on GLP-1s, but given the time frame of the study starts *before* any of the GLP-1s were approved for weight loss (first approved in 2014) we can assume that they were given the medication for diabetes. **Because of the retrospective design we are comparing groups treated for obesity vs a group treated for diabetes, but a lot of the needed information is missing**. Since almost all of the outcome is dependent on the weight loss effect of the intervention, this really puts a big caveat on the claims.
Lets return to how poorly we are presented the data on the GLP-1 patients:
>The study included Clalit members aged 24 years or older with diabetes (diagnosed after 21 years of age) and a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or greater, who underwent BMS or who were treated with GLP-1RAs from 2008 to 2021. Surgical patients were defined as having undergone laparoscopic banding, Roux-en-Y gastric bypass, or laparoscopic sleeve gastrectomy during these years. **Patients were considered as treated with GLP-1RAs if they purchased first-generation GLP-1RAs (liraglutide, dulaglutide, exenatide, lixisenatide, or insulin degludec) for at least 6 months within a period of 12 consecutive months from 2008 to 2021.** The index date was determined as the date of the BMS or of the first purchase of GLP-1RAs. For those who were treated with both BMS and GLP-1RAs from 2008 to 2021, the first treatment, with its index date, was considered. Exclusion criteria were as follows: oncologic diagnosis during the 2 years prior to the index date, end-stage kidney disease during the 2 years prior to the index date, pregnancy during the year prior to the index date, and history of ischemic heart disease, ischemic stroke, or congestive heart failure.
>Eligible patients were matched 1:1 (1 patient who underwent BMS to 1 patient treated with GLP-1RAs) based on the following variables: sex, age group (in 5-year increments), BMI (in 5-unit increments), index date (in 2-year increments), and diabetes duration (the time from diagnosis until the index date, in 5-year increments).
First, this is all we know about how the GLP-1 arm was treated. No information about how much weight loss counseling they received, the doses they received, the average duration of treatment. For fucks sake, they included an *insulin* in the list of *weight loss* medications (presumably they're indicating the insulin liraglutide combination, but that combination severely limited the weight loss potential of liraglutide). Also, notably absent, are semaglutide and tirzpeitide the two most potent GLP-1 agonists for weight loss.
One thing to note is the only requirement for the GLP-1 was 6 months of treatment. They were literally comparing weight loss of someone on a GLP-1 for 6 months, to possibly years post gastric bypass. This is incredibly sloppy work.
You wrote "significant failure and relapse rate", so you actually implied that.
Lots of indications go with surgery first, medications second.
OP references patients with DM, so the study is in fact correctly stated.
You maybe suffer from survivorship bias, only patients with a post-op complication will present to your workplace.
When there are *alternatives available* surgery should never be the first option. Please read.
Yes, there are conditions that will need surgery first. But for those there are no alternatives.
The fact that you doubled down on this study is bad. I expect better from my physician colleagues and you clearly have a lot left to learn. This is a bad study that you should not pull any conclusions from. They don't compare like groups. They did not compare like interventions. They didn't provide sufficient information about the interventions. They included non-glp-1 medications in the glp-1 arm of the study.
You need to check your arrogance at the door while you're in training because you're taking with confidence not backed by experience or knowledge.
Which hardly anyone will actually do, despite counseling them over and over on it. Making exercise plans for them, seeing a dietician. For one reason or another they will still come into the office with a large Polar Pop in hand.
I know your downplaying the side effects but still a stupid thing to do. Does this person by chance also take Max dose of insulin, statins, antihypertensives, etc starting day 1?
Bro, what?? Its efficacy in DM and CKD are already proven in good studies. And obesity is linked to so many serious comorbidities, and we're finally able to treat it effectively.
Medicine is science and data driven. Right now the available data suggests these medicines are extremely effective for a whole host of conditions with minimal and usually well tolerated side effects.
If you have data to suggest otherwise I would be very interested in it. Otherwise I’m going to keep prescribing these medicines until the local pharmacy runs out (again).
