I take tirzepatide, cut down my calories to about 1500, walk 4-6 miles a day, and exercise 3 times a week. With the help of tirzepatide, I have been able to curb the cravings. I have lost about 25 pounds so far with 25 more to go. I always understood that it was on shaky ground however pay the $350/mo to get 5 mg of tirzepatide. My work has a Medical Weight Loss program that uses semaglutide instead which is free. I plan to switch to that. If it becomes unavailable, then I will have to switch back to regular discipline, food tracking, exercise, etc that I probably should have did all along. I will do whatever I have to do in the meantime to safely lose weight.
I think you've accomplished something really incredible with your weightloss and I'm very proud of you! .... but this part right here concerns me.
The reasons for eating beyond maintenance calories are broad, complicated and robust and I don't think it's fair to say "I should have just been more disciplined, 4head". The negative side-effects of food cravings can be really serious and "too hard" to fight against and that's a reasonable enough stance, especially when there are chemical changes you can make for yourself, such as this medication, that can help you.
In a very related sense, I was taking a (relatively) high dosage of a medication for myself that I needed for a time. I gained 30 pounds over about 2 years while on that stronger medication. I also tried to lose weight; but the cravings for food were becoming too much - far too much; and I had just come off the best shape of my life, where I actually had to force myself to eat *more* so that I would gain muscle. I just plain wasn't hungry. But this med I was on, yeah, I just ate more, regularly. It was easier - but trying to slow down my eating? The cravings were bad. Unlike any I'd ever had. And if I didn't eat, I was tired, angry, unfocused, a world of problems.
Now that I've reduced this medication (with the help of a psychiatrist), the cravings have effectively disappeared; and when they are present, it's very easy to overpower them and just move on. They don't cause my to be literally unable to sleep. I don't lose all my focus, it's just ... easier - easier enough that it's actually doable.
And a medication changed helped that.
Crutches are a very good thing when you can't walk or when it hurts too much to walk. It's okay to use a crutch. It is not a personal failing, it is a medical aide and an accessibility tool.
Please, I encourage you, give yourself some grace :)
I agree, but let me get on a soapbox for a moment. In the context of weight loss, "cravings" is just a judgemental way of saying "hunger".
I have gained a ton of weight in the past four years, going from a BMI of 19 to a BMI of 28. I do not have "cravings". I experience constant hunger. I got tired of being hungry all the time and started eating until I am no longer hungry, and that's why I'm fat now.
Calories in, calories out, and all that nonsense that doesn't account for hunger is just a way of dismissing the very real struggle of people who, for whatever reason, have a disproportionate amount of hunger relative to the amount of energy they need on a daily basis.
>In the context of weight loss, "cravings" is just a judgemental way of saying "hunger".
I always assumed cravings was when something sounded good and you could eat it but weren't necessarily hungry. Like most days I have a craving for some ice cream but I'm not actually physically hungry. Ignoring that craving means that I eat a lot less overall.. it doesn't mean that I end up eating alternative foods instead.
>I experience constant hunger. I got tired of being hungry all the time and started eating until I am no longer hungry, and that's why I'm fat now.
You seem like someone that Ozempic type drugs would help since they slow down digestion and make you feel full for longer.
A lot of people do though, the confuse the desire to have a rush from sweets or the lack of feeling overly stuffed as being hungry. Hell, we all do something similar during holidays when we choke down that extra serving of our favorite food because we enjoy the taste, despite being beyond full.
There was an interesting theory that obesity was connected to a duller taste sense. I think that can relate to the dulling effect when repetitively eating the same thing.
In essense, when one has a craving for something expected/remembered that is actually unattainable, one over eats.
Of course, that conflicts with a common theory of smoking and weight loss being about taste reduction as opposed to an alternative craving as a substitute or some other cause.
> common theory of smoking and weight loss being about taste reduction
I didn't realize that was a thing people thought. I know smoking screws up your sense of taste but I assumed the prevailing thought was that something about nicotine or some other part of smoking just curbs hunger.
I can only offer what has worked for me, at one point losing over 170 lbs. Admittedly gaining 50 back thanks to the good old pandemic making some bad habits easy again and limiting my chosen form of exercise due to swimming pool closures. Thankfully back on the right track and down 30 and still dropping since June.
The name of the game in controlling hunger is finding a diet that creates satiety. For me this was keto. Getting that fat macro up to 75% was the magic bullet, if I was below that, I had “cravings”. If I was at or above that I was fine.
I am not suggesting that is the right way of eating for everyone. I think diet is an individual endeavor, but for me it was the right way to keep that hunger at bay.
Not the person you're responding to; but, it's called "hangry" for a reason!
I definitely have the:
* "I could eat"
* "I should probably eat soon"
* "Everyone around me is now annoying and I hate everyone and everything and why is this work problem so hard and darn it, I have a meeting in 3 minutes? Who schedules a meeting at this time?!" level.
There is another kind of hunger that kicks in when you’re actually dying from not eating.
I had advanced gallbladder disease that went misdiagnosed for a long time and the last month I was able to eat about 500 total calories. I had a desperate desire to eat something, anything, that is impossible to describe accurately.
One interesting thing I have noticed on tirzepatide is I am much better able to differentiate when I am thirsty vs. when I am hungry. Before, if I wasn't getting to "my mouth is dry" levels of thirst, they were indistinguishable for me.
It frequently became a guessing game for me to try and figure out which it was - did I gamble that I just needed to drink some more, and run the risk of feeling worse from what turned out to be actual hunger? Or did I just eat some food, which also included drinking more fluids, and make sure I was back to feeling OK soon after?
I can tell you which option I chose most of the time, particularly if I was busy with work or a personal project.
Same. Down 80. Healthy weight for the first time since I was a child. Taking this has led me to feeling less shame about my previous weight and that maybe a lot of this discipline you talk about might also be some of our biology just being not super compatible with modernity. I've personally gone from feeling a bit like a fat cat who you have to take the bowl away from to one who just eats responsibly. Wouldn't really be an issue for the cat in the wild or us 100 years ago. But here we are needing to take away our own bowls. Maybe it really just isn't as easy for some of us.
>> our biology just being not super compatible with modernity.
This! our body through millions of years of evolution is just not built for an abundance of easy to obtain dense caloric food, while living in relative leisure. It just isn't.
CICO proponents don't understand you are asking an individual to fight millions of years of evolution with self-discipline.
Fitness is absolutely important. One thing I've found is that it's not just physically easier to do that work but mentally easier as I approached a healthy number on the scale.
You can’t / shouldn’t however my beef with the compounders is that they encourage people to stay dependent via maintenance doses once they reach their goal weight.
Out of curiosity, do you find yourself eating more nutritiously or just fewer calories?
For most people (now), their food habits don't deliver very good nutrition in just 1500 calories and the problems with that compound if they're living an active life that needs more nutrients. Neurotic dieters have hurt themselves through that problem for decades, as so much cultural focus in on "calories in, calories out" that they don't even think about whether their broader nutritional needs are still being met during calorie restriction.
Do you find that these drugs have provided any help in making your diet sufficiently dense in nutrition to compensate for the reduction in volume? I hear that they strongly affect appetite and food appeal, so I worry for what it might mean for people who dive in without taking nutrition density seriously. It seems so easy to just buy the drug and let it help you eat less, but that's such a dangerous thing to do naively.
I find it significantly easier to eat healthier foods.
I am struggling with getting enough calories in general - even on the lowest dose I have to force myself to eat more than a meal a day. But I don't miss the processed/fried/etc. foods while on tirzepatide the way I do when I'm just counting calories, etc. I throw in a a protein shake and a broad spectrum of supplements to help. (I stick to the ones that have actual research studies to back their efficacy - examine.com is great for quickly sorting things into 'ignore as marketing garbage' and 'research more' piles)
I've also found it significantly easier to be motivated to work out.
> do you find yourself eating more nutritiously or just fewer calories?
I am definitely eating better and watching what I eat. Mostly because I care now. I am up to 80-100g of protein per day. I stopped drinking soda altogether. I drink water multiple days. I am no longer suffering from sleep apnea.
> Do you find that these drugs have provided any help in making your diet sufficiently dense in nutrition to compensate for the reduction in volume? I hear that they strongly affect appetite and food appeal
You are satiated faster when used in combination with protein heavy meals. I am also weighing my food and following the serving sizes.
They do affect your appetite but I also think it was a mindshift because I can stop taking the medication after it wears off beyond my weekly shot and I am not that hungry anymore. I attribute it to maybe my stomach got smaller and I used this opportunity to retrain myself and have better healthy eating habits.
I absolutely eat better than before. Part of it may be mindfulness, but overall I do not crave specific kinds of foods like I did before and by that I mean... any specific kind of food.
One way of thinking about it is that I have always enjoyed fruits like apples, blueberries, etc but I have always enjoyed a bag of chips or a great sandwich more. What I've found now is if I keep fruits, yogurts, cottage cheese etc in the fridge I will opt for them over the more junky foods, or at least just as much.
I started out getting injured just walking 2 miles. It was bad. I weighed 255 lb at start and that didnt seem like a lot but it makes sense now why I would get injured just walking around a big city like Washington DC with my family. I was out of shape. Now I can walk 6 miles a day every day (this took me 2 months to get to) without injury.
It is significantly easier if you are starting from being totally sedentary.
I've gone from fit and powerlifting for years to fat for years to trying to get back into lifting, etc. (the latter, multiple times) and while age is a bit of a confounding factor, the fatter I am, the more difficult exercise is - both cardio and resistance training. It's just harder on your tendons and ligaments. It's not insurmountable, and training can make those more resilient as well, but when you're starting from effectively zero, doing that a 250lb is tougher than doing it at 200 is tougher than doing it at 175, etc.
Running is pretty high impact, too. It's going to put quite a lot of stress on your joints.
I'd recommend everyone incorporate exercise as much as they can regardless of their weight, but I've found it easier and easier to ramp mine back up as my weight has gone down.
By easier I was referring to intensity, rather than the experience of your ligaments.
Presumably now that you've gotten into powerlifting you don't still lift the same weight you did when you started. If you did, it would indeed be easier. But you probably lift more weight, so that the intensity is similar.
(To be completely transparent, I wasn't trying to state a universal truth. That phrase is just a common tongue-in-cheek joke among runners and cyclists; I misread the crowd a bit assuming it'd be recognized)
You have to be able to do the activity long enough to get benefits, such as cardio. And an extra 20 lbs can put that in jeopardy. Once you hit that threshold, the weight doesn't matter. But getting off the plateau you're stuck on is the first big step.
It's easier, less weight falling on your knees, hips, and ankles for one. The aerobic endurance also becomes easier to build because you are moving less weight, i.e. expending less energy, per step.
The majority of people who run do not set their intensity by measuring the weight on their knees.
If you take someone with a fixed fitness and reduce their mass, they will expend less energy per unit of time, but in order to effectively train you need to keep a target intensity, so you increase the amount of distance you cover per step or increase your cadence, either / both of which increases the energy consumed per unit of time.
That's all I mean when I say that you just go faster.
I'm on the heavy side for a distance runner, but compared to the general population, I've never been very heavy or very light (BMI currently around 26). I mostly run longer distances (a half marathon most weeks, lots of six mile runs, full marathons and the distances to train for them about twice a year).
In my experience, qualitatively, what you say is absolutely true. I don't even notice a change in pace if my weight floats up or down a bit, I mostly run at a specific level of effort and the pace adjusts itself depending on how much I've over-indulged. However, there are thresholds.
