Stan and Clarence chat with Dr. Sarah Molasky - a local pharmacist - about weight loss medications.Join the conversation at healthchatterpodcast.comBrought to you in support of Hue-MAN, who is Creating Healthy Communities through Innovative Partnerships.More about their work can be found at http://huemanpartnership.org/
Hello, everybody. Welcome to Health Chatter. Today's show is on weight loss drugs, which is a really a hot topic. And we have a great guest with us. We'll get to her in just a moment. We have a great crew that always helps us do our illustrious shows. We have Maddy Levine-Wolf, Aaron Collins, Deandra Howard, who help us with our research, our production team.
manager is Matthew Campbell, who gets all the shows out in beautiful form. And then, of course, there's Sheridan Nygaard, who's actually helping us today with our recording, but also she is one of our researchers and also helps us with marketing. So thank you to you guys. You're great. Then, of course, there's Clarence Jones, And he and I are a great tag team and we enjoy working together.
So Clarence, it's always great to have you on. And again, our sponsor is Human Partnership. And they're a great community health organization. Do wonderful work in the community to help all of us address all the various different health issues that we all face. Check them out at humanpartnership.org. Check us out at healthchatterpodcast.org.
I'm Stan Shandling, one of the hosts, along with Clarence. And we can get on with our show. Clarence, I'll let you introduce our wonderful guest for the day.
Thank you, Stan. This is one of those times where I'm really excited about Health Chatter and the podcast that we're doing because of the way in which we seek out treasures in our community who are people that are doing things that are noteworthy and that we should be sharing information with. And today we have a wonderful guest, Vissera Malaski, who is a pharmacist.
She has served patients in North Minneapolis for eight years. first as an intern, and then later as a pharmacist. And she is passionate about culturally competent care, addressing healthcare disparities, and focusing on evidence-based therapies.
And I think that you're going to find out as we start talking with her, because as you just said, Sam, we are talking about this research for weight loss drugs. And it's really been a big issue. We were working with MDH, and they were talking about childhood obesity. And we know that this thing is just blowing up.
And so we're excited that we have the opportunity on Health Chatter to be able to enter into this conversation. So welcome, Ms. Sarah. And why don't you tell us a little bit about yourself so our listeners can get to know you.
Yeah, so I have been in pharmacy since I believe 2011, 2012 as a technician and eventually became a pharmacist. I tried out different types of pharmacy, but my passion was community pharmacy. which is not generally what pharmacy schools want you to go into. They want you to go into hospital or research or more clinical care, which is more prestigious.
But I really love working with people directly and building relationships with people. And I've been a pharmacist on Northside for almost five years. In July, it'll be five years that I'll have been a pharmacist in Northside. So really happy serving the community I serve and I wouldn't do anything else.
You know, interesting enough, though, Sarah, when we started talking about this whole issue around weight loss drugs, your name came up. And, you know, whenever I mention your name, people are like, oh, yeah, yeah, yeah, yeah, we need to talk to Sarah. So we're excited to have you. And so with that, I am going to let our prober, Mr. Stan, start with the first question for you.
So, Sarah, you know, it seems to me, you know, you kind of hear about these weight loss drugs. And, you know, our research crew has done, you know, some great background research for us. So give us a little bit of history on this. You know, more than anything, it's like all of a sudden it kind of hit the scene. And it almost seemed at least,
to me as a healthcare professional, is almost like it came across as almost like a fad. Something, oh my God, you know, wow, this is something I could just take and I don't have to worry about getting fat or obese or whatever. So help us with that kind of conversation and then also the history of it a little bit.
Yeah, so historically speaking, weight loss drugs have been around for decades, right? And possibly longer if we go back into really old school pharmacy where you had tinctures and all of that. But in terms of government recognized weight loss medications, they started out as stimulants. And so stimulants can include things like caffeine.
Because caffeine and other stimulants have a side effect of appetite suppression. So this was based on the idea that weight gain was solely due to overconsumption of calories. Is that medically accurate? Not necessarily. Everybody has very different bodies. And so the cause for weight gain can be varied. It can be medical. It can be a medication that's causing it.
interaction with another medication, certain types of foods. So it's really dependent on each person, but the original types of weight loss medications were stimulants. So they would make people feel very energetic. They might move around more. It would raise their heart rate and blood pressure, but also it might make them feel like eating less food.
And that's kind of been the main sorts of therapies we've had. There's a lot of over-the-counter weight loss medications that use the same exact concept, including ones that are still around today. I never recommend them to my patients because I think they're trash.