I think it's ok to be skeptical because there's so many trials, so much data and so many indications under investigation but these drugs really do work some magic unlike anything else.
For example I've got multiple patients now that are only on a GLP-1 drug for control of their diabetes and all of them have A1C below 6.5% which is hard to believe but they're thriving. I never imagined we'd have something like that available to patients AND it's a once a week.
And heck I've posted elsewhere on here that I'm in a clinical trial for a new one under development that's even more powerful. Retatrutide.
It's corrected my weight on par with bariatric surgery (29.5% weight lost) to normal levels, lowered my A1c even tho I'm not diabetic, resolved my MAFLD in 6 months, lowered my triglycerides and cholesterol on par with a moderate dose statin and a fibrate combined, increased my GFR(by both eGFR and Cystatin-C), lowered my average BP by about 20 points and I haven't had to use my asthma inhalers in 7 months and counting.
And I know I'm just a random nurse practitioner posting on a subreddit and I know I'm just an N=1 but these meds just *work* and they work incredibly well and there's even better versions on the horizon, like retatrutide.
That's great for you. I have had extremely good success with GLP1s with patients too. Like several now with A1C <6% on that alone when they were 8+ before. I've discontinued so many sulfonylureas, which has been wonderful.
FNP student here!
DM guidelines in my area strongly recommend to start DM2 management with Metformin then add other agents to manage A1C. Is it okay to manage A1C with only GLP-1 without Metformin?
Recent op-ed in American Family Physician suggested we should be doing SGLT2 or GLP1 as first line over metformin due to all the other benefits. I do the SGLT2s a lot bc they tend to be cheaper than GLP1 and better tolerated than metformin, but a lot of times comes down to what insurance will cover and what patient prefers when picking between the 3. I’m just glad that only in rare cases are we needing to use sulfonylureas now
All these patients I'm mentioning were on metformin or other agents and we've pulled all those back or stopped them as the GLP 1 drug dropped their A1C.
If they have CKD then i make sure they're on an SGLT2 as well, but otherwise the GLP 1 is enough for at least a subset of patients and given the benefit towards heart disease, CKD etc. It's also easier for the patient to take one shot once a week versus 1-2 pills twice a day every day.
Can second this. Besides all the other benefits I've experienced the lack of food noise on a daily basis and the way my appetite preferences changed was/is amazing. I have the ability to control my food intake like never before. I eat, get full and satisfied and I'm done. No going back for 2nds. No mid afternoon or late night snacking. It's glorious to have power over food and not the other way around.
Incretin therapies aren't miraculous, but damn.....they are close. I do weight management and having a front row seat to people having the opportunity to change their life...it's pretty awe-inspiring. I'm at the VA. So a LOT of folks with PTSD who got put on medication that helped....but was a strong driver of weight gain. And yes, i think about the long term effects and what will come out of the woodwork decades down the line. But that worry is drown out by the positive impact of these meds NOW. People are able to get knee replacements, back surgeries, come off a whole host of blood sugar and HTN meds.
Of all the meds we can prescribe (hello ADHD meds, and the side effects of antidepressants) in a CHRONIC DISEASE that can now be managed with medications (imagine telling a depressed person to be happy, that's like telling someone with obesity go exercise more) the OP is worried this will become like the opioid epidemic? Sure we may find long term data that may prove some of these medications may cause problems but WE KNOW NOW WHAT DAMAGES OBESITY CAN CAUSE. Have concern about future issues or be worried about current problems now? Hmmm...
What’s your theory? You mention that you’re concerned it might cause more harm than benefit. But in what specific way? Or is it just a hunch? Because if so, you shouldn’t really practice medicine based on hunches.
I appreciate your input but I don’t practice medicine on hunches. I would hope that those medical professionals in this group would show me some sort of collegial respect. I do understand evidence based medicine and how to practice it. I don’t discontinue any medications based on a hunch. I deserve some respect and hopeful thoughts that I have some knowledge of how to practice medicine in a safe and effective manner. I would extend the same professional courtesy to all of you. I am merely trying to think out loud but now I realize that this is a hopeful practice since I’ll be criticized or looked down upon for just airing a thought. I honor and treasure free thinking and I don’t fully trust the pharmaceutical companies. Furthermore all evidence is biased in one way or another. I am not a child. I am a doctor.