If I try to run a pace that is too slow, there's a point where it almost becomes more shuffle than run, gait goes to hell, and there's a loss of efficiency. As I've gotten more fit (but not lighter) I can now do zone 2 running on the flat with workable form, but this wasn't always the case. It's still less efficient than a fast pace, but at least it looks like running.
So if one is too heavy to even run with actual running form for any length of time, it's harder to be heavy. That's okay, they should probably try run/walk intervals until they get there.
On the other hand, it can also be harder when you're more fit. My pain tolerance has gone way up. I can just beat the ever living snot out of myself, and if I'm not careful, I do just that. It's much easier to do too many miles way too quickly now and that starts manifesting itself in all kinds of noisome ways. Find anyone who considers themselves a runner and get them talking about their injuries and you better not have anywhere else you need to be.
Yes, I agree. I mentally consider "running" to include "walking, if that's the speed you should be at for your target intensity". I do a lot of walking on my runs even still :)
I got up to half marathon walking distance at a little over 3 hours for six weeks this summer, and have been in PT ever since. 'Too hard' doesn't necessarily manifest the day you make the mistakes. It could be weeks later.
You'll have to define easy. If you go faster, that means you're outputting more wattage per second. You may get there faster, but you've used up the new capacity that your body has developed so you're back to what are likely similar levels of discomfort.
By your definition, Usain Bolt running the fastest 100m time ever set by a human is having an easier time than me because I do it slower.
What most people mean by easier is that it "feels" easier: this would be accomplished by aiming to take the same amount of time even in the face of capacity increasing.
> If you go faster, that means you're outputting more wattage per second.
It's not just a comparison of fast versus slow, it's also heavy versus lighter body weight. You can move faster at lower weights while spending the same amount of energy as someone moving more weight slowly.
The net result is that it's easier to run a fixed distance when you're in shape. The same energy output makes you move faster, making the run shorter in time duration, meaning you actually spend less energy.
Further, getting in better shape often coincides with improvements in metabolic efficiency, so you get further benefits.
Usain Bolt has exceptionally improved musculature and metabolism for sprinting over the standard person, so his maximum energy output results in an exceptional speed.
At that point, we aren't talking about equivalent energy outputs anymore, which means it isn't relevant to the "easier" qualifier.
Of course it's objectively easier, particularly if you hold some variables constant (distance or pace) relative to weight.
The wrinkle is that most runners run to a pain point. Over time, I went from neverrunning to running decent mileage per week, and my runs hurt _more_ now than they did when I started because I run to a pain point. I run further, faster, and more frequently and I have a higher pain tolerance, so it hurts more while I run and the recovery is rougher.
So my runs are at least as hard, but yes, I'd absolutely destroy the version of me that thought three miles was an accomplishment by any objective metric.
Thanks, this is what I was trying to articulate with my original comment. I've never heard of a runner who gets a little faster and decides "oh ok, I'll just take it easier now". You don't get fitter by training with respect to yesterday's fitness.
Great to hear the kind of progress you are making. Keep it up!. One thing I have found to be successful for exercising(weight training, running, swimming) is taking a mindful and inquisitive approach to it. It goes like this:
- Be mindful of when your mind wanders from paying attention to Form(Posture/Gait/Technique), Breath and Pace. When it wanders, bring it back to focus on these aspects.
- Try observing when the first feeling and proceeding thought enters your mind and try separating the feeling like tiredness, anxiousness, overwhelmed from the distracting thoughts you have due to it(e.g. "I wanna quit", or "I can't do this"). But stay with the feeling and this thought. Just observe it and bring back your attention to the aforementioned things: your Form, Breath and Pace. Over time the though and feeling dissipate and you come to be at ease with the process.
Over time, this has helped my motivation because often I was fighting my thoughts(which in the long run is like stuffing mail in a full post box) and not paying attention to the actual exercise.
I don't know if weight loss via calorie tracking and self control is really worthwhile if you can just do a cycle of appetite suppressant to keep weight around target baseline.
Seems like drugs have made weight management a solved problem. No reason to over think it for genpop if you can cycle drugs.
The unsolved problem is body composition -> picking right exercise regimes and diet macronutrients so you're losing more fat than muscle.
But really that should also be a solved problem if west weren't stupid about steroids and poured serious research into them.
Just eat4 grams of inulin gummies and a teaspoon of allulose in the morning amd evening. Costs maybe 30 bucks a months also pounds glp1 just like semaglutide. Mirafiber makes some decent ones in usa market. Restorafiber is sold in two packs at costco for cgep in canada
The patent for semaglutide doesn't expire until 2030 (in the US), so a generic is not currently available. I say this as someone who is looking into purchasing the drug: I don't think many people buying the compounded formula know it is not a "generic" and is not FDA approved. The companies selling it often do not even say where it comes from.
It shouldn't be surprising that Novo Nordisk is fighting these compounding pharmacies that are purely interested in undercutting them. Not to say they need our sympathy, since I'm sure a significant cost of Ozempic is due to the injection pen with a million patents.
The pill version is showing similar safety and efficacy profiles as the injectable (leveraging higher dosage to get through the gut to the bloodstream), so runs to Canada and Mexico are probably in consumer futures to evade patent regulatory capture until 2030 (or getting it mailed from India, I have had personal success with this for other non controlled pharma products).
> The pill version is showing similar safety and efficacy profiles as the injectable
The pill, Rybelsus, barely works. They've having to put 700%+ more than the injections to still get a lower overall effectiveness. They're actively working on alternative delivery methods to resolve this.
A daily pill GLP-1 will be a massive commercial success. Rybelsus isn't very good for either the manufacturer or the consumer. You're burning a lot of expensive peptide to get a worse outcome at every dose level.
Perfect is the enemy of good enough. I agree with your assessment, that a pill is not ideal current state of the art, but if a pill format improves compliance and delivery vs injectables, and the cost of the pill can be driven down to where it is similar to Metformin, the outcome is still the same (even if there is waste from a suboptimal delivery mechanism).
An efficient drug delivery mechanism you can’t get into the hands of a broad population cohort is not efficient. We are optimizing for accessibility for everyone who needs access to this drug family (imho).
Rybelsus is harder on compliance (1-per-day, rather than 1-per-week), and the cost of the pill will always be high due to the excessive amount of peptide it wastes (700% more per day * 7-days = 7000% more wasteful than a single injection per week).
At some point it isn't "perfect Vs. good" it is "effective Vs. ineffective." Rybelsus is an ineffective medication. Even with the eye watering waste set out above, it is reported as being less effective as a GLP-1 too. There is no upside.
A pill GLP-1 is an absolute game-changer. We just aren't there yet.
Oral medications are much cheaper to manufacture than injectables. The Apis Bull is working on a drug combination that prevents the digestive system from burning up all the semaglutide.
Yeah, but the Mounjaro/Zepbound cost with injector in the UK is £139 for 4 weekly 5mg injections/month. They're still making over 90% margins. The margins in the US are completely insane >99%.
Victoza (liraglutide)'s patent expired, but its effect on weight loss is pitiful relative to later-generation GLP-1 agonists. Same story for Trulicity (dulaglutide), for which patent protections end in 2027.
Liraglutide is an older version that is now available as a generic, but it's results, particularly for weight loss, are far behind semaglutide, tirzepatide, etc.
I'd be more sympathetic if they actually met the demand of their prescribed base. I have about a 40% success rate actually getting my rx filled and have to use compounded versions.
My feeling is that Ozempic, and Wegovy, has been prescribed to too many, to fast. It was always clear that Novo Nordisk would not be able to the need of both diabetics, people who truly need to lose weight and those who just want to lose weight. The latter group should not be serviced at all at this point.
Starting to push Wegovy was just a money grab, Novo must have known that it would disrupt their delivery of Ozempic.
The venn diagram of people who are diabetic and people who need to lose weight are almost a circle.
If you're drastically overweight and not diabetic, that's because not enough time has passed.
What people fail to realize is that obesity correlates highly with pretty much every bad thing you can develop. The faster you control obesity, the lower your risk will be. Virtually every organ in the body, from liver to kidneys to heart to lungs, is negatively impacted by obesity.
I view it as people taking those drugs pre-emptively. They would require them, eventually.
It's frustrating that nobody actually offers evidence for the drugs either being available or unavailable. Can Nordisk point to a warehouse with enough available supply to meet the capacity that the compounders are cranking out? Or can the compounders point to a bunch of customers waiting on unfulfilled shipments from Nordisk?
My understanding is that they're almost completely separate customer bases right now. Ozempic is (generally) only approved by insurance when used as a diabetic drug and off insurance, it's in the $1000/month range.
Weightloss folks are shit out of luck for insurance coverage, and so they go to compounding pharmacies and pay in the $200/month range. Forcing them to ~5 times the price will have a lot of folks unable or unwilling to do so and demand will drop.
Our insurance just started covering Ozempic for weight loss, but they will only supply it via their online pharmacy for diabetes. If you are prescribed it for weight loss, you have to find it retail and pay a $200 copay. But at least it's for branded Ozempic, not grey market compounded meds. Mounjaro is the better product if you need for both weight loss and diabetes, but the supply on that is even worse than for Ozempic.
Most of the advertising I've seen has been from weight loss clinics or online pharmacies that will get you the prescription and perhaps sell you a compounded version rather than the Novo Nordisk or Eli Lilly advertising their glp1.
Increased demand can justify the high prices? Companies generally want to have a backpressure of demand outstripping supply because then they can creep prices up without impacting sales.
Alternatively, if everyone is clamoring for the drug, maybe that influences regulators/lawmakers for what gets covered by Medicare. Honestly, the way people are talking about semaglutide - it could become a drug that is just provided to everyone who wants it, by default, paid by the government. (And would probably be a net positive ROI by the government - the amount of savings and increased productivity if America reduced obesity rates by 10+% would be incredible)
A cynic would say that some of those TV ads are to purchase influence with media companies and essentially buy favorable editorial coverage. More like stealth PR than something intended to drive consumer sales.
Interesting that the insurance companies aren't interested in supporting weight loss, the complications from being overweight are gonna be a whole lot worse than getting the drug. Did someone run the tables and find that obese people are dying too quickly to end up with medical bills?
I imagine there is too much churn for insurance companies to be able to be confident that they will be the ones to benefit from lower long-term health costs and not Medicare or some other insurance provider.
This is right. I worked in health insurance for a while. If you aren't in Medicare Advantage (which has relatively lower plan churn) it is very unclear that preventative spend on an employer based plan will benefit the payor that paid for it.
Health insurance has cost+ pricing in the form of capped margins. One could say it is a case of misaligned incentives. But how would incentives get aligned absent a single payer system?
Obesity leads to diabetes, fatty liver disease, various cancers and other problems. It's shortsighted to not cover drugs that can actually reduce it, but if the actuarial tables are silent on the matter or actually support obesity leading to lower payouts from increased mortality, then that's exactly what the insurance companies are gonna do.
>Did someone run the tables and find that obese people are dying too quickly to end up with medical bills?
Genuinely would not be surprised if this does increase medical costs for society as a whole. Obesity related deaths seem like they're more likely to be sudden compared to what might get you if you live longer.
I doubt it's anywhere near that clearcut. "Weight" by itself is neither a disease nor a symptom. I have read numerous reports saying that weight loss often does not improve outcomes for various specific problems. Or that weight loss can help, but the way that it is lost matters more than the amount lost, and losing it the wrong way can be worse than maintaining the original weight. Not to mention that there are plenty of healthy overweight people and unhealthy skinny people. So I wouldn't be surprised if insurance companies are sitting back to see what the empirical effects of semaglutide-induced weight loss are on health outcomes. Perhaps there are data available on that now; I haven't looked.