They have a lot of side effects that are really problematic, especially for patients who already have risks for heart disease or where high blood pressure can cause a lot more health issues for them. So then came in the Other therapies like bupropion, topiramate, fentramine, these are ones that, again, are meant to suppress craving or suppress appetite.
So then we have diabetic injectables, which are called GLP-1s or glucagon-like peptide 1 receptor agonists. It's just a fancy way of saying it gloms onto a certain receptor in our body that tells our body to make more insulin to bring down our blood sugar. And it also can get that same receptor in our brain, but it tells it, hey, we're actually full. We don't have to eat more.
So it has a dual action to make us potentially lose weight. This was not developed as a weight loss drug. The first JLP1 that was approved in America was Biada, which was a two-time-a-day injectable. It's still used today, but less often just because adherence isn't great, right? Not many people want to inject themselves twice a day if they have the option of once a day.
So then in comes Victoza, which was a once a day dosing drug. And that seemed to show more efficacy for certain types of important health issues that many diabetics face. And that includes, you know, heart health and potentially kidney health. And then you got once a week ones as well. And the big one that we hear about is Ozempic, right?
That's the trendy one that you've been hearing about with Hollywood stars injecting Ozempic to lose their seven extra pounds or whatever. And that has really been a trip in retail pharmacy because my patients who are diabetic need that medication. And there were months where I could not get that medication in the correct dose to my patients.
There is first a period of time where the fancy special needle they used for that one, because Ozempic uses a different needle than the typical diabetes pens do, they couldn't get that needle in. So the medication was in stock, but they couldn't get the medication out to patients because they didn't have enough of the needle because of shortages.
So I already got to see that shortage impact my diabetic patients. But then we got Hollywood stars starting to talk about how they're using Ozempic to lose weight. And I do have friends who live in the L.A. area who said everyone's talking about Ozempic. This is whether they're in health care or not, they're talking about it. So it really has become a trend.
And I think part of it is social media, which is a double edged sword. Right. People can become aware of really important things like some people may find out, oh, you know, that health problem I've been having that sounds exactly what this like what this person is describing. I'm going to talk to my doctor about it. That's great.
But when it comes to, oh, this person has lost weight using this drug, I want to lose weight using this drug. That's where we get a really big problem. And Ozempic technically is not meant to be used for weight loss. It is meant to be used for diabetes.
But of course, when the drug manufacturer realized there was a larger weight loss component than many other medications in that same class, they applied for a patent to have it approved for weight loss specifically and created a separate product called Wagovi, which is literally the same thing, but in a slightly different dose. Eventually.
Three of the doses are actually the same between Ozempic and Wegovy. And so those have really taken flight. But Wegovy is on constant shortage. And in case anyone's wondering, no, my pharmacy does not have it in stock. Please don't call. We literally field 10 plus calls a day just of people asking if we have certain types of Wegovy in stock. We don't. This is a nationwide shortage.
And then there's one other injectable that came out more recently that people were really excited about both for the weight loss aspect, but also for the glucose control aspect. And that was Terzepatide or Munjaro. And Mujaro is a dual action medication. It is a GLP-1, just like Ozempic or Victoza or Biada, but it also contains GIP, which has like seven different technical names.
But essentially what it does is when the blood sugar is getting too low, it taps on the liver and says, hey, can you just produce a little bit more sugar just so we can stay balanced? And so it's cool because it responds to what's actually going on in the body and tries to prevent really, really low blood sugar, which in diabetics can be very dangerous. It's called hypoglycemia.
And if your blood sugar gets too low and your liver is not being responsive and pumping out more sugar, you can pass out or have other health issues. So manjaro is really interesting, but also has much higher weight loss than sugar. you know, Ozempic did. And so that's now like the, the star when it comes to weight loss meds.
And again, we also are dealing with a shortage of Moonjaro and please do not call my pharmacy to ask if I have it in stock because no.
All right. So let me, let me ask you a quick follow-up clearance. Um, First of all, for our listening, this isn't an over-the-counter medication. It's got to be prescribed. So give me a little bit of a sense of who's prescribing it and for what specific reason? very specific, not just, is there a health condition that has to be linked with it? And then the other one that I was thinking about is,
Is it higher risk for certain ages? You know, like if you're over, say, like 65, for instance. Okay, so first of all, prescribing and for what specifically? Because like you said, we have had weight loss medications before. So why this now?
Yeah, so I mean, in terms of the why this now for weight loss specifically, because they work. Right? They work with caveats. They work in certain patients with certain types of obesity and levels of obesity.