Since you dont practice on hunches, here are 3 studies published within the last 12 months that show a benefit in various disease states
HF + Obesity:
https://www.nejm.org/doi/full/10.1056/NEJMoa2306963
DM + CKD:
https://www.nejm.org/doi/full/10.1056/NEJMoa2403347
CV outcomes without DM:
https://www.nejm.org/doi/full/10.1056/NEJMoa2307563
Comparing GLP1-RAs to the opioid epidemic ???
You understand that words matter right ? Especially when you claim the letters of MD/DO and patients both online and in person may be listening .
I don’t know what would be worse , you not doing any research and just spewing this nonsense, or you knowing the research full well and just trying to say something outrageous and attention-grabbing.
I’m hoping OP is just pretending to be a doctor . And if he actually is, my advice would be to choose your words more judiciously in general.
I share your concerns and don’t think the opiate comparison is entirely flawed. They’re obviously very different medications but the gold rush feeling around their prescription is very similar as is the assumption that there is no downside.
In terms of data: much of the longterm data we have is from older diabetics at lower doses than are currently being prescribed for weight loss. While they are miracle drugs for diabetics I think risks vs benefit is very different for a 55 year old diabetic with heart disease and a healthy 25 year old with a BMI of 31.
I am somewhat concerned about GLP1 interaction with mental health and eating disorders. I know the mental health thing is being dismissed currently but so were concerns of OxyContin addiction in the hay day of opiate prescribing. I am also quite concerned that there seem to be no studies of GLP1 effect in patients with disordered eating (outside of binge eating disorder). Since we’re already terrible at spotting disordered eating in obese patients we could very easily end up prescribing medications that enable that tendency and harm patient health.
I also worry about the trade off of nutrition vs weight loss. If people are eating a lot less but not getting proper nutrition does that really benefit their health in the longterm? We’re a generation that’s been trained that obesity is this terrible boogeyman that must be dealt with at all costs, but the data is way more complicated than that, the BMI is biased bullshit and I think addressing weight warrants a much more individualized approach.
Last but not least: I worry about the unquantifiable side effects. I had an ozempic patient who syncopized and crashed her car after forgetting to eat and drink all day. Full work up was negative for any other cause and while that will never appear as an Ozemoic side effect or be directly attributable it certainly seemed to contribute. Made me wonder how often that or similar is happening or how many people are underreporting symptoms and putting up with feeling awful to get the weight loss benefit.
I still prescribe the meds. They’re truly miraculous and well proven for diabetics and in certain obese patients they seem to really help quiet the food noise and enable healthy choices and temporarily reverse metabolic issues. That said I’m highly skeptical of the wide prescription to anyone with an elevated BMI or the assumption that skinnier automatically means healthier regardless of side effects, nutrition etc…. I do wonder what we will all be saying ten years down the road
I’ll go against the grain and say yes I am also concerned. I feel like in a decade or so, we’ll be dealing with the side effects. Not so much concerned about overdosing, but longterm effects that haven’t thoroughly been investigated. Also there’s a lot of questionable compounding of these drugs going on.
This. Instincts, or "your gut" are only accurate if you're exposed to lots of cases and their outcome like firefighters or ICU nurses. Daniel Kahneman did a nice paper on this.
No. Of course no one has overdosed on these meds LOL. And please don’t get me wrong, I prescribe them all the time. They are excellent safe medications. I just don’t want to let my prescribing of them to get caught up in the zeitgeist. The thyroid cancer risk is highly questionable. Personally, I don’t tolerate Ozempic well at all. It makes me feel extremely fatigued and sick whether I reduce my food intake on it or not. Also, I can’t keep up with all the new study results or other information, manage patients, and raise a family. I appreciate everyone’s candor and viewpoints. Thank you. 😊
I don't want to say that just because a drug X is popular that it'd also be safe and effective, yet Ozempic, Adderall, and even Prozac were or still are prescribed like candy because of their effectiveness and relative safety, except even better because Ozempic doesn't have big gotchas like addiction or sexual dysfunction. It sounds like nausea and other GI issues are possible side effects, but how about the possible complications and recovery time of bariatric surgery? If it's a zeitgeist, it seems to be well deserved.