Besides, it's hard to know what the health effects really are of being overweight, because it's such a convenient rug for doctors to sweep any and all problems under. "Let's see if you still have this problem after you've dropped 20 pounds, ok?" Because clearly your weight is due to a moral failing, and it suggests you're probably screwing up all kinds of other things. Why bother to work on helping you when you're unwilling to even try to do your part? Fat => lazy and weak-willed => won't stick to medication schedule or exercise or diet or anything => unworthy of help. There's not a lot of questioning whether being overweight is an effect or has a common cause; it's assumed to be the relevant cause, or at least has a high enough probability of being the only relevant cause worth looking at because it's common knowledge.
(Neither I nor anyone in my immediate family are overweight, by the way, so don't ignore my rant by assuming I'm being bitter about personal experience.)
> (Neither I nor anyone in my immediate family are overweight, by the way, so don't ignore my rant by assuming I'm being bitter about personal experience.)
If you haven't been living with extra weight for a decade, you wouldn't have the first-hand experience of why being overweight is definitely a symptom of and contributor to health issues as well as quality of life degredation.
> I have read numerous reports...
> Besides, it's hard to know what the health effects really are of being overweight...
I can agree that being overweight is often what a doctor sees, but honestly any doctor that makes assumptions like that is not interested in root causes. They're trying to see as many patients as possible, e.g. as a GP, and offer fixes for what they can fix, and referrals to specialists for that which they can't fix with the usual prescription or advice.
All this to say that I really disagree with the first paragraph, and this entire post feels like just opinion despite conjecture on what numerous reports you've read.
> Not to mention that there are plenty of healthy overweight people
This is only true in the most disingenuous of interpretations and look purely at BMI. The "health overweight" people are nearly exclusively those with significant lean body mass from the hypertrophy induced by resistance training. If it's fat pushing you into the overweight category, you're almost certainly unhealthy in a variety of manners. Insulin resistance, lipid profiles, blood sugar, arterial calcification, visceral fat pressing on organs, etc. etc. etc. all the way to less obvious ones like high estrogen levels in men causing issues with mood, etc.
Being overweight is one of the worst things you can do to your health.
There an are a few reasons. First, the cost of being overweight may take a long time to appear, going decades without any problems is realistic. By the time that happens there may be a different insurer on the hook(Medicare?). The second reason as you alluded to is that end of life care is extremely expensive for everyone in this country, and a shorter life span may actually save the insurer money even if there’s a massive bill for heart surgery.
It's mostly not the insurance companies. What a lot of people fail to realize is that most medical "insurance" companies no longer provide much insurance, in the sense of bearing financial risk for medical expenses. Their main business now is administering health plans for self-insured employers. If Ozempic isn't covered by your health plan then the decision was most likely made by your employer's HR department. An insurer will be happy to include Ozempic in their formulary with liberal claim approval rules if the customer wants it; they design custom plans for large customers all the time. This actually means higher profits for insurers (including their captive PBMs and mail-order pharmacies).
I have to admit that I'm baffled as to what is happening here. Semaglutide is still under patent protection, so anyone producing feedstock is doing so under license with Nova Nordisk. Why on earth would NN offer licensing terms that allow them to sell the feedstock to anyone but NN? There are no generic manufacturers because the patent is still active.
Compounding pharmacies are getting the drug from the feedstock producers, but how on earth are they contractually permitted to sell it?
Your usage of the term 'feedstock' here is confusing, and it seems like you're probably operating under the erroneous assumption that contract manufacturer supplies commissioned by Novo Nordisk are somehow being routed to compounding pharmacies, which isn't the case.
In practice, there are generic manufacturers for semaglutide, and many other peptides still protected by US patents, mostly located in China. The more reputable of these manufacturers produce these drugs at levels of purity rivaling the 'name brand'. These manufacturers export lyophilized product en masse to middlemen that operate in the grey/black-market 'research chemical' sales market, or ship to compounding pharmacies. The consumers purchasing on the grey/black market reconstitute the drug at home (which requires a trivial level of effort), and assume some extra degree of risk in terms of product purity and sterility. Consumers wanting an extra level of assurance for product quality purchase from a compounding pharmacy that ostensibly is conducting its own assessments of product purity, and following best practices for sterile reconstitution.
Henry's, one of the compounding pharmacies, says that they get the chemicals from legitimate licensed producers of feedstock [1].
There is a compounding loophole, but there is no loophole for patent encumbrances -- if a compounding pharmacy is violating NN's intellectual property, then can just sue them directly; they don't have to pursue the regulatory crackdown they're going for now.
There are companies that do grey/black market reconstitutions, like Pivotal Peptides. But they are not compounders. The compounders are legally selling the real thing directly to customers. Do you have a specific source that indicates that any compounding pharmacy is getting its feedstock illegally from China?
You're massively misunderstanding that Reddit post, and it doesn't help that the 'HenryMedsInfo' account is misconstruing how the pharma manufacturing supply chain works.
For one, the FDA does not 'license' any manufacturer, period. They do enforce safety and quality standards, but this is not controlled through some sort of a general license, and operates on a per-facility basis.
DMF listing (which isn't a 'license') does not necessarily have any relation to whether that manufacturer is supplying a brand name provider.
The 'license' that account is posting about a complete fiction. There is not a license granted here in any government context, nor a license between NN and the manufacturers the post discusses.
> The compounders are legally selling the real thing directly to customers.
This is debatable. They are not selling 'OEM' NN product to consumers.
Also - stop talking about 'feedstock'. It's weird. It's not standard industry lingo and obscures whatever the hell it is you're talking about (precursors? lyophilized product? something else?)
I'll stop saying feedstock -- I thought I saw that in the astralcodexten article but I am mistaken.
When I say "the real thing" I mean that they are selling semaglutide, which they are obtaining somehow. The reddit post was the closest thing I've seen to an answer to the question "where are they getting it".
So if they are not getting it from producers under license from NN, where are they getting it? Why isn't the legality of that path under active legal attack? There must be some fig leaf at least that they can use to say how they got the substance when the patent is still in force, otherwise judges would immediately shut them down with an injunction.
My understanding is that a significant number of them are getting them from Chinese manufacturers (that are also selling them to other Chinese companies, that then sell them to individuals, more resellers, or compounding pharmacies)
I've got a high enough risk tolerance that I've got lyophilized tirzepatide on the way from a Chinese seller. Even if I send one of the vials off to be tested, it will still be cheaper than I can get it from a compounding pharmacy in the US.
>When I say "the real thing" I mean that they are selling semaglutide, which they are obtaining somehow
>So if they are not getting it from producers under license from NN, where are they getting it?
They're obtaining it from pharma labs with the right equipment and talent to produce it. The synthesis process is well understood, it's not like it's a Novo Nordisk secret.
> Why isn't the legality of that path under active legal attack?
I tried looking around at these links but I couldn't find the actual lawsuit itself, and I'm curious what they specifically say. There's a difference between saying that a compounding pharmacy is selling junk claiming that it is semaglutide (that is, making false claims that may reflect on NN when the substance is ineffective), vs. claims that the drug is being produced in violation of their intellectual property rights for the synthesis of the drug.
In the Aesthetic Maison and Medioak pharmacy cases, Novo Nordisk alleges that they're selling a product claiming to contain semaglutide without a prescription or FDA approval. In the BOF Medical case, they're claiming "trademark infringement, false advertising, and unfair competition."
They're not suing for damages, just injunctive relief ordering the defendants to stop. It doesn't look like it even matters to their cases whether the products contain real semaglutide.
> Why are Eli Lilly and Novo Nordisk suing compounding pharmacies, then?
> Why is the FDA warning that some compounding pharmacies are using the salt forms of semaglutide and tirzepatide?
because $
$$$$$$$$$$$$
that's why. not safety. MONEY.
while there may be some very shady sources of fake grey/black market semiglutide that should be avoided, there are also the legal "compounders" who produce white-ish/grey market semiglutide. in the later case, it's the same active ingredient. the FDA, in it's infinite infallible wisdom (and $$$$$$$ pressure from pharma) refuses to acknowledge that while there is a tiny risk that the different buffers, processing methods, delivery and non-active ingredients, etc. have "not been studied" and might not be "less effective", that these are really small risks. tiny.
i feel like the FDA deliberately conflates the dangers of questionable overseas knock-offs with the legitimately pure, regulated, legal products of compounders.
are these guys violating a patent or two? meh? (note: this is a tort, but is not illegal) so sue them. but is it safe? it's as safe as anything else the FDA allows.
meanwhile we keep supporting a system of patents in medicine (and software) that are actively doing exactly the opposite of what the system was put in place for: stifling innovation instead of encouraging it. padding the rich cats pockets instead of giving the small guys a chance.
You misunderstood my question. I'm pointing out that the compounding pharmacies and the med spas the buy from them are not getting it from any sort of official source - thus them getting sued.
I've swapped to buying from Chinese manufacturers and reconstituting my own so I'm not exactly lining the pockets of Eli Lilly or Novo Nordisk ;)
Compounded drugs have a difficult line to walk. AFAIK, compounded drugs are those which are made custom to the patient due to allergy, or unavailability. The concern is when a compounding pharmacy makes a drug that already exists on the market, but the pharmacy sells it anyways even though it's identical, or at a lower cost.
There's also value in individualized dosing. I take tirzepatide, and 5mg is too intense for the first couple days, but 2.5 doesn't last long enough. Ideally I'd take 2.5 every 4 days, instead of 5.0 every 7 days, but that option doesn't exist, but is something that compounding could provide. But I'm not willing to risk the safety-murkiness of compounding, so just stick with the 5.0 and deal with it.
compounding veterinary medication was also common during Covid during medication shortages.
It’s a way to get the same medicine just through different suppliers and circumventing various restrictions/regulations, and then prepared by the compounding pharmacy for ingestion by the patient.
Common use cases are, in animals for example, you might need to put a dog a medication and the supplier may not manufacture the right size dose (or maybe your animal won’t eat pills so the compounding pharmacy reformulates it into a liquid)
My veterinarian recommended sticking with brand name meds for my dog even though I was having trouble due to the size of the pill. Her reasoning was compounded equivalents simply aren’t tested in any medical or academic trials, only brand name formulations are tested in trials, so there’s no guarantee of efficacy since you’re literally taking a formulation of a medication that has gone through zero scientific testing (the isolated ingredients or a similar formula may have trials and testing, but not the exact formula you’re taking)
Which is also why no compounded drug can be FDA approved.
Logically I want to trust compounding pharmacies and I want to believe the efficacY and side effects are equivalent to name brand.
But the fact that my veterinarian cautioned me against compounding my dog’s medicine gave me pause about compounding medicine for myself…
the modern twist is that large health startups like Hims and 23andme are getting into the compounding business and the drug makers arent happy to have the competition.
Hims strikes me as a giant liability lawsuit just waiting to happen. The things they are selling should never be advertised/sold that recklessly. All they're doing is playing on folks insecurities and potentially giving them serious medical issues down the line due to their willful negligence with prescribing/distribution
The one (and only) time I filled a prescription for propecia a couple decades ago, one of the warnings said something akin to: pregnant women should not even touch a broken propecia capsule due to the risk of birth defect.
After that, I decided to just allow nature to take its course on my hairline.