They also work really well for people with diabetes or prediabetes and for some people with insulin resistance, which is a kind of umbrella term for people whose bodies don't, the cells in their bodies aren't responding to the message the insulin is sending, which is, hey, here's sugar, store it, use it as fuel. And the muscle cells will go, okay, we'll take in more sugar and use it up.
Well, if someone's insulin resistant, the body, the pancreas is sending out all this insulin being like, hey, there's a lot of sugar in the blood. Let's bring it in. And their body isn't doing it. So for some people who are insulin resistant, drugs like this can potentially be somewhat helpful. Although I do have one medication I'll talk about that is much more helpful with that later.
That is sometimes used for weight loss. But it works and it works relatively quickly. And when it comes to weight loss... It's very difficult for people to see results from weight loss when it comes to doing lifestyle remedies like changing your diet, exercising more. Those are things that are important, but they take a really long time for you to notice something.
Whereas with these injectables, a lot of people are seeing results much more quickly, like say in a month or in two months, they're noticing, oh, I have way less of an appetite.
So for people who, I would argue that a prescriber who's doing their due diligence and really being picky about what patient they're giving this to, they're choosing patients whose BMI is very high because technically I have a BMI of 30 right now. So I qualify for Wigovi. I'm not going to do it, but I technically qualify.
But doctors and nurse practitioners and PAs who are being more diligent will do it for people who are a certain size. whose health would likely support it, who don't have pancreatic issues or thyroid issues that potentially might be concerning with these kinds of medications.
And also for patients who have diabetes or prediabetes, then the Ozempic side of things might be considered appropriate because, again, Ozempic is supposed to be for diabetics, right?
Yeah.
Unfortunately, what I'm actually seeing in practice is very different from that. I am seeing patients who do not have diabetes or prediabetes being prescribed, you know, Monjaro and Ozempic and When I get these prescriptions, I have to call the doctor and say, you know, this isn't really, that's not what this is prescribed for.
I have patients on my wait list to get this medication who are actually diabetics. So I'm going to reserve this for my patients. And that's kind of a tough discussion to have with prescribers because some prescribers don't like when pharmacists contradict them, but I'm going to prioritize my patients first.
So they're definitely, whenever there's an opportunity to make money, there will be a small number of people who will take advantage of that because they don't care about patients the way most prescribers do. And unfortunately, that small group is then prescribing to people who just want to lose a small amount of weight. Well, I shouldn't say small because everything's relative, right?
An amount of weight that isn't necessarily representative of what kind of weight loss these medications were
So Clarence, I know you've got some thoughts here.
I want to know from Sarah, I love this conversation, but I want to know from you, what is your community conversation with people who come to you around weight loss drugs? What do you say to the community?
Yeah, so it really depends on the person, of course. But if the person comes up to me saying, you know, I've been doing all these things to lose weight and nothing's working, I really want to try one of these injectables. Obviously, the first thing I say is you need to talk to your doctor about it.
But another first line thing that I tell patients is, have you ever spoken to a registered dietitian? And that's really important because first of all, nutritionists and dietitians are two different things. You can be a registered dietitian and still be a nutritionist. But if I like literally anyone can call themselves a nutritionist. and get away with it.
Like I could call myself a nutritionist online, right? I have no credentials, but you don't need them to call yourself a nutritionist. To be a registered dietitian in America, you need a certain set of schooling. So I tell my patients, talk to your doctor, right?
Your clinic or whatever, and ask them if you can have an appointment with a registered dietitian to find out, okay, I'm eating less or I'm eating more carefully, but am I eating effectively? Because when it comes to dietary changes, that looks very different for each person. And I tell my patients, look, I can give you the quick and dirty, right? Cut out pop, cut out sugary drinks, cut out juice.
Just getting rid of really easy sources of quick sugar is a very... simple way to cut down on excess calories that also flood your body with sugar that gets stored as fat because your your blood sugar spikes and then your body is like, OK, let's pump out insulin and store that as fat. So those are the main things I tell people is talk to a registered dietitian first. Talk to your
you know, clinical team and find out what they recommend for you specifically. When people come up to me asking about diet pills that they can buy over the counter, I say, absolutely not. That's going to raise your blood pressure. Some of them can have been found to cause liver damage. Like it's not something that's worthwhile.
And if people say, you know, my, my doctor said they're going to prescribe me Ozempic because I have diabetes and I'm really worried. Like I've like, I don't know, I don't necessarily want to lose a lot of weight, valid because some patients don't want to lose too much weight, right?
Or they're worried that they may lose muscle mass, which is a concern with some of these meds if someone isn't getting both enough calories and enough weight resistant exercise. So it really is about what is the patient who comes up to me like concerned about and addressing that directly. But the main thing is get more information that's customized to you. Right.