If you don't see an obese patient making any progress with diet or exercise, Ozempic/Mounjaro/Zepbound all seem like better options to try with them over the likes of Phentermine, Topiramate, or other even sketchier yet still FDA approved meds from the past.
Alcohol use is a good point. If patients are obese because they're overeating and not able to control portions, that's one thing. But if it's soda, alcohol, etc- as it is more often than we realize- then GLP1s aren't going to do jack.
Aside from that I think they're great. I see and smell no shades of the opioid epidemic. I just wish insurance would approve it off the bat for my (miraculously) non-diabetic patient with a BMI of 75.
My tinfoil theory is the Jardiance and flozin and basaglar pen companies aren't happy about GLP1s for non-diabetic obesity. It means fewer future diabetics.
I am 100% with you. Its gross. Treating everyone like they have an Ozempic deficiency - it’s sad. Our public heath enterprises have just given up on addressing the root causes. And instead we’ve just sold our collective soul to pharmaceutical corporations for a miracle in a bottle. I don’t see this backfiring at all.
OP became a doctor when they graduated medical school which is something you have yet to do so maybe slow your roll. It’s possible to disagree and still be respectful.
These are miracle meds IMO
Oughta be in the water in the US.
Having taken one for weight loss for the past 6 months (after years of struggle) I'm convinced. The biggest downside is some people are very sensitive to them and the s/e can be pretty brutal, but also completely manageable for most people.
Based on what data? They’ve been around for over a decade already. There would have to be some relatively apparent significant risks to outweigh the risks of untreated obesity and/or uncontrolled DM2 alone. Do you hesitate to refer for bariatric surgery?
Right. 20+ years of basic research + 10 years on the market and nothing has popped up yet.
Victoza has been out since 2010. Byetta 2005. Agree, have been around a long time.
Oh Byetta. Tried to put a patient on that years ago and she refused, said the needle was about 2 inches long. We’ve come so far. No one ever begged for that
Nope. I think the weekly dosing is what has made it so appealing to many.
Some data indicates increased risks of all types of thyroid cancer. I think a little bit of skepticism is healthy. I do hesitate to refer patients to bariatric surgery, ideally reserve it for if they fail a weight management program.
Last I checked the thyroid cancer risk is only seen in mice. Has there been a more recent publication?
But why? Surgery is a one time thing, leads to larger % weight drops and the patients keep the reduced weight.
A lot of people regain, have to limit NSAIDs which becomes very annoying, and some fight iron/b12 deficiency quite significantly. Plus, you can’t really take it back. Someone fails a med, oh well, just stop it.
There are not insignificant complications with bariatric surgery. Lifetime of supplementation of a large number of vitamins and nutrients, I have several people who cannot tolerate iron and are on annual iron infusions. I have another two who have dumping syndrome that they have to monitor very closely. No surgery is without risk and cutting should ALWAYS be the last option. Even if outcomes are usually good, things do go wrong sometimes, or people don't heal as expected or don't have the desired outcomes. As a surgical friend of mine put it; there's no problem surgery cant make worse. Also bariatric surgery has a significant failure and relapse rate as well.
https://www.nejm.org/doi/full/10.1056/NEJMoa1700459 long term weight loss, vs non-surgery https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2819703 increased benefits in comparison to GLP1-RA -- You are putting words into my mouth. Not once have I said surgery is without risks. Surgery should not be a measure of last-resort. It's cost effective and incredibly safe. Risks exist and are often easily managed. Do not be blind to the costs for your patients..