> The one (and only) time I filled a prescription for propecia a couple decades ago, one of the warnings said something akin to: pregnant women should not even touch a broken propecia capsule due to the risk of birth defect.
Lots of drugs are bad for pregnant and/or nursing women. Propecia is not particularly special in this regard, nor is it especially dangerous compared to all the other drugs out there which are also bad for pregnant women.
"Do not handle" is a warning for topical formulations, just because those are intended to be absorbed transdermally.
At one point I was going to a human compounding pharmacy to get drugs for my cat. I don’t even remember what it was but they put it in fish oil to make it more palatable. Did not work.
I purchased four 5ml bottles of semaglutide from China for $50. It's available at underground lab steroid sites and easy to find. Many people are ordering this and getting them tested and the results are posted. I realize the risk.
I'm 6' 2" and weigh 215. I ride my bike 20 miles/week. Not a lot, but not nothing. My goal isn't really to lose a bunch of weight. I'm always hungry and I'm eating plenty. There's an ongoing hunger background noise in my stomach and brain. I'm definitely doing some self experimentation to get this figured out.
It's a hugely important thing to do for your health in general, but the amount of effort needed to counteract the modern diet via exercise is absurd.
The alternative is eating better - better food, less calories. But for a lot of people, they have tried and failed to do this for years. Even people that have had a history of being able to do this successfully can find themselves struggling. And once you're fat, the feedback loops kick in and make it more and more difficult. Is it within everyone's power to not be fat? Yes. Is it significantly harder for some people for a variety of reasons? Also yes.
So we could act like this is a moral failing and fat people should just be fat until they manage to scrape together the willpower to ignore their body pushing them to eat, or we could recognize that these medications are extremely effective at helping tame those signals their body is sending. (Plus seeing a tons of other positive impact on things like fat deposits in the liver, insulin resistance, cardiovascular protection, sleep apnea, etc. - and these are seen even before significant weight loss occurs.)
These medications aim to reduce the addictiveness of foods. A very apt analogy is nicotine gum/patches. This is that, but for food (although early studies also show success for opioids and alcoholism).
I feel like there is a lot of hypocrisy going on around this. People asking overweight/obese people "why not just eat less?!" and people responding "GLP-1 medications help me do just that," and the critics essentially saying "it is unfair fair that this drugs helps you do the thing I claim I want you to do."
Also, calorie restriction, not exercise is what successful people use to lose weight. Exercise is highly recommended and will help you live a long and healthy life, but it won't help an Obese person loose >20 lbs of body fat. TDEE and calorie restriction will though.
"Why not do the more difficult thing instead of the very easy and cheap thing that also accomplishes your goal?" will always be a bizarre question to ask in earnest. The answer should be so glaringly obvious that the question just falls out of your head.
Someone made a drug, and they want all of the money for their work.
Maybe that's justified, maybe it isn't.
But because we use money as both our dopamine reward and also the entire basis of how we allocate all scarce resources in our finite reality, and because patents are the only way for them to get said dopamine reward/resources, the strat is to just let millions of people sit in the crossfire while we work out what kind of money they should get.
They come back from ayahuasca trips thinking they've unlocked some profound knowledge after experiencing ego death but in the end they just tweak what they were doing before and add fresh wise-guru paint to their operation.
They already got many many billions. If there's a mechanism for medicine to skip extra studies when extraordinary efficacy is shown, why is there no mechanism to skip the patent protection and crank out at scale what can prevent so many bad health outcomes in the future. Hell, give them another $10B, who even cares, it's saving much more in healthcare expenditures.
After decades of suffering with weight problems (and resulting health issues), Ozempic brought about life-changing results in months. It is a fantastic drug, and I hope it becomes widely available as soon as possible.
If by compounding you mean producing semaglutide, no.
If you have a source to buy lyophilized semaglutide and some BAC water, you could certainly reconstitute it yourself and pick a dosage, or compound in some vitamin b12 or similar.
In practice for an average person, this means either buying them as research chemicals directly from china, or from resellers that mark it up by 10-50x. You might get a COA that testifies the chemical in question and it's purity level for that batch, and maybe that COA will actually match the batch in your vial. But you almost certainly won't get any guarantee on sterility. And there are reports of the contents of vials getting mislabeled, so people got entirely different products.
You can try to counter some of the sterility issues with filter syringes, etc., but you're only mitigating some risk, not eliminating it.
They're buying semaglutide salts from China and mixing it into distilled water. It's not that difficult. I wouldn't trust the sources to be pure and not doped with something else though. You're taking an even larger risk with an injectable.
Assuming you can get your hands on actual raw semaglutide and know what you are doing, absolutely. It's not rocket science, drug dealers do that all the time. Pill presses can be had on Alibaba for a few hundred bucks and you can order virtually anything from "research chemical" online stores as well.
But it is not risk free either. Contaminations of all kinds are the worst issue (particularly with anything supposed to be injected, so never try it with insulin...), but the most pressing one is agent distribution. That's what causes a lot of people to OD on stuff cut with fentanyl - if the fent, the actual drug (say, heroin) and the fillers aren't properly mixed, you may end up with a bunch of pills with far higher doses than intended while other pills essentially consist of pure filler.
bear in mind, Ozempic is dramatically more expensive in the USA then any other country. The Pharma company has explicitly decided to price-gouge the United States. USA is 1300 versus 300 in canada.
Additionally, semaglutide was developed as a drug for diabetes. It took a decade or so for NN to realize they walked backward into a giant money pit with the weight and addiction component and they are doing their damnedest to get every last cent they can before the patent expires. As is their prerogative, technically, but at this point I think this drug promises a real significant public health benefit that we haven't seen in our lifetime, especially around addiction and other impulse disorders.
Millions of peoples lives could be made better within months if this stuff was made freely available tomorrow. It would cause all manner of downstream benefits for society, in particular I think it would have a real impact on reducing some load on a healthcare industry that is buckling at the weight of our collective unhealthiness.
I honestly think the FDA should find a way to put the screws to NN such that they reduce the cost of this drug and license it at an affordable cost to the compounders.
You're right that drugs are generally more expensive in the US, but it's not because "the US has to pay top dollar to subsidize the world's drugs".
It's simply that companies charge more in the US because they can.
And the reason they can is that the US hasn't got its sh*t together to stop the drug companies from doing this. For this, blame your political system and the power that money has to influence your politicians and set policy.
It does not have to. It chooses to pay higher prices to """subsidize""" the research that is already paid for by my tax dollars, and to help pay for """development""" that amounts to changing a drug from a mixture of both chiral versions to just the biologically active chiral compound, which somehow justifies another 25 years of monopoly for the exact same chemical.
They could barely be bothered to change the name because they didn't want to lose brand mindshare.
It's worse. They want Ozempic for all through Medicare. At those prices that's 3 trillion dollars. As RFK Jr. put it, for $3T we could give every man, woman, and child in the United States three organic meals a day. Or pay for gym memberships, which would be even cheaper.
The President could issue an executive order saying Medicare won't pay a higher price than EU nations or Canada. If they want to raise their prices there, fine. But we're not going to be the ones paying through our nose because you think the American taxpayers have bigger bank accounts.
Medicare is provided by the Department of Health and Human Services, which is part of the Executive branch of the U.S. federal government which is answerable to... the President.
We don't live in a dictatorship, but the President absolutely has the power to say how much Medicare is willing to pay for a particular drug. President Biden could do this today, if he chose. The President can't say how much pharmaceutical companies may charge. But that's not what we're talking about here.
Nope. You're making things up. Just because the Department of Health and Human Services is part of the Executive branch doesn't mean they can obey an illegal order from the President.
Medicare is authorized to negotiate drug prices in certain limited ways. But that doesn't extend to setting a maximum price by executive fiat. Instead of posting nonsense you could try reading the law.
An executive order directing the implementation of reference pricing is not illegal and is permitted under the ACA. Reference pricing includes being able to say, for example, that Medicare won't pay more than the cost of the same drug in Germany.
I'm not making things up, you're just ill informed.
Nothing in the Affordable Care Act of 2010 grants the President (or any part of the executive branch) the statutory authority to implement reference pricing or otherwise set a limit on the prices of prescription drugs purchased under Medicare Part D. Your citation of 42 U.S.C. § 1315a is irrelevant and concerned with entirely separate programs. For something more relevant see 42 U.S.C. § 1320f as well as the current CMS guidance. The law requires a defined drug selection and negotiation process which can't be overridden by executive order.
It's great and I'm happy for you that you have a body that is such that you can do that. Many people do not have similar experiences. Often times people who are not able to do things like are labeled as having a lack of control or a failing in the character. The truth is that many people have different chemistry which makes doing something like this borderline impossible.
I take tirzepatide, cut down my calories to about 1500, walk 4-6 miles a day, and exercise 3 times a week. With the help of tirzepatide, I have been able to curb the cravings. I have lost about 25 pounds so far with 25 more to go. I always understood that it was on shaky ground however pay the $350/mo to get 5 mg of tirzepatide. My work has a Medical Weight Loss program that uses semaglutide instead which is free. I plan to switch to that. If it becomes unavailable, then I will have to switch back to regular discipline, food tracking, exercise, etc that I probably should have did all along. I will do whatever I have to do in the meantime to safely lose weight.
> that I probably should have did all along
I think you've accomplished something really incredible with your weightloss and I'm very proud of you! .... but this part right here concerns me.
The reasons for eating beyond maintenance calories are broad, complicated and robust and I don't think it's fair to say "I should have just been more disciplined, 4head". The negative side-effects of food cravings can be really serious and "too hard" to fight against and that's a reasonable enough stance, especially when there are chemical changes you can make for yourself, such as this medication, that can help you.
In a very related sense, I was taking a (relatively) high dosage of a medication for myself that I needed for a time. I gained 30 pounds over about 2 years while on that stronger medication. I also tried to lose weight; but the cravings for food were becoming too much - far too much; and I had just come off the best shape of my life, where I actually had to force myself to eat *more* so that I would gain muscle. I just plain wasn't hungry. But this med I was on, yeah, I just ate more, regularly. It was easier - but trying to slow down my eating? The cravings were bad. Unlike any I'd ever had. And if I didn't eat, I was tired, angry, unfocused, a world of problems.
Now that I've reduced this medication (with the help of a psychiatrist), the cravings have effectively disappeared; and when they are present, it's very easy to overpower them and just move on. They don't cause my to be literally unable to sleep. I don't lose all my focus, it's just ... easier - easier enough that it's actually doable.
And a medication changed helped that.
Crutches are a very good thing when you can't walk or when it hurts too much to walk. It's okay to use a crutch. It is not a personal failing, it is a medical aide and an accessibility tool.
Please, I encourage you, give yourself some grace :)
I agree, but let me get on a soapbox for a moment. In the context of weight loss, "cravings" is just a judgemental way of saying "hunger".
I have gained a ton of weight in the past four years, going from a BMI of 19 to a BMI of 28. I do not have "cravings". I experience constant hunger. I got tired of being hungry all the time and started eating until I am no longer hungry, and that's why I'm fat now.
Calories in, calories out, and all that nonsense that doesn't account for hunger is just a way of dismissing the very real struggle of people who, for whatever reason, have a disproportionate amount of hunger relative to the amount of energy they need on a daily basis.
>In the context of weight loss, "cravings" is just a judgemental way of saying "hunger".