I, as your pharmacist only have your medication, assuming you're even my, my patient, right. I only have your medication list. I don't have your lab results. I don't have your health history, but your clinic does. And your healthcare, your larger healthcare team does have access to that. So work with a dietician for that.
And I personally have worked with a dietician myself because I was trying to, um, I had the opposite problem where I stress starve, where I forget to eat when I'm stressed out. And so I went to a dietician to say, Hey, I feel like I'm eating enough, but I don't know if I'm eating effectively.
And she was able to educate me on what sorts of foods to look for, for my personal health and my eating habits. So registered dieticians are horribly underutilized, especially when it comes to, you know, weight in blood sugar, just general health. So that would be my number one thing is.
registered dietitian, and also talk to your healthcare team about whether any of these are even remotely appropriate for your overall health.
So Sarah, a couple of things I want to attach to this is, you know, some people have problems where, you know, their weight goes up and down. Okay. Or they go on this particular diet, You know, and it might work for a little while and then it doesn't work. So they up and down and up and down. And they aren't necessarily diabetic, for instance.
So are these drugs that we're talking about good for these types of patients? Or again, is that something that you specifically really should connect with your health care team on?
I mean, if someone's weight is going up and down, that's again, something that should be, you know, discussed with their healthcare team. And that can happen for a lot of reasons. If we're talking a weight loss or gain of like five to 10 pounds at a time, a lot of people with uteruses naturally go through that throughout the month.
So it's a matter of is this weight gain and loss like necessarily metabolic or is it just hormonal or fluid retention or is it in a cycle? But when it comes to people who are doing these crash diets or things like keto is really popular and I can't roll my eyes enough at that because I have to counsel patients on that all the time on why it's not the best idea overall for most people.
I really do think that talking to their healthcare team, getting a meal plan from registered dietitian, and then also potentially, you know, seeing occupational therapy or physical therapy about how should I be exercising correctly so I don't injure myself. All of those are things that people should be doing first before they turn to medication.
But if we're talking somebody who, yeah, my weight fluctuates by 10, 20 pounds, but I'm morbidly obese, well, I don't care about the 10, 20 pound fluctuation. I care about how, if this morbid obesity is negatively impacting your life and your health, how are we going to address that? And for some of those patients- then these medications may be clinically appropriate.
But again, I, as their pharmacist, can't give them that advice. They would need to talk to their whole team and try to set up a plan. And healthy, maintainable weight loss is not fast. That's one thing I wanted to say is outside of bariatric surgery, if we're talking the behavior I'm doing is going to change my weight,
when you're losing weight in a way that's maintainable long-term, it's not going to be like that. It's going to be a slog. And that's what's really hard for people. And I think that's maybe what isn't communicated super accurately a lot of the time in a lot of social media about weight loss, where we get to see the before and after. And it's like, yeah, a year went by. No big deal.
That was a year. That was a year of discouraging stuff in the middle that isn't being shown.
Yeah. Sheridan, you have a thought.
Okay, yeah. So I'm speaking kind of of social media and maybe some other things that I've seen online. Can you speak to any of the not FDA approved weight loss?
medications or methods that I've kind of seen promoted, you know, like there's like tummy detox teas and there's like all of the, I know you're a pharmacist and you specialize in things that are approved, but have you seen any implications from the things that aren't?
Yeah. So I fortunately or unfortunately went viral while I was on clinical rotations because I went on a gigantic rant about some of those like weight loss supplements and It wasn't tummy tea, although that's basically just a laxative. So you're, you're basically trying to poop really, really quickly so that you can eat stuff, but you're not absorbing it very well.
And that definitely does damage to your GI tract and should not be done. And many of those weight loss teas and supplements, again, also contain stimulants. But there are the biggest, Story I have about those sorts of weight loss shakes and supplements and teas and how they can impact your health is the woman I saw in the hospital was on rotation.
She was in there for like heart failure and other things. And one of the biggest issues they could not resolve was that her legs were super swollen with fluid. Right. So she had major water retention and they were pumping her with diuretics and just nothing was working.
And I went in and, you know, did my medication rec, which is, you know, as a pharmacist or a nurse, you go through their med list. And I asked about supplements, health shakes. And her daughter was like, oh, mom, you're using that shake.
I looked up that shake, which was very difficult because they make it hard to find the ingredients list and cross referenced every ingredient and found out that one of the ingredients, which was ginseng, can cause diuretic resistance.
So when I said that, they switched to a different diuretic that was harder hitting, got the water retention under control, and I don't know what happened with the patient after that because I moved rotations at that point.