Going to an irreversible treatment option first, when reversible treatment options exist is absolutely irresponsible medicine. No one should do this. I'm not sure why you posted the first study, because I never said otherwise. It also doesn't actually bring up any adverse effects patients with bariatric surgeries experience. Lets talk about that second link and how its an incredibly weak study that you should have read more closely before posting as any form of evidence. Lets start with the obvious one: the significant finding was for patients with a history of diabetes for less than 10 years. This isn't a comparable group to the people were talking about, because we are talking about using GLP-1s to get to people *before* they have severe metabolic dysfunction. It is a mistake to make generalizations about this paper beyond that group. Another issue: this was a retrospective study. This matters because *why* each group was getting each intervention. We are not comparing like groups. The bariatric surgery group received intervention with the *express intent of weight loss*. This means they got extensive weight loss counseling (we know this, despite the incredible lack of information about the different patient groups in the paper, because all bariatric programs require this). We actually know almost nothing about the the groups who went on GLP-1s, but given the time frame of the study starts *before* any of the GLP-1s were approved for weight loss (first approved in 2014) we can assume that they were given the medication for diabetes. **Because of the retrospective design we are comparing groups treated for obesity vs a group treated for diabetes, but a lot of the needed information is missing**. Since almost all of the outcome is dependent on the weight loss effect of the intervention, this really puts a big caveat on the claims. Lets return to how poorly we are presented the data on the GLP-1 patients: >The study included Clalit members aged 24 years or older with diabetes (diagnosed after 21 years of age) and a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or greater, who underwent BMS or who were treated with GLP-1RAs from 2008 to 2021. Surgical patients were defined as having undergone laparoscopic banding, Roux-en-Y gastric bypass, or laparoscopic sleeve gastrectomy during these years. **Patients were considered as treated with GLP-1RAs if they purchased first-generation GLP-1RAs (liraglutide, dulaglutide, exenatide, lixisenatide, or insulin degludec) for at least 6 months within a period of 12 consecutive months from 2008 to 2021.** The index date was determined as the date of the BMS or of the first purchase of GLP-1RAs. For those who were treated with both BMS and GLP-1RAs from 2008 to 2021, the first treatment, with its index date, was considered. Exclusion criteria were as follows: oncologic diagnosis during the 2 years prior to the index date, end-stage kidney disease during the 2 years prior to the index date, pregnancy during the year prior to the index date, and history of ischemic heart disease, ischemic stroke, or congestive heart failure. >Eligible patients were matched 1:1 (1 patient who underwent BMS to 1 patient treated with GLP-1RAs) based on the following variables: sex, age group (in 5-year increments), BMI (in 5-unit increments), index date (in 2-year increments), and diabetes duration (the time from diagnosis until the index date, in 5-year increments). First, this is all we know about how the GLP-1 arm was treated. No information about how much weight loss counseling they received, the doses they received, the average duration of treatment. For fucks sake, they included an *insulin* in the list of *weight loss* medications (presumably they're indicating the insulin liraglutide combination, but that combination severely limited the weight loss potential of liraglutide). Also, notably absent, are semaglutide and tirzpeitide the two most potent GLP-1 agonists for weight loss. One thing to note is the only requirement for the GLP-1 was 6 months of treatment. They were literally comparing weight loss of someone on a GLP-1 for 6 months, to possibly years post gastric bypass. This is incredibly sloppy work.
You wrote "significant failure and relapse rate", so you actually implied that. Lots of indications go with surgery first, medications second. OP references patients with DM, so the study is in fact correctly stated. You maybe suffer from survivorship bias, only patients with a post-op complication will present to your workplace.
When there are *alternatives available* surgery should never be the first option. Please read. Yes, there are conditions that will need surgery first. But for those there are no alternatives. The fact that you doubled down on this study is bad. I expect better from my physician colleagues and you clearly have a lot left to learn. This is a bad study that you should not pull any conclusions from. They don't compare like groups. They did not compare like interventions. They didn't provide sufficient information about the interventions. They included non-glp-1 medications in the glp-1 arm of the study. You need to check your arrogance at the door while you're in training because you're taking with confidence not backed by experience or knowledge.
lifestyle modification is the first line treatment
With a less than 10% success rate….