I always assumed cravings was when something sounded good and you could eat it but weren't necessarily hungry. Like most days I have a craving for some ice cream but I'm not actually physically hungry. Ignoring that craving means that I eat a lot less overall.. it doesn't mean that I end up eating alternative foods instead.
>I experience constant hunger. I got tired of being hungry all the time and started eating until I am no longer hungry, and that's why I'm fat now.
You seem like someone that Ozempic type drugs would help since they slow down digestion and make you feel full for longer.
> I always assumed cravings was when something sounded good and you could eat it but weren't necessarily hungry.
I do not eat when I am not hungry. Why would I do that? I'm already fat enough.
A lot of people do though, the confuse the desire to have a rush from sweets or the lack of feeling overly stuffed as being hungry. Hell, we all do something similar during holidays when we choke down that extra serving of our favorite food because we enjoy the taste, despite being beyond full.
There was an interesting theory that obesity was connected to a duller taste sense. I think that can relate to the dulling effect when repetitively eating the same thing.
In essense, when one has a craving for something expected/remembered that is actually unattainable, one over eats.
Of course, that conflicts with a common theory of smoking and weight loss being about taste reduction as opposed to an alternative craving as a substitute or some other cause.
> common theory of smoking and weight loss being about taste reduction
I didn't realize that was a thing people thought. I know smoking screws up your sense of taste but I assumed the prevailing thought was that something about nicotine or some other part of smoking just curbs hunger.
I can only offer what has worked for me, at one point losing over 170 lbs. Admittedly gaining 50 back thanks to the good old pandemic making some bad habits easy again and limiting my chosen form of exercise due to swimming pool closures. Thankfully back on the right track and down 30 and still dropping since June.
The name of the game in controlling hunger is finding a diet that creates satiety. For me this was keto. Getting that fat macro up to 75% was the magic bullet, if I was below that, I had “cravings”. If I was at or above that I was fine.
I am not suggesting that is the right way of eating for everyone. I think diet is an individual endeavor, but for me it was the right way to keep that hunger at bay.
Thank you for the add. You've clarified something I didn't even realize needed clarifying! This is a fantastic way of thinking about it.
Do you feel like there are different kinds of hunger?
For me there is the kind I can usually ignore and the “I feel sick” kind I can’t.
Not the person you're responding to; but, it's called "hangry" for a reason!
I definitely have the:
There is another kind of hunger that kicks in when you’re actually dying from not eating.
I had advanced gallbladder disease that went misdiagnosed for a long time and the last month I was able to eat about 500 total calories. I had a desperate desire to eat something, anything, that is impossible to describe accurately.
One interesting thing I have noticed on tirzepatide is I am much better able to differentiate when I am thirsty vs. when I am hungry. Before, if I wasn't getting to "my mouth is dry" levels of thirst, they were indistinguishable for me.
It frequently became a guessing game for me to try and figure out which it was - did I gamble that I just needed to drink some more, and run the risk of feeling worse from what turned out to be actual hunger? Or did I just eat some food, which also included drinking more fluids, and make sure I was back to feeling OK soon after?
I can tell you which option I chose most of the time, particularly if I was busy with work or a personal project.
Now, I have a much easier time differentiating.
>I take tirzepatide
Same. Down 80. Healthy weight for the first time since I was a child. Taking this has led me to feeling less shame about my previous weight and that maybe a lot of this discipline you talk about might also be some of our biology just being not super compatible with modernity. I've personally gone from feeling a bit like a fat cat who you have to take the bowl away from to one who just eats responsibly. Wouldn't really be an issue for the cat in the wild or us 100 years ago. But here we are needing to take away our own bowls. Maybe it really just isn't as easy for some of us.
>> our biology just being not super compatible with modernity.
This! our body through millions of years of evolution is just not built for an abundance of easy to obtain dense caloric food, while living in relative leisure. It just isn't.
CICO proponents don't understand you are asking an individual to fight millions of years of evolution with self-discipline.
Once you lose the weight it is critical to get fit, because you won't have the same amount of weight stressing your connective tissue.
Besides all the other benefits of exercise, it will help keep the weight off. You can't stay on ozempic forever.
Fitness is absolutely important. One thing I've found is that it's not just physically easier to do that work but mentally easier as I approached a healthy number on the scale.
You can’t / shouldn’t however my beef with the compounders is that they encourage people to stay dependent via maintenance doses once they reach their goal weight.
Out of curiosity, do you find yourself eating more nutritiously or just fewer calories?
For most people (now), their food habits don't deliver very good nutrition in just 1500 calories and the problems with that compound if they're living an active life that needs more nutrients. Neurotic dieters have hurt themselves through that problem for decades, as so much cultural focus in on "calories in, calories out" that they don't even think about whether their broader nutritional needs are still being met during calorie restriction.
Do you find that these drugs have provided any help in making your diet sufficiently dense in nutrition to compensate for the reduction in volume? I hear that they strongly affect appetite and food appeal, so I worry for what it might mean for people who dive in without taking nutrition density seriously. It seems so easy to just buy the drug and let it help you eat less, but that's such a dangerous thing to do naively.
I find it significantly easier to eat healthier foods.
I am struggling with getting enough calories in general - even on the lowest dose I have to force myself to eat more than a meal a day. But I don't miss the processed/fried/etc. foods while on tirzepatide the way I do when I'm just counting calories, etc. I throw in a a protein shake and a broad spectrum of supplements to help. (I stick to the ones that have actual research studies to back their efficacy - examine.com is great for quickly sorting things into 'ignore as marketing garbage' and 'research more' piles)
I've also found it significantly easier to be motivated to work out.
> do you find yourself eating more nutritiously or just fewer calories?
I am definitely eating better and watching what I eat. Mostly because I care now. I am up to 80-100g of protein per day. I stopped drinking soda altogether. I drink water multiple days. I am no longer suffering from sleep apnea.
> Do you find that these drugs have provided any help in making your diet sufficiently dense in nutrition to compensate for the reduction in volume? I hear that they strongly affect appetite and food appeal
You are satiated faster when used in combination with protein heavy meals. I am also weighing my food and following the serving sizes.
They do affect your appetite but I also think it was a mindshift because I can stop taking the medication after it wears off beyond my weekly shot and I am not that hungry anymore. I attribute it to maybe my stomach got smaller and I used this opportunity to retrain myself and have better healthy eating habits.
I absolutely eat better than before. Part of it may be mindfulness, but overall I do not crave specific kinds of foods like I did before and by that I mean... any specific kind of food.
One way of thinking about it is that I have always enjoyed fruits like apples, blueberries, etc but I have always enjoyed a bag of chips or a great sandwich more. What I've found now is if I keep fruits, yogurts, cottage cheese etc in the fridge I will opt for them over the more junky foods, or at least just as much.
It’s a lot easier to exercise when you weigh 30 lbs less. Runners claim more than 2 seconds per mile per pound.
I started out getting injured just walking 2 miles. It was bad. I weighed 255 lb at start and that didnt seem like a lot but it makes sense now why I would get injured just walking around a big city like Washington DC with my family. I was out of shape. Now I can walk 6 miles a day every day (this took me 2 months to get to) without injury.
It doesn't get easier, you just go faster.
It is significantly easier if you are starting from being totally sedentary.
I've gone from fit and powerlifting for years to fat for years to trying to get back into lifting, etc. (the latter, multiple times) and while age is a bit of a confounding factor, the fatter I am, the more difficult exercise is - both cardio and resistance training. It's just harder on your tendons and ligaments. It's not insurmountable, and training can make those more resilient as well, but when you're starting from effectively zero, doing that a 250lb is tougher than doing it at 200 is tougher than doing it at 175, etc.
Running is pretty high impact, too. It's going to put quite a lot of stress on your joints.
I'd recommend everyone incorporate exercise as much as they can regardless of their weight, but I've found it easier and easier to ramp mine back up as my weight has gone down.
By easier I was referring to intensity, rather than the experience of your ligaments.
Presumably now that you've gotten into powerlifting you don't still lift the same weight you did when you started. If you did, it would indeed be easier. But you probably lift more weight, so that the intensity is similar.
(To be completely transparent, I wasn't trying to state a universal truth. That phrase is just a common tongue-in-cheek joke among runners and cyclists; I misread the crowd a bit assuming it'd be recognized)
You have to be able to do the activity long enough to get benefits, such as cardio. And an extra 20 lbs can put that in jeopardy. Once you hit that threshold, the weight doesn't matter. But getting off the plateau you're stuck on is the first big step.
It's easier, less weight falling on your knees, hips, and ankles for one. The aerobic endurance also becomes easier to build because you are moving less weight, i.e. expending less energy, per step.
The majority of people who run do not set their intensity by measuring the weight on their knees.
If you take someone with a fixed fitness and reduce their mass, they will expend less energy per unit of time, but in order to effectively train you need to keep a target intensity, so you increase the amount of distance you cover per step or increase your cadence, either / both of which increases the energy consumed per unit of time.
That's all I mean when I say that you just go faster.
I'm on the heavy side for a distance runner, but compared to the general population, I've never been very heavy or very light (BMI currently around 26). I mostly run longer distances (a half marathon most weeks, lots of six mile runs, full marathons and the distances to train for them about twice a year).
In my experience, qualitatively, what you say is absolutely true. I don't even notice a change in pace if my weight floats up or down a bit, I mostly run at a specific level of effort and the pace adjusts itself depending on how much I've over-indulged. However, there are thresholds.
If I try to run a pace that is too slow, there's a point where it almost becomes more shuffle than run, gait goes to hell, and there's a loss of efficiency. As I've gotten more fit (but not lighter) I can now do zone 2 running on the flat with workable form, but this wasn't always the case. It's still less efficient than a fast pace, but at least it looks like running.
So if one is too heavy to even run with actual running form for any length of time, it's harder to be heavy. That's okay, they should probably try run/walk intervals until they get there.
On the other hand, it can also be harder when you're more fit. My pain tolerance has gone way up. I can just beat the ever living snot out of myself, and if I'm not careful, I do just that. It's much easier to do too many miles way too quickly now and that starts manifesting itself in all kinds of noisome ways. Find anyone who considers themselves a runner and get them talking about their injuries and you better not have anywhere else you need to be.
Yes, I agree. I mentally consider "running" to include "walking, if that's the speed you should be at for your target intensity". I do a lot of walking on my runs even still :)
I got up to half marathon walking distance at a little over 3 hours for six weeks this summer, and have been in PT ever since. 'Too hard' doesn't necessarily manifest the day you make the mistakes. It could be weeks later.
If you go for your 5km, then all in all, it's easier (you are done sooner)
You'll have to define easy. If you go faster, that means you're outputting more wattage per second. You may get there faster, but you've used up the new capacity that your body has developed so you're back to what are likely similar levels of discomfort.
By your definition, Usain Bolt running the fastest 100m time ever set by a human is having an easier time than me because I do it slower.
What most people mean by easier is that it "feels" easier: this would be accomplished by aiming to take the same amount of time even in the face of capacity increasing.
> If you go faster, that means you're outputting more wattage per second.
It's not just a comparison of fast versus slow, it's also heavy versus lighter body weight. You can move faster at lower weights while spending the same amount of energy as someone moving more weight slowly.
The net result is that it's easier to run a fixed distance when you're in shape. The same energy output makes you move faster, making the run shorter in time duration, meaning you actually spend less energy.
Further, getting in better shape often coincides with improvements in metabolic efficiency, so you get further benefits.
Usain Bolt has exceptionally improved musculature and metabolism for sprinting over the standard person, so his maximum energy output results in an exceptional speed.