But, you know, for someone with heart issues, taking a stimulant containing weight loss supplement, which is what almost all these over-the-counter weight loss supplements contain, is a laxative probably, right? a stimulant almost definitely. And then a bunch of other things that might cause many problems.
And another one is a lot of focus supplements, like certain types of like coffee for focus or whatever. A lot of those contain additional things that can raise blood pressure and suppress appetites through the stimulant activity, but can cause, you know, really big issues for the heart. In some cases for the liver, it's, I do not ever recommend them is the short answer.
Yeah. So talk to me about age differences. So like, are you at, for these drugs that we're talking about here, are you at higher risk if you're older by taking these medications?
Right. So I would, I don't feel as well versed at the age difference because most of my patients are on the younger end who are taking this. I have seen a lot of insurances not be willing to cover these for patients over a certain age because potentially there is higher risk. I would also argue that most of these meds weren't studied on that patient population. That's a big key issue.
We talk about studies, but studies and data don't, they're not made equal, right? There's the clinical trials where you have a very specific subset of patients, like only patients from this age range, no pregnant patients, no patients on this list of medications, no patients with this list of problems, but only patients with this list of problems.
Like it's very narrow and the drug companies are motivated to make sure it's the patient population that's most likely to show really great results, right? They're not trying to get some Joe Schmoe off the street who like may or may not care about their weight. Like they're really going for people where we're hopefully going to see really good weight loss off these people.
So then you have post-marketing data and that's once a drug hits the market and you have the general population taking it and you have prescribers prescribing it to not just the very specific study group subset, what are we seeing? And that's where we're seeing a lot more side effects. There's like gastroparesis is a really big one where your GI tract basically gets paralyzed, which is horrible.
There's potentially issues with the pancreas, potentially issues with the thyroid. That data is still very weak because, again, these injectables are quite new. So we don't have long-term data on, you know, Ozempic and Moonjara right now because they're they're pretty new to the market. So I would say the older you are, the more likely you are to have certain types of GI issues.
And also I would be worried if somebody is already on a lot more medications, which the older you are statistically, the more medications you'll be on. So there's confounding factors. There's various reasons why someone who's older may be at a higher risk of side effects with these medications. So just logicking my way through it, that's what I would say.
But I haven't seen the hard data stratifying different age groups.
So medication management, especially for older people, could be an issue if you add to it a weight loss medication like this. You know, one thing that's really hit me, there's two major things. One is if you start this medication from at least what I've read, you have to stay on it. I mean, you don't just go off of it. Am I correct with that?
Is that, in other words, you just don't stay on it for a month and say, okay, I lost whatever I need to. Thank you very much. Is this a maintenance type of, are these maintenance types of medications where you stay on them for a long period of time?
Yeah, so that's a really big question. point of discussion when it comes to these meds. And I have a maybe slightly different view than some would. I think the concept that these are forever drugs is oversimplified. I think for a small number of people, these might have to be forever meds. And when I'm saying these, I'm talking strictly the weight loss ones.
Because there are diabetics who I have absolutely no qualms about certain diabetic patients being on Ozempic or Victoza or whatever for the long haul to control their blood sugar. I'm speaking strictly for people who do not have blood sugar issues but want weight loss.
I think these drugs for people where they're clinically appropriate to use and clinically safe to use can be an excellent stepping stone. towards long-term maintained weight loss without lifelong use. And my example would be one of my patients who was in a wheelchair for a really, really long time and was using, they had like diabetes as well.
So, you know, but they ended up losing a lot of weight. They were able to stop relying on the scooter basically when they were getting around and they were able to walk. more often. And this led to, you know, increased exercise, and they were able to continue losing weight.
And, you know, even though they're still on this medication, I feel like that's a really good example of if your mobility is so negatively impacted by your weight, and this weight loss medication helps you get down to a low enough weight that you can increase your exercise, then potentially between diet and exercise, you can maintain that weight loss
and not need to stay on the medication, you could safely taper off of it. And that's the other thing is tapering off. Unfortunately, many of our patients on these meds, either for diabetes or weight loss have not gotten to taper off of them, they just suddenly stop because they're not available anywhere. So I mean, we've gotten to see what people are experiencing when they don't get to taper.
And it's extreme hunger, right? Like that hunger comes back with a With a passion. So if someone were to say, I'm going to try using this medication to get down to a certain level of weight loss so I can be more mobile.
And while I'm doing that, and I have the suppressed appetite, I'm going to work with a dietician to make sure I'm getting enough food to maintain my muscle mass because I don't want to starve myself. but also not overeating so that I'm not going to, you know, meaninglessly take this medication, then I think it can be a really useful tool for a small subset of people.