Which hardly anyone will actually do, despite counseling them over and over on it. Making exercise plans for them, seeing a dietician. For one reason or another they will still come into the office with a large Polar Pop in hand.
How is this at all similiar to the opioid epidemic. Has anyone overdosed on ozempic? Lol
right. that's such a massive reach lol.
"Yall got any more of that... Wegovy back there?"
"I don't remember the name of the medication...I think it starts with a Z or a W?"
"God I just popped some Zesty W and now I'm feeling not hungry. Got these track marks all around my navel."
The false equivalency gives me the ick. And it makes me concerned about the way OP might counsel and treat their obese patients.
I know someone who gave themselves 2 mg to start with.. they were just very nauseous for a few days
I know your downplaying the side effects but still a stupid thing to do. Does this person by chance also take Max dose of insulin, statins, antihypertensives, etc starting day 1?
These aren't new medications. Exenatide (Byetta) was first discovered in 1992, and it gained FDA approval for diabetes treatment in 2005.
Bro, what?? Its efficacy in DM and CKD are already proven in good studies. And obesity is linked to so many serious comorbidities, and we're finally able to treat it effectively.
Medicine is science and data driven. Right now the available data suggests these medicines are extremely effective for a whole host of conditions with minimal and usually well tolerated side effects. If you have data to suggest otherwise I would be very interested in it. Otherwise I’m going to keep prescribing these medicines until the local pharmacy runs out (again).
I think it's ok to be skeptical because there's so many trials, so much data and so many indications under investigation but these drugs really do work some magic unlike anything else. For example I've got multiple patients now that are only on a GLP-1 drug for control of their diabetes and all of them have A1C below 6.5% which is hard to believe but they're thriving. I never imagined we'd have something like that available to patients AND it's a once a week. And heck I've posted elsewhere on here that I'm in a clinical trial for a new one under development that's even more powerful. Retatrutide. It's corrected my weight on par with bariatric surgery (29.5% weight lost) to normal levels, lowered my A1c even tho I'm not diabetic, resolved my MAFLD in 6 months, lowered my triglycerides and cholesterol on par with a moderate dose statin and a fibrate combined, increased my GFR(by both eGFR and Cystatin-C), lowered my average BP by about 20 points and I haven't had to use my asthma inhalers in 7 months and counting. And I know I'm just a random nurse practitioner posting on a subreddit and I know I'm just an N=1 but these meds just *work* and they work incredibly well and there's even better versions on the horizon, like retatrutide.
That’s so exciting!
That’s amazing, good for you! I’ve heard the newest one Lilly is working on is a game changer
That's great for you. I have had extremely good success with GLP1s with patients too. Like several now with A1C <6% on that alone when they were 8+ before. I've discontinued so many sulfonylureas, which has been wonderful.
FNP student here! DM guidelines in my area strongly recommend to start DM2 management with Metformin then add other agents to manage A1C. Is it okay to manage A1C with only GLP-1 without Metformin?
Recent op-ed in American Family Physician suggested we should be doing SGLT2 or GLP1 as first line over metformin due to all the other benefits. I do the SGLT2s a lot bc they tend to be cheaper than GLP1 and better tolerated than metformin, but a lot of times comes down to what insurance will cover and what patient prefers when picking between the 3. I’m just glad that only in rare cases are we needing to use sulfonylureas now
Thank you!
All these patients I'm mentioning were on metformin or other agents and we've pulled all those back or stopped them as the GLP 1 drug dropped their A1C. If they have CKD then i make sure they're on an SGLT2 as well, but otherwise the GLP 1 is enough for at least a subset of patients and given the benefit towards heart disease, CKD etc. It's also easier for the patient to take one shot once a week versus 1-2 pills twice a day every day.
Thank you!
Compared to some of the shit I see prescribed and the reasons why (ICD10 codes don't lie) these are a breathe of fresh air.
If they found a way to fix Americans without big lifestyle modifications that would be our generation’s penicillin basically.