At that point, we aren't talking about equivalent energy outputs anymore, which means it isn't relevant to the "easier" qualifier.
Of course it's objectively easier, particularly if you hold some variables constant (distance or pace) relative to weight.
The wrinkle is that most runners run to a pain point. Over time, I went from neverrunning to running decent mileage per week, and my runs hurt _more_ now than they did when I started because I run to a pain point. I run further, faster, and more frequently and I have a higher pain tolerance, so it hurts more while I run and the recovery is rougher.
So my runs are at least as hard, but yes, I'd absolutely destroy the version of me that thought three miles was an accomplishment by any objective metric.
Thanks, this is what I was trying to articulate with my original comment. I've never heard of a runner who gets a little faster and decides "oh ok, I'll just take it easier now". You don't get fitter by training with respect to yesterday's fitness.
force = mass * acceleration
work = force * displacement
work = mass * acceleration * displacement
lower mass, less work.
You don't think running with, say, an extra 50 lbs of weight is more difficult?
Great to hear the kind of progress you are making. Keep it up!. One thing I have found to be successful for exercising(weight training, running, swimming) is taking a mindful and inquisitive approach to it. It goes like this:
- Be mindful of when your mind wanders from paying attention to Form(Posture/Gait/Technique), Breath and Pace. When it wanders, bring it back to focus on these aspects.
- Try observing when the first feeling and proceeding thought enters your mind and try separating the feeling like tiredness, anxiousness, overwhelmed from the distracting thoughts you have due to it(e.g. "I wanna quit", or "I can't do this"). But stay with the feeling and this thought. Just observe it and bring back your attention to the aforementioned things: your Form, Breath and Pace. Over time the though and feeling dissipate and you come to be at ease with the process.
Over time, this has helped my motivation because often I was fighting my thoughts(which in the long run is like stuffing mail in a full post box) and not paying attention to the actual exercise.
>I probably should have did all along
I don't know if weight loss via calorie tracking and self control is really worthwhile if you can just do a cycle of appetite suppressant to keep weight around target baseline.
Seems like drugs have made weight management a solved problem. No reason to over think it for genpop if you can cycle drugs.
The unsolved problem is body composition -> picking right exercise regimes and diet macronutrients so you're losing more fat than muscle.
But really that should also be a solved problem if west weren't stupid about steroids and poured serious research into them.
Just eat4 grams of inulin gummies and a teaspoon of allulose in the morning amd evening. Costs maybe 30 bucks a months also pounds glp1 just like semaglutide. Mirafiber makes some decent ones in usa market. Restorafiber is sold in two packs at costco for cgep in canada
Won’t that make you go poop more often ?
The patent for semaglutide doesn't expire until 2030 (in the US), so a generic is not currently available. I say this as someone who is looking into purchasing the drug: I don't think many people buying the compounded formula know it is not a "generic" and is not FDA approved. The companies selling it often do not even say where it comes from.
It shouldn't be surprising that Novo Nordisk is fighting these compounding pharmacies that are purely interested in undercutting them. Not to say they need our sympathy, since I'm sure a significant cost of Ozempic is due to the injection pen with a million patents.
The pill version is showing similar safety and efficacy profiles as the injectable (leveraging higher dosage to get through the gut to the bloodstream), so runs to Canada and Mexico are probably in consumer futures to evade patent regulatory capture until 2030 (or getting it mailed from India, I have had personal success with this for other non controlled pharma products).
> The pill version is showing similar safety and efficacy profiles as the injectable
The pill, Rybelsus, barely works. They've having to put 700%+ more than the injections to still get a lower overall effectiveness. They're actively working on alternative delivery methods to resolve this.
A daily pill GLP-1 will be a massive commercial success. Rybelsus isn't very good for either the manufacturer or the consumer. You're burning a lot of expensive peptide to get a worse outcome at every dose level.
Perfect is the enemy of good enough. I agree with your assessment, that a pill is not ideal current state of the art, but if a pill format improves compliance and delivery vs injectables, and the cost of the pill can be driven down to where it is similar to Metformin, the outcome is still the same (even if there is waste from a suboptimal delivery mechanism).
An efficient drug delivery mechanism you can’t get into the hands of a broad population cohort is not efficient. We are optimizing for accessibility for everyone who needs access to this drug family (imho).
Rybelsus is harder on compliance (1-per-day, rather than 1-per-week), and the cost of the pill will always be high due to the excessive amount of peptide it wastes (700% more per day * 7-days = 7000% more wasteful than a single injection per week).
At some point it isn't "perfect Vs. good" it is "effective Vs. ineffective." Rybelsus is an ineffective medication. Even with the eye watering waste set out above, it is reported as being less effective as a GLP-1 too. There is no upside.
A pill GLP-1 is an absolute game-changer. We just aren't there yet.
Oral medications are much cheaper to manufacture than injectables. The Apis Bull is working on a drug combination that prevents the digestive system from burning up all the semaglutide.
Yeah, but the Mounjaro/Zepbound cost with injector in the UK is £139 for 4 weekly 5mg injections/month. They're still making over 90% margins. The margins in the US are completely insane >99%.
https://www.simpleonlinepharmacy.co.uk/online-doctor/weight-...
>The patent for semaglutide doesn't expire until 2030 (in the US), so a generic is not currently available.
Aren't there a handful of similar drugs in that class though? I wonder if some of them come off patent sooner.
Victoza (liraglutide)'s patent expired, but its effect on weight loss is pitiful relative to later-generation GLP-1 agonists. Same story for Trulicity (dulaglutide), for which patent protections end in 2027.
Most are newer, so the patents will expire later.
Liraglutide is an older version that is now available as a generic, but it's results, particularly for weight loss, are far behind semaglutide, tirzepatide, etc.
I'd be more sympathetic if they actually met the demand of their prescribed base. I have about a 40% success rate actually getting my rx filled and have to use compounded versions.
My feeling is that Ozempic, and Wegovy, has been prescribed to too many, to fast. It was always clear that Novo Nordisk would not be able to the need of both diabetics, people who truly need to lose weight and those who just want to lose weight. The latter group should not be serviced at all at this point.
Starting to push Wegovy was just a money grab, Novo must have known that it would disrupt their delivery of Ozempic.
The venn diagram of people who are diabetic and people who need to lose weight are almost a circle.
If you're drastically overweight and not diabetic, that's because not enough time has passed.
What people fail to realize is that obesity correlates highly with pretty much every bad thing you can develop. The faster you control obesity, the lower your risk will be. Virtually every organ in the body, from liver to kidneys to heart to lungs, is negatively impacted by obesity.
I view it as people taking those drugs pre-emptively. They would require them, eventually.
Compounding exists to fill the market gaps
It's frustrating that nobody actually offers evidence for the drugs either being available or unavailable. Can Nordisk point to a warehouse with enough available supply to meet the capacity that the compounders are cranking out? Or can the compounders point to a bunch of customers waiting on unfulfilled shipments from Nordisk?
My understanding is that they're almost completely separate customer bases right now. Ozempic is (generally) only approved by insurance when used as a diabetic drug and off insurance, it's in the $1000/month range.
Weightloss folks are shit out of luck for insurance coverage, and so they go to compounding pharmacies and pay in the $200/month range. Forcing them to ~5 times the price will have a lot of folks unable or unwilling to do so and demand will drop.
Our insurance just started covering Ozempic for weight loss, but they will only supply it via their online pharmacy for diabetes. If you are prescribed it for weight loss, you have to find it retail and pay a $200 copay. But at least it's for branded Ozempic, not grey market compounded meds. Mounjaro is the better product if you need for both weight loss and diabetes, but the supply on that is even worse than for Ozempic.
Why are these drugs being advertised at every commercial break on TV when the supply is so limited?
Most of the advertising I've seen has been from weight loss clinics or online pharmacies that will get you the prescription and perhaps sell you a compounded version rather than the Novo Nordisk or Eli Lilly advertising their glp1.
Increased demand can justify the high prices? Companies generally want to have a backpressure of demand outstripping supply because then they can creep prices up without impacting sales.
Alternatively, if everyone is clamoring for the drug, maybe that influences regulators/lawmakers for what gets covered by Medicare. Honestly, the way people are talking about semaglutide - it could become a drug that is just provided to everyone who wants it, by default, paid by the government. (And would probably be a net positive ROI by the government - the amount of savings and increased productivity if America reduced obesity rates by 10+% would be incredible)
They are rapidly scaling up supply, and most of the shortages have been dealt with according to the FDA and Novo Nordisk.
A cynic would say that some of those TV ads are to purchase influence with media companies and essentially buy favorable editorial coverage. More like stealth PR than something intended to drive consumer sales.
Interesting that the insurance companies aren't interested in supporting weight loss, the complications from being overweight are gonna be a whole lot worse than getting the drug. Did someone run the tables and find that obese people are dying too quickly to end up with medical bills?
I imagine there is too much churn for insurance companies to be able to be confident that they will be the ones to benefit from lower long-term health costs and not Medicare or some other insurance provider.
This is right. I worked in health insurance for a while. If you aren't in Medicare Advantage (which has relatively lower plan churn) it is very unclear that preventative spend on an employer based plan will benefit the payor that paid for it.
Not for any specific payor, but when people shop around insurances and every insurance pays Ozempic, then everyone will profit from it in the end.
But they'd also benefit as recipients of these "churning" patients. To abuse a saying, "A slimmer population lowers all insurance costs."
Health insurance has cost+ pricing in the form of capped margins. One could say it is a case of misaligned incentives. But how would incentives get aligned absent a single payer system?
Healthcare economics on of the most interesting subfields imo. Extremely tough to get markets to work here
Obesity leads to diabetes, fatty liver disease, various cancers and other problems. It's shortsighted to not cover drugs that can actually reduce it, but if the actuarial tables are silent on the matter or actually support obesity leading to lower payouts from increased mortality, then that's exactly what the insurance companies are gonna do.
>Did someone run the tables and find that obese people are dying too quickly to end up with medical bills?
Genuinely would not be surprised if this does increase medical costs for society as a whole. Obesity related deaths seem like they're more likely to be sudden compared to what might get you if you live longer.
I doubt it's anywhere near that clearcut. "Weight" by itself is neither a disease nor a symptom. I have read numerous reports saying that weight loss often does not improve outcomes for various specific problems. Or that weight loss can help, but the way that it is lost matters more than the amount lost, and losing it the wrong way can be worse than maintaining the original weight. Not to mention that there are plenty of healthy overweight people and unhealthy skinny people. So I wouldn't be surprised if insurance companies are sitting back to see what the empirical effects of semaglutide-induced weight loss are on health outcomes. Perhaps there are data available on that now; I haven't looked.
Besides, it's hard to know what the health effects really are of being overweight, because it's such a convenient rug for doctors to sweep any and all problems under. "Let's see if you still have this problem after you've dropped 20 pounds, ok?" Because clearly your weight is due to a moral failing, and it suggests you're probably screwing up all kinds of other things. Why bother to work on helping you when you're unwilling to even try to do your part? Fat => lazy and weak-willed => won't stick to medication schedule or exercise or diet or anything => unworthy of help. There's not a lot of questioning whether being overweight is an effect or has a common cause; it's assumed to be the relevant cause, or at least has a high enough probability of being the only relevant cause worth looking at because it's common knowledge.
(Neither I nor anyone in my immediate family are overweight, by the way, so don't ignore my rant by assuming I'm being bitter about personal experience.)
> (Neither I nor anyone in my immediate family are overweight, by the way, so don't ignore my rant by assuming I'm being bitter about personal experience.)