I don't think it's clinically appropriate to have people stay on this medication for the rest of their life if it's strictly for weight loss, unless we get more data indicating that it would make sense and for who it makes sense to, right? Because we don't, We just don't have enough information right now.
But as things stand for now, I think for a small number of people, it could be very useful to get them to a point where healthy eating habits, which means something different for everybody, and healthy exercise habits, which look different for everybody, can be maintained, can become a habit for that person, and then slowly taper off that med while they still maintain those healthy habits.
Yeah, that makes sense. Clarence. So Sarah, for this portion, I'd just like for you to talk about the side effects. I think we need to have a section. I mean, because usually when people talk about some of these drugs, they always talk about the good things. What are the side effects that happen as a result of using these drugs?
Yeah, so the most common ones would be nausea, vomiting, stomach ache, just GI discomfort in general. Most of my patients... complain about these side effects when they start the medication. And I've had some patients go off of these medications because of the side effects, right? Where they're just like, I constantly felt nauseated.
I don't want to lose weight if it means I feel like I'm going to throw up all the time. So, and for some patients, you know, these side effects may peter off after a couple of weeks on a certain dose, but for others, they persisted and it was very uncomfortable. I believe one of the studies that
on Ozempic, like a third of the participants dropped out within a certain period of time because they just couldn't handle the side effects. So that's something worth talking about. That's a lot. That's a lot. And when it comes to nausea is one thing, but vomiting that causes damage to your esophagus over time.
I mean, if you look at the health issues that many bulimic patients have, one of them is, you know, erosion of their esophagus, erosion of the valves that, you know, keep the acid in their stomach and not in their esophagus.
So all of that is really important to consider and a good reason why, you know, we really need to think about should this patient even be on this if they're having this level of side effect. And another thing that is much more serious that I mentioned before is gastroparesis. I'm not going to go through the whole list because we don't have time.
But gastroparesis is the biggest one that I wanted to talk about. And that's when the GI tract is paralyzed. So suddenly you just can't move things through your system anymore because the smooth muscle that's supposed to move things along is just like, no. I'm good. We're full. We don't have to move things right now.
So it can go a little too far because slowed gastric emptying is one of the potential benefits of this medication that you feel full for longer because your stomach isn't just taking in food and then dumping it into your intestines. It's taking in food and then like slowly moving it into your intestines. But if that gets way too slow, it is horrible.
And like I said, there are some things with like potential pancreatic cancer risk, potential thyroid cancer risk, but that hasn't really been supported with data yet because we don't have long-term data.
So let's talk a little bit about some clarity here on the medication itself for our listening audience. These aren't tablets and they aren't capsules. They're injections. All right. And all right. So that's number one. Number two, how often do you take this medication? Is it daily? Is it monthly? Is it every other day? How is it administered?
Yeah.
And taken. It's administered by a shot.
Right. Via shot, by yourself, hopefully. Yeah, right. So the two main ones I wanted to discuss when it comes to the injectables is Victoza and Ozempic, because those are the only two brands that also have specific weight loss injections. So Victoza's weight loss version is Saxenda.
Again, literally liraglutide.
Same thing. And then for semaglutide, there's Ozempic and Ligovi. However, there is also an oral version of semaglutide called ribelsis, which is strictly for diabetes. And that comes in three different doses. And the complaints I've gotten from my patients on side effects have been the same as the complaints I got from them about the injections.
Um, so despite it being a daily pill, which, you know, my, my thought process was, well, if it's daily, maybe the side effects are less noticeable because it's more steady over time and you're not like doing an injection and then whatever. Uh, no, I haven't noticed a difference. I'm still noticing patients complaining about, you know, nausea, upset stomach, et cetera. Yeah.
But Ozempic or Wegovy are once a week dosing, whereas Victoza and Saxenda are daily. So there's definitely a, not only does Ozempic show a higher weight loss than Victoza did, but also it's once a week. So for people who really don't like poking themselves, it's much more convenient.
So let's talk about also the economics on all of this, which we'll get into. Right.
Yeah, and Munjaro is once a week, sorry.
Once a week, okay.
Yeah, they are hideously expensive, and actually pharmacies have been suffering because we take a bath on these medications. I think a lot of people don't realize that it's possible for a pharmacy to take a loss, but because... many insurances aren't a fan of these medications, they don't reimburse at a great rate.
And if you work in a location where it's high Medicare and high Medicaid patient population, you're more likely to be taking a loss on these medications. So we are sometimes taking like hundreds of dollars of a loss for every prescription we fill for these, depending on the patient's insurance.