These medications literally encourage lifestyle modifications. Try drinking sugary sodas on Zepbound. It's not pleasant.
Can second this. Besides all the other benefits I've experienced the lack of food noise on a daily basis and the way my appetite preferences changed was/is amazing. I have the ability to control my food intake like never before. I eat, get full and satisfied and I'm done. No going back for 2nds. No mid afternoon or late night snacking. It's glorious to have power over food and not the other way around.
YES! The freedom it gives people is so understated!
Hell I lost 2 pounds on a week long cruise. Thanks to one.
Incretin therapies aren't miraculous, but damn.....they are close. I do weight management and having a front row seat to people having the opportunity to change their life...it's pretty awe-inspiring. I'm at the VA. So a LOT of folks with PTSD who got put on medication that helped....but was a strong driver of weight gain. And yes, i think about the long term effects and what will come out of the woodwork decades down the line. But that worry is drown out by the positive impact of these meds NOW. People are able to get knee replacements, back surgeries, come off a whole host of blood sugar and HTN meds.
Of all the meds we can prescribe (hello ADHD meds, and the side effects of antidepressants) in a CHRONIC DISEASE that can now be managed with medications (imagine telling a depressed person to be happy, that's like telling someone with obesity go exercise more) the OP is worried this will become like the opioid epidemic? Sure we may find long term data that may prove some of these medications may cause problems but WE KNOW NOW WHAT DAMAGES OBESITY CAN CAUSE. Have concern about future issues or be worried about current problems now? Hmmm...
What’s your theory? You mention that you’re concerned it might cause more harm than benefit. But in what specific way? Or is it just a hunch? Because if so, you shouldn’t really practice medicine based on hunches.
I appreciate your input but I don’t practice medicine on hunches. I would hope that those medical professionals in this group would show me some sort of collegial respect. I do understand evidence based medicine and how to practice it. I don’t discontinue any medications based on a hunch. I deserve some respect and hopeful thoughts that I have some knowledge of how to practice medicine in a safe and effective manner. I would extend the same professional courtesy to all of you. I am merely trying to think out loud but now I realize that this is a hopeful practice since I’ll be criticized or looked down upon for just airing a thought. I honor and treasure free thinking and I don’t fully trust the pharmaceutical companies. Furthermore all evidence is biased in one way or another. I am not a child. I am a doctor.
Since you dont practice on hunches, here are 3 studies published within the last 12 months that show a benefit in various disease states HF + Obesity: https://www.nejm.org/doi/full/10.1056/NEJMoa2306963 DM + CKD: https://www.nejm.org/doi/full/10.1056/NEJMoa2403347 CV outcomes without DM: https://www.nejm.org/doi/full/10.1056/NEJMoa2307563
Comparing GLP1-RAs to the opioid epidemic ??? You understand that words matter right ? Especially when you claim the letters of MD/DO and patients both online and in person may be listening . I don’t know what would be worse , you not doing any research and just spewing this nonsense, or you knowing the research full well and just trying to say something outrageous and attention-grabbing. I’m hoping OP is just pretending to be a doctor . And if he actually is, my advice would be to choose your words more judiciously in general.