If you haven't been living with extra weight for a decade, you wouldn't have the first-hand experience of why being overweight is definitely a symptom of and contributor to health issues as well as quality of life degredation.
> I have read numerous reports... > Besides, it's hard to know what the health effects really are of being overweight...
I can agree that being overweight is often what a doctor sees, but honestly any doctor that makes assumptions like that is not interested in root causes. They're trying to see as many patients as possible, e.g. as a GP, and offer fixes for what they can fix, and referrals to specialists for that which they can't fix with the usual prescription or advice.
All this to say that I really disagree with the first paragraph, and this entire post feels like just opinion despite conjecture on what numerous reports you've read.
> there are plenty of healthy overweight people
No, there aren't. Being significantly overweight is unhealthy, full stop.
> Not to mention that there are plenty of healthy overweight people
This is only true in the most disingenuous of interpretations and look purely at BMI. The "health overweight" people are nearly exclusively those with significant lean body mass from the hypertrophy induced by resistance training. If it's fat pushing you into the overweight category, you're almost certainly unhealthy in a variety of manners. Insulin resistance, lipid profiles, blood sugar, arterial calcification, visceral fat pressing on organs, etc. etc. etc. all the way to less obvious ones like high estrogen levels in men causing issues with mood, etc.
Being overweight is one of the worst things you can do to your health.
There an are a few reasons. First, the cost of being overweight may take a long time to appear, going decades without any problems is realistic. By the time that happens there may be a different insurer on the hook(Medicare?). The second reason as you alluded to is that end of life care is extremely expensive for everyone in this country, and a shorter life span may actually save the insurer money even if there’s a massive bill for heart surgery.
And that's why health care should be universal and not subject patients to the worst outcomes of capitalistic tendencies.
It's mostly not the insurance companies. What a lot of people fail to realize is that most medical "insurance" companies no longer provide much insurance, in the sense of bearing financial risk for medical expenses. Their main business now is administering health plans for self-insured employers. If Ozempic isn't covered by your health plan then the decision was most likely made by your employer's HR department. An insurer will be happy to include Ozempic in their formulary with liberal claim approval rules if the customer wants it; they design custom plans for large customers all the time. This actually means higher profits for insurers (including their captive PBMs and mail-order pharmacies).
I also know of people who travel to Guatemala to source it.
I have to admit that I'm baffled as to what is happening here. Semaglutide is still under patent protection, so anyone producing feedstock is doing so under license with Nova Nordisk. Why on earth would NN offer licensing terms that allow them to sell the feedstock to anyone but NN? There are no generic manufacturers because the patent is still active.
Compounding pharmacies are getting the drug from the feedstock producers, but how on earth are they contractually permitted to sell it?
Your usage of the term 'feedstock' here is confusing, and it seems like you're probably operating under the erroneous assumption that contract manufacturer supplies commissioned by Novo Nordisk are somehow being routed to compounding pharmacies, which isn't the case.
In practice, there are generic manufacturers for semaglutide, and many other peptides still protected by US patents, mostly located in China. The more reputable of these manufacturers produce these drugs at levels of purity rivaling the 'name brand'. These manufacturers export lyophilized product en masse to middlemen that operate in the grey/black-market 'research chemical' sales market, or ship to compounding pharmacies. The consumers purchasing on the grey/black market reconstitute the drug at home (which requires a trivial level of effort), and assume some extra degree of risk in terms of product purity and sterility. Consumers wanting an extra level of assurance for product quality purchase from a compounding pharmacy that ostensibly is conducting its own assessments of product purity, and following best practices for sterile reconstitution.
I don't think this is true.
Henry's, one of the compounding pharmacies, says that they get the chemicals from legitimate licensed producers of feedstock [1].
There is a compounding loophole, but there is no loophole for patent encumbrances -- if a compounding pharmacy is violating NN's intellectual property, then can just sue them directly; they don't have to pursue the regulatory crackdown they're going for now.
There are companies that do grey/black market reconstitutions, like Pivotal Peptides. But they are not compounders. The compounders are legally selling the real thing directly to customers. Do you have a specific source that indicates that any compounding pharmacy is getting its feedstock illegally from China?
[1] https://www.reddit.com/r/henrymeds/comments/1av14cm/comment/..., discovered via https://www.astralcodexten.com/p/the-compounding-loophole
You're massively misunderstanding that Reddit post, and it doesn't help that the 'HenryMedsInfo' account is misconstruing how the pharma manufacturing supply chain works.
For one, the FDA does not 'license' any manufacturer, period. They do enforce safety and quality standards, but this is not controlled through some sort of a general license, and operates on a per-facility basis.
DMF listing (which isn't a 'license') does not necessarily have any relation to whether that manufacturer is supplying a brand name provider.
The 'license' that account is posting about a complete fiction. There is not a license granted here in any government context, nor a license between NN and the manufacturers the post discusses.
> The compounders are legally selling the real thing directly to customers.
This is debatable. They are not selling 'OEM' NN product to consumers.
Also - stop talking about 'feedstock'. It's weird. It's not standard industry lingo and obscures whatever the hell it is you're talking about (precursors? lyophilized product? something else?)
I'll stop saying feedstock -- I thought I saw that in the astralcodexten article but I am mistaken.
When I say "the real thing" I mean that they are selling semaglutide, which they are obtaining somehow. The reddit post was the closest thing I've seen to an answer to the question "where are they getting it".
So if they are not getting it from producers under license from NN, where are they getting it? Why isn't the legality of that path under active legal attack? There must be some fig leaf at least that they can use to say how they got the substance when the patent is still in force, otherwise judges would immediately shut them down with an injunction.
My understanding is that a significant number of them are getting them from Chinese manufacturers (that are also selling them to other Chinese companies, that then sell them to individuals, more resellers, or compounding pharmacies)
I've got a high enough risk tolerance that I've got lyophilized tirzepatide on the way from a Chinese seller. Even if I send one of the vials off to be tested, it will still be cheaper than I can get it from a compounding pharmacy in the US.
>When I say "the real thing" I mean that they are selling semaglutide, which they are obtaining somehow
>So if they are not getting it from producers under license from NN, where are they getting it?
They're obtaining it from pharma labs with the right equipment and talent to produce it. The synthesis process is well understood, it's not like it's a Novo Nordisk secret.
> Why isn't the legality of that path under active legal attack?
It is.
For at least some compounding pharmacies, their source for semaglutide is crushed Rybelsus pills.
See, for example:
https://a4pc.org/2024-04/mass-confusion/
https://subsema.com/wp-content/uploads/2024/05/White-Paper-S...
https://mynextgenrx.com/wp-content/uploads/2024/03/Compounde...
Why are Eli Lilly and Novo Nordisk suing compounding pharmacies, then?
https://www.reuters.com/business/healthcare-pharmaceuticals/...
https://www.fiercepharma.com/pharma/lilly-files-complaints-a...
Why is the FDA warning that some compounding pharmacies are using the salt forms of semaglutide and tirzepatide?
https://www.fda.gov/drugs/postmarket-drug-safety-information...
Hey, thanks -- this is great stuff!
I tried looking around at these links but I couldn't find the actual lawsuit itself, and I'm curious what they specifically say. There's a difference between saying that a compounding pharmacy is selling junk claiming that it is semaglutide (that is, making false claims that may reflect on NN when the substance is ineffective), vs. claims that the drug is being produced in violation of their intellectual property rights for the synthesis of the drug.
You can just search for the the phrase "Novo Nordisk v [company name]". For example:
NOVO NORDISK INC. v AESTHETIC MAISON LLC and AESTHETIC CASA LLC: https://www.safemedicines.org/wp-content/uploads/2019/09/Nov...
NOVO NORDISK INC. v MEDIOAK PHARMACY LLC: https://www.safemedicines.org/wp-content/uploads/2019/09/Nov...
NOVO NORDISK A/S AND NOVO NORDISK INC. v BOF MEDICAL CENTER, INC.: https://www.safemedicines.org/wp-content/uploads/2019/09/Nov...
In the Aesthetic Maison and Medioak pharmacy cases, Novo Nordisk alleges that they're selling a product claiming to contain semaglutide without a prescription or FDA approval. In the BOF Medical case, they're claiming "trademark infringement, false advertising, and unfair competition."
They're not suing for damages, just injunctive relief ordering the defendants to stop. It doesn't look like it even matters to their cases whether the products contain real semaglutide.
> Why are Eli Lilly and Novo Nordisk suing compounding pharmacies, then?
> Why is the FDA warning that some compounding pharmacies are using the salt forms of semaglutide and tirzepatide?
because $
$$$$$$$$$$$$
that's why. not safety. MONEY.
while there may be some very shady sources of fake grey/black market semiglutide that should be avoided, there are also the legal "compounders" who produce white-ish/grey market semiglutide. in the later case, it's the same active ingredient. the FDA, in it's infinite infallible wisdom (and $$$$$$$ pressure from pharma) refuses to acknowledge that while there is a tiny risk that the different buffers, processing methods, delivery and non-active ingredients, etc. have "not been studied" and might not be "less effective", that these are really small risks. tiny.
i feel like the FDA deliberately conflates the dangers of questionable overseas knock-offs with the legitimately pure, regulated, legal products of compounders.
are these guys violating a patent or two? meh? (note: this is a tort, but is not illegal) so sue them. but is it safe? it's as safe as anything else the FDA allows.
meanwhile we keep supporting a system of patents in medicine (and software) that are actively doing exactly the opposite of what the system was put in place for: stifling innovation instead of encouraging it. padding the rich cats pockets instead of giving the small guys a chance.
You misunderstood my question. I'm pointing out that the compounding pharmacies and the med spas the buy from them are not getting it from any sort of official source - thus them getting sued.
I've swapped to buying from Chinese manufacturers and reconstituting my own so I'm not exactly lining the pockets of Eli Lilly or Novo Nordisk ;)
Compounded drugs have a difficult line to walk. AFAIK, compounded drugs are those which are made custom to the patient due to allergy, or unavailability. The concern is when a compounding pharmacy makes a drug that already exists on the market, but the pharmacy sells it anyways even though it's identical, or at a lower cost.
There's also value in individualized dosing. I take tirzepatide, and 5mg is too intense for the first couple days, but 2.5 doesn't last long enough. Ideally I'd take 2.5 every 4 days, instead of 5.0 every 7 days, but that option doesn't exist, but is something that compounding could provide. But I'm not willing to risk the safety-murkiness of compounding, so just stick with the 5.0 and deal with it.
compounding veterinary medication was also common during Covid during medication shortages.
It’s a way to get the same medicine just through different suppliers and circumventing various restrictions/regulations, and then prepared by the compounding pharmacy for ingestion by the patient.
Common use cases are, in animals for example, you might need to put a dog a medication and the supplier may not manufacture the right size dose (or maybe your animal won’t eat pills so the compounding pharmacy reformulates it into a liquid)
My veterinarian recommended sticking with brand name meds for my dog even though I was having trouble due to the size of the pill. Her reasoning was compounded equivalents simply aren’t tested in any medical or academic trials, only brand name formulations are tested in trials, so there’s no guarantee of efficacy since you’re literally taking a formulation of a medication that has gone through zero scientific testing (the isolated ingredients or a similar formula may have trials and testing, but not the exact formula you’re taking)
Which is also why no compounded drug can be FDA approved.
Logically I want to trust compounding pharmacies and I want to believe the efficacY and side effects are equivalent to name brand.