So even if the patient's copay is only, you know, zero to four dollars and 60 cents or something, I might be losing six hundred dollars just filling that medication for them. Just on cost of medication, not even talking about the overhead, my pay, my technicians pay the power. Right. Just on the cost of the drug, we're taking like a six hundred dollar bath.
So that is pretty rough on top of all the phone calls we get all the time about them. Like it's these medications are not doing pharmacies any favors right now.
So these are all, these medications are like the wow now. After what, a 17 year, how long is it that that period of time before it goes generic or possibly generic?
I think it's supposed to be due in 2026 sometime.
Oh, so that's actually quicker than most medications that I remember historically. But even still, would that help, a generic form of this?
So I've been dealing with generic forms of insulin.
Yeah.
And it's very tricky because these... The pill forms being generic would potentially be helpful, right? But when you have a new generic, we're talking, okay, the brand name costs us $500 to order. The generic may cost anywhere from like $50 to $450 to order. It really depends on the pricing that they decide on. And anytime there's a drug shortage, we see drug prices go up.
Yeah.
Because why not charge more for our product right now? You all want it. So so I don't know that a generic is going to help that much when it comes to cost. Also, you know, I don't have a whole lot of private pay patients. Right. And I don't have a whole lot of patients on fancy work insurance. I mostly have patients on government insurance at my location.
So my colleagues at other stores have said that there are people who are
legitimately paying 500 a month for their co-payment for these medications and i just don't know that that's going to change unless the generics are significantly cheaper and in my experience they haven't been that much cheaper when the generics initially come out it seems to take at least five to ten years before enough other manufacturers are making that generic for it to bring the cost down and this is in america specifically other countries it's much cheaper
Clarence, you're on mute.
Let me unmute here. When your patients come in, and I kind of sort of asked this question before, but when your patient comes in and they really want to do this, what are you saying to them?
You know, like what is it, what I want to know is my patient's motivation, right? Like what is it that you're wanting to get out of this medication, weight loss, okay, how much weight are you looking to lose? Why that number? Are there certain activities you're not able to do right now that you miss being able to do or that you want to be able to do?
And based on their answers, you know, I'm just going to give honest opinions, you know, from me about whether I even think that medication is
worth asking their clinician about, or if it makes more sense, like, hey, you haven't really, okay, you've, you've cut down on, like, this thing, but you're still, I'm looking at your cart, and you have these things in it that, you know, you have, like, three boxes of pop in your cart, like, just cut out the pop. cut out the pop for a month and see how you do.
I would rather give like non-medical options to people first before they jump to a medical option. And people may be surprised for a pharmacist to say that, but just because I'm an expert on drugs doesn't mean I want everyone to be on them. I want people to be solely on the things they need to be on in order to maintain a happy, healthy life, whatever that looks like for them.
And, you know, I really try to push the lifestyle changes first. But if someone says, look, This is how I've been eating all this time. I'm working with a registered dietitian. I'm exercising, you know, in this many times day doing this type of exercise, and I'm still just not losing the weight. Depending on their body type, I might also ask if they've ever been put on metformin.
And metformin was one of the drugs I wanted to talk about that's a diabetes med, but it's also used for various issues like polycystic ovarian syndrome. pre-diabetes and insulin resistance.
And for some people who hold a lot of fat, like on their torso, rather than like all throughout their body or towards their lower body, insulin resistance might be part of what's going on because insulin resistance doesn't cause you to be obese.
But if you are already holding a lot of fat in that midsection area, that can lead to insulin resistance, which can then lead to weight being harder to lose, or like, it's a vicious cycle. So metformin is extremely cheap. It's a very old medication, very well studied. And while it has side effects, we're talking like diarrhea,
There are many other side effects to it, but the common one is diarrhea, and it's pretty manageable for most patients. So I would ask, have you talked to your doctor about trying that since you've done all these other things? Ask your doctor if this is appropriate for you, right? Because it's very cheap.
Even if they don't have really good insurance, I think through like the discount program that my work uses, it's like 30 something bucks for a three month supply. Like it's really not bad. So it's worth trying.
And for many people, by taking metformin to address insulin resistance, that can actually, that combined with not eating a ton of extra sugar and exercising can be really helpful because metformin also tells the muscles in the body, hey, there's extra sugar. sugar floating around the blood, could you like snatch it up and use it for fuel, which helps your muscles grow too.
So then if somebody is actually working out because they want to have more muscle in their body than fat, metformin has been shown to cause a small amount of weight reduction. It's known for that. That's one of its known side effects. But also if you have insulin resistance, it can really be impactful.