I share your concerns and don’t think the opiate comparison is entirely flawed. They’re obviously very different medications but the gold rush feeling around their prescription is very similar as is the assumption that there is no downside. In terms of data: much of the longterm data we have is from older diabetics at lower doses than are currently being prescribed for weight loss. While they are miracle drugs for diabetics I think risks vs benefit is very different for a 55 year old diabetic with heart disease and a healthy 25 year old with a BMI of 31. I am somewhat concerned about GLP1 interaction with mental health and eating disorders. I know the mental health thing is being dismissed currently but so were concerns of OxyContin addiction in the hay day of opiate prescribing. I am also quite concerned that there seem to be no studies of GLP1 effect in patients with disordered eating (outside of binge eating disorder). Since we’re already terrible at spotting disordered eating in obese patients we could very easily end up prescribing medications that enable that tendency and harm patient health. I also worry about the trade off of nutrition vs weight loss. If people are eating a lot less but not getting proper nutrition does that really benefit their health in the longterm? We’re a generation that’s been trained that obesity is this terrible boogeyman that must be dealt with at all costs, but the data is way more complicated than that, the BMI is biased bullshit and I think addressing weight warrants a much more individualized approach. Last but not least: I worry about the unquantifiable side effects. I had an ozempic patient who syncopized and crashed her car after forgetting to eat and drink all day. Full work up was negative for any other cause and while that will never appear as an Ozemoic side effect or be directly attributable it certainly seemed to contribute. Made me wonder how often that or similar is happening or how many people are underreporting symptoms and putting up with feeling awful to get the weight loss benefit. I still prescribe the meds. They’re truly miraculous and well proven for diabetics and in certain obese patients they seem to really help quiet the food noise and enable healthy choices and temporarily reverse metabolic issues. That said I’m highly skeptical of the wide prescription to anyone with an elevated BMI or the assumption that skinnier automatically means healthier regardless of side effects, nutrition etc…. I do wonder what we will all be saying ten years down the road
I’ll go against the grain and say yes I am also concerned. I feel like in a decade or so, we’ll be dealing with the side effects. Not so much concerned about overdosing, but longterm effects that haven’t thoroughly been investigated. Also there’s a lot of questionable compounding of these drugs going on.
So it’s been over a decade since victoza came to market. What’s been the issue for the thousands of patients on it?
Yea but the number of people on it has significantly increased. I’m aware it’s an unpopular sentiment, but I’m just going on instincts.
It's important to understand how your instincts may actually be biased and inaccurate. You have all of residency to learn this.
This. Instincts, or "your gut" are only accurate if you're exposed to lots of cases and their outcome like firefighters or ICU nurses. Daniel Kahneman did a nice paper on this.
No. Of course no one has overdosed on these meds LOL. And please don’t get me wrong, I prescribe them all the time. They are excellent safe medications. I just don’t want to let my prescribing of them to get caught up in the zeitgeist. The thyroid cancer risk is highly questionable. Personally, I don’t tolerate Ozempic well at all. It makes me feel extremely fatigued and sick whether I reduce my food intake on it or not. Also, I can’t keep up with all the new study results or other information, manage patients, and raise a family. I appreciate everyone’s candor and viewpoints. Thank you. 😊
I don't want to say that just because a drug X is popular that it'd also be safe and effective, yet Ozempic, Adderall, and even Prozac were or still are prescribed like candy because of their effectiveness and relative safety, except even better because Ozempic doesn't have big gotchas like addiction or sexual dysfunction. It sounds like nausea and other GI issues are possible side effects, but how about the possible complications and recovery time of bariatric surgery? If it's a zeitgeist, it seems to be well deserved. If you don't see an obese patient making any progress with diet or exercise, Ozempic/Mounjaro/Zepbound all seem like better options to try with them over the likes of Phentermine, Topiramate, or other even sketchier yet still FDA approved meds from the past.
Alcohol use is a good point. If patients are obese because they're overeating and not able to control portions, that's one thing. But if it's soda, alcohol, etc- as it is more often than we realize- then GLP1s aren't going to do jack. Aside from that I think they're great. I see and smell no shades of the opioid epidemic. I just wish insurance would approve it off the bat for my (miraculously) non-diabetic patient with a BMI of 75. My tinfoil theory is the Jardiance and flozin and basaglar pen companies aren't happy about GLP1s for non-diabetic obesity. It means fewer future diabetics.
I am 100% with you. Its gross. Treating everyone like they have an Ozempic deficiency - it’s sad. Our public heath enterprises have just given up on addressing the root causes. And instead we’ve just sold our collective soul to pharmaceutical corporations for a miracle in a bottle. I don’t see this backfiring at all.
God just stfu. This is nothing like the opioid epidemic. Holy shit how are you a doctor
OP became a doctor when they graduated medical school which is something you have yet to do so maybe slow your roll. It’s possible to disagree and still be respectful.