But the fact that my veterinarian cautioned me against compounding my dog’s medicine gave me pause about compounding medicine for myself…
the modern twist is that large health startups like Hims and 23andme are getting into the compounding business and the drug makers arent happy to have the competition.
Hims bugs me a lot with these compounded all in one masculinity drugs. We don’t know the effects of mixing the timing of these drugs in one shot.
Hims strikes me as a giant liability lawsuit just waiting to happen. The things they are selling should never be advertised/sold that recklessly. All they're doing is playing on folks insecurities and potentially giving them serious medical issues down the line due to their willful negligence with prescribing/distribution
Truly I think male pattern baldness drugs are poison and hims is probably a net negative for society at this point.
Which?
The one (and only) time I filled a prescription for propecia a couple decades ago, one of the warnings said something akin to: pregnant women should not even touch a broken propecia capsule due to the risk of birth defect.
After that, I decided to just allow nature to take its course on my hairline.
> The one (and only) time I filled a prescription for propecia a couple decades ago, one of the warnings said something akin to: pregnant women should not even touch a broken propecia capsule due to the risk of birth defect.
Lots of drugs are bad for pregnant and/or nursing women. Propecia is not particularly special in this regard, nor is it especially dangerous compared to all the other drugs out there which are also bad for pregnant women.
"Do not handle" is a warning for topical formulations, just because those are intended to be absorbed transdermally.
I got finesteride from them and used it for a couple months. Stopped taking it and my nuts ached for almost 2 weeks.
At one point I was going to a human compounding pharmacy to get drugs for my cat. I don’t even remember what it was but they put it in fish oil to make it more palatable. Did not work.
I purchased four 5ml bottles of semaglutide from China for $50. It's available at underground lab steroid sites and easy to find. Many people are ordering this and getting them tested and the results are posted. I realize the risk.
Why not just exercise?
I'm 6' 2" and weigh 215. I ride my bike 20 miles/week. Not a lot, but not nothing. My goal isn't really to lose a bunch of weight. I'm always hungry and I'm eating plenty. There's an ongoing hunger background noise in my stomach and brain. I'm definitely doing some self experimentation to get this figured out.
You can't exercise out of being fat.
It's a hugely important thing to do for your health in general, but the amount of effort needed to counteract the modern diet via exercise is absurd.
The alternative is eating better - better food, less calories. But for a lot of people, they have tried and failed to do this for years. Even people that have had a history of being able to do this successfully can find themselves struggling. And once you're fat, the feedback loops kick in and make it more and more difficult. Is it within everyone's power to not be fat? Yes. Is it significantly harder for some people for a variety of reasons? Also yes.
So we could act like this is a moral failing and fat people should just be fat until they manage to scrape together the willpower to ignore their body pushing them to eat, or we could recognize that these medications are extremely effective at helping tame those signals their body is sending. (Plus seeing a tons of other positive impact on things like fat deposits in the liver, insulin resistance, cardiovascular protection, sleep apnea, etc. - and these are seen even before significant weight loss occurs.)
These medications aim to reduce the addictiveness of foods. A very apt analogy is nicotine gum/patches. This is that, but for food (although early studies also show success for opioids and alcoholism).
I feel like there is a lot of hypocrisy going on around this. People asking overweight/obese people "why not just eat less?!" and people responding "GLP-1 medications help me do just that," and the critics essentially saying "it is unfair fair that this drugs helps you do the thing I claim I want you to do."
Also, calorie restriction, not exercise is what successful people use to lose weight. Exercise is highly recommended and will help you live a long and healthy life, but it won't help an Obese person loose >20 lbs of body fat. TDEE and calorie restriction will though.
> Why not just exercise?
"Why not do the more difficult thing instead of the very easy and cheap thing that also accomplishes your goal?" will always be a bizarre question to ask in earnest. The answer should be so glaringly obvious that the question just falls out of your head.
Exercise makes you hungry, so hard way to lose weight when the root of the problem is in the eating.
Because it's not that simple.
Lets be clear on how all this works.
Someone made a drug, and they want all of the money for their work.
Maybe that's justified, maybe it isn't.
But because we use money as both our dopamine reward and also the entire basis of how we allocate all scarce resources in our finite reality, and because patents are the only way for them to get said dopamine reward/resources, the strat is to just let millions of people sit in the crossfire while we work out what kind of money they should get.
> patents are the only way for them
Citation needed.
Too bad there's no drug that cuts down on greed.
I read that Ozempic works against all cravings, even addictions. Maybe we can cure money addiction.
If ketamine can't chill these people out, I'm not sure there's a chemical solution. Their brains might just be yet another neurodivergency.
They come back from ayahuasca trips thinking they've unlocked some profound knowledge after experiencing ego death but in the end they just tweak what they were doing before and add fresh wise-guru paint to their operation.
SSRIs are commonly prescribed for hoarding disorders.
You think billionaires would let that come to market? hah.
They already got many many billions. If there's a mechanism for medicine to skip extra studies when extraordinary efficacy is shown, why is there no mechanism to skip the patent protection and crank out at scale what can prevent so many bad health outcomes in the future. Hell, give them another $10B, who even cares, it's saving much more in healthcare expenditures.
I have a family member that went on Ozempic.
After decades of suffering with weight problems (and resulting health issues), Ozempic brought about life-changing results in months. It is a fantastic drug, and I hope it becomes widely available as soon as possible.
https://archive.ph/hrnrO
I'm curious as to what steps are taken to compound Ozempic? Could I try this at home?
If by compounding you mean producing semaglutide, no.
If you have a source to buy lyophilized semaglutide and some BAC water, you could certainly reconstitute it yourself and pick a dosage, or compound in some vitamin b12 or similar.
In practice for an average person, this means either buying them as research chemicals directly from china, or from resellers that mark it up by 10-50x. You might get a COA that testifies the chemical in question and it's purity level for that batch, and maybe that COA will actually match the batch in your vial. But you almost certainly won't get any guarantee on sterility. And there are reports of the contents of vials getting mislabeled, so people got entirely different products.
You can try to counter some of the sterility issues with filter syringes, etc., but you're only mitigating some risk, not eliminating it.
They're buying semaglutide salts from China and mixing it into distilled water. It's not that difficult. I wouldn't trust the sources to be pure and not doped with something else though. You're taking an even larger risk with an injectable.
Assuming you can get your hands on actual raw semaglutide and know what you are doing, absolutely. It's not rocket science, drug dealers do that all the time. Pill presses can be had on Alibaba for a few hundred bucks and you can order virtually anything from "research chemical" online stores as well.
But it is not risk free either. Contaminations of all kinds are the worst issue (particularly with anything supposed to be injected, so never try it with insulin...), but the most pressing one is agent distribution. That's what causes a lot of people to OD on stuff cut with fentanyl - if the fent, the actual drug (say, heroin) and the fillers aren't properly mixed, you may end up with a bunch of pills with far higher doses than intended while other pills essentially consist of pure filler.
bear in mind, Ozempic is dramatically more expensive in the USA then any other country. The Pharma company has explicitly decided to price-gouge the United States. USA is 1300 versus 300 in canada.
https://www.healthline.com/health-news/heres-how-much-more-o...
So yeah, fsck these guys. I have _zero_ problems in that context with the compounders here.
Additionally, semaglutide was developed as a drug for diabetes. It took a decade or so for NN to realize they walked backward into a giant money pit with the weight and addiction component and they are doing their damnedest to get every last cent they can before the patent expires. As is their prerogative, technically, but at this point I think this drug promises a real significant public health benefit that we haven't seen in our lifetime, especially around addiction and other impulse disorders.
Millions of peoples lives could be made better within months if this stuff was made freely available tomorrow. It would cause all manner of downstream benefits for society, in particular I think it would have a real impact on reducing some load on a healthcare industry that is buckling at the weight of our collective unhealthiness.
I honestly think the FDA should find a way to put the screws to NN such that they reduce the cost of this drug and license it at an affordable cost to the compounders.
All meds are. The US has to pay top dollar to subsidize the worlds drugs.
You're right that drugs are generally more expensive in the US, but it's not because "the US has to pay top dollar to subsidize the world's drugs".
It's simply that companies charge more in the US because they can.
And the reason they can is that the US hasn't got its sh*t together to stop the drug companies from doing this. For this, blame your political system and the power that money has to influence your politicians and set policy.
Indeed, the US needs some good ol' fashion protectionism
It does not have to. It chooses to pay higher prices to """subsidize""" the research that is already paid for by my tax dollars, and to help pay for """development""" that amounts to changing a drug from a mixture of both chiral versions to just the biologically active chiral compound, which somehow justifies another 25 years of monopoly for the exact same chemical.
They could barely be bothered to change the name because they didn't want to lose brand mindshare.
The vast majority of drugs have a positive ROI after two years on the market.
Almost all drugs currently on the market are older than two years.
And yet, prices are still much higher in America than elsewhere.
Therefore I posit that greed is the motivator, not ROI.
Don't fall for the propaganda.
It's worse. They want Ozempic for all through Medicare. At those prices that's 3 trillion dollars. As RFK Jr. put it, for $3T we could give every man, woman, and child in the United States three organic meals a day. Or pay for gym memberships, which would be even cheaper.
The President could issue an executive order saying Medicare won't pay a higher price than EU nations or Canada. If they want to raise their prices there, fine. But we're not going to be the ones paying through our nose because you think the American taxpayers have bigger bank accounts.
> They want Ozempic for all through Medicare.
Right. It seems pretty obvious who is behind all these media articles proposing these drugs being given to all overweight people.
The President has no statutory authority to issue such an executive order. We don't live in a dictatorship.
Medicare is provided by the Department of Health and Human Services, which is part of the Executive branch of the U.S. federal government which is answerable to... the President.
We don't live in a dictatorship, but the President absolutely has the power to say how much Medicare is willing to pay for a particular drug. President Biden could do this today, if he chose. The President can't say how much pharmaceutical companies may charge. But that's not what we're talking about here.
Nope. You're making things up. Just because the Department of Health and Human Services is part of the Executive branch doesn't mean they can obey an illegal order from the President.
Medicare is authorized to negotiate drug prices in certain limited ways. But that doesn't extend to setting a maximum price by executive fiat. Instead of posting nonsense you could try reading the law.
https://www.cms.gov/inflation-reduction-act-and-medicare/med...
An executive order directing the implementation of reference pricing is not illegal and is permitted under the ACA. Reference pricing includes being able to say, for example, that Medicare won't pay more than the cost of the same drug in Germany.
I'm not making things up, you're just ill informed.
https://www.ssa.gov/OP_Home/ssact/title11/1115A.htm
Nothing in the Affordable Care Act of 2010 grants the President (or any part of the executive branch) the statutory authority to implement reference pricing or otherwise set a limit on the prices of prescription drugs purchased under Medicare Part D. Your citation of 42 U.S.C. § 1315a is irrelevant and concerned with entirely separate programs. For something more relevant see 42 U.S.C. § 1320f as well as the current CMS guidance. The law requires a defined drug selection and negotiation process which can't be overridden by executive order.
https://www.cms.gov/files/document/medicare-drug-price-negot...
Can ozempic help one get shredded?
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It's great and I'm happy for you that you have a body that is such that you can do that. Many people do not have similar experiences. Often times people who are not able to do things like are labeled as having a lack of control or a failing in the character. The truth is that many people have different chemistry which makes doing something like this borderline impossible.
Its pretty much my only option, I asked for help years ago and doctors just don't give a shit.