Yeah. So let me, you know, I'm trying to think about, you know, somebody coming into a pharmacist and they might have an actual prescription for one of these weight loss medications. And all of a sudden they're told it's an injectable. It seems to me one of the questions that might arise is this. All right. Pretend it's me, you know, and I come in and I'm seeing you.
excuse me, I feel like I'm getting poked for everything lately. I'm getting these vaccinations for COVID. I'm getting these vaccinations for flu, for shingles, for whatever. And now this, is there any potential problem with interactions with all these vaccinations that we're taking at the same time in injectable medication like this?
Yeah, so I would explain that the vaccines and the injectable diabetes or weight loss meds have very different purposes and go through the body in very different ways. Generally, the diabetic injections are done in the fat, whereas vaccines, most of them are done in the muscle.
So like all the ones I give, that's not true, I do MMR, but most of the vaccines I give are in the muscle and they go into your body, your immune system responds to it done like that's that's it the vaccine doesn't hang around in your body forever, right?
And with these injectables, they're being injected every week or every day or whatever, because they need to tell your body, give your body the messages, right? These are just messenger molecules that are saying, hey, do this. And your body's like, fine, I will. And then you have to keep telling your body to do this over and over. So they just work very differently.
The vaccines are a one-time message that basically tells your body how to drop a wanted poster for a specific pathogen for a specific bad guy that's trying to invade your body so that your body can recognize it faster. These injectables are just telling your body the message.
It's reminding your body, Hey, I need you to, you know, do these things so that we can keep the blood sugar under control and as a side effect, potentially lose the weight.
So they're metabolized differently in, in our bodies.
Right. They're metabolized at different rates. Yeah.
Yeah. Yeah. Okay. And that's an important message for people to hear.
Clarence, Let me just say this. I know that we got me to the end of our show. Sarah, I am really, really pleased with the information that you provided today. I definitely look forward to the opportunity to work with you some more and to actually have you come back on the show and to share more information with us. I think you've been an exciting guest.
Thank you. I've loved being here. This is the kind of thing I like talking about. And I don't There's one thing I wanted to say, just because I feel like there's a lot of takeaways from these drugs that are usually not helpful on social media. And I feel like this is a good place to do it. But I just like to remind everybody that every single body is different.
What works for your friend doesn't mean it's going to work for you. Even if it works for your mom or your sister, your brother, it doesn't mean it'll work for you. So it really is important to get customized health care that is aimed at you. from your healthcare team, which can include your pharmacist, but it should be a whole host of people.
And also when it comes to exercise, I think there's a lot of stuff on social media that's misleading, burn belly fat in this much time or whatever. I just want to tell people exercise, there's no right or wrong exercise for everybody. You need to focus on what you'll actually do, even though weight training is supposed to be really good for you. I find it so terribly boring.
And my weight training is through rock climbing because that's weight training. It's just not boring to me. So find what you're able to do safely because not everybody has access to a gym. Not everybody has access to safe outdoor areas to exercise and just do what you can actually do on a regular basis to build your health.
And if you have access to a physical therapist or to an occupational therapist, they can actually be amazing resources to to help you figure out how to exercise in a way that's good for your specific body and your needs, also in the environment that you have to exercise in.
That's great. Great insight. It really is everything. You know, I, you know, one thing I, I, I got from this show is everything in balance and you really have to think it's not just, wow, let's just take this medication. You have to think about it overall, how everything is kind of interacting for you personally. And,
You really need good, good medical insight before you start these kinds of medications. Frankly, any medication. But for sure, this one, for sure.
And over-the-counter stuff, because I tell everybody, any time before you're about to buy any supplement over-the-counter, ask me first. I will happily...
look at the ingredients list and figure out you know whether i feel comfortable with you taking it as my patient whose medication list i know and i always tell people especially a lot of herbal supplements or a lot of weight loss supplements have ingredients that can interfere with your existing medications and other supplements so it's really important to not put your health in jeopardy because uh the vitamin and supplement industry is a multi-billion dollar industry as well they're also out to get your money so let's keep your hard-earned cash
for something that's actually going to be appropriate for your body.
Right. Good, healthy food. Sarah, you've been an absolutely wonderful, wonderful guest on our show. Very timely. This is kind of a hot topic right now. And I'm hoping that the information that you've provided our listening audience will be useful for them and truly informative. It certainly was for me. So thank you for being on our show today. For our listening audience, great shows coming up.
We have a show coming up on narcissism, organ donation, loneliness, which has become a real public health issue now, and also the vision for public health going forward. So stay tuned for those shows. In the meantime, everybody keep health chatting away.