We dream of pills that will make us slimmer, stronger, smarter or younger. Advertisers insist that they have precisely what we want.  Drug companies tease us with pills and injections that accomplish some of what we desire, but they spoil the fun by inevitably discovering some problem with the ‘wonder drug’ that they insisted was safe and effective. 

Unfortunately, numerous ‘safe and effective’ drugs proved to be unsafe after they were widely consumed. Heroin was developed as a highly effective cough suppressant for children. Unfortunately, their coughs were replaced by opioid addiction and withdrawal torment. Amphetamines helped people reduce their need for sleep and was an excellent appetite suppressant. They also caused seizures, psychoses, and deranged judgment. Anabolic steroids could transform a skinny teenager into a world-class body builder. With that world class build came coronary arteries that barely supplied blood to an overstressed heart.

The most recent wonder drugs vying for our affection are weight-loss remedies.  Advertising for Ozempic [semaglutide], Wegovy [semaglutide] and Mounjaro [tirzepatide] has been intense. Another agent, Zepbound [tirzepatide], has also been approved for weight loss, and it will soon be the subject of an advertising blitz. Ozempic and Wegovy have the same active agent, as do Mounjaro and Zepbound, but each of these drugs has been approved for type 2 diabetes mellitus management or weight loss, but not for both. That companies can sell the same agents under different names for different indications is a consequence of U.S. Patent laws that require different approval routes for drug use targeting different problems.

Expectations are high. That our dream for a simple cure for obesity will again be frustrated is tangible. Time will tell.

We have been disappointed many times before. Weight loss remedies usually fail us either because their desired effects are transient or because their adverse effects are permanent. The combination drug containing fenfluramine and phentermine and referred to as Fen-Phen in the 1990s had short-lived popularity as a weight loss agent.  It did help considerably in reducing a person’s weight, but it also caused heart disease and lung complications.  It was banned in the United States in 1997.

The latest candidates, semaglutide and tirzepatide, promising to make us slim down effortlessly are delivered by injection. They fool the brain into feeling ‘satiated’ after eating relatively little and slow the gastrointestinal tract to discourage our gorging ourselves after we have had relatively small food portions.  Some people have had extreme effects with virtual loss of appetite for days or weeks and others have had protracted paralysis of the gut. These have not been frequent problems, and who is at most risk for these undesirable effects remains to be determined. No other widespread, severe side effects have been identified yet, and hopes that these drugs will prove as safe and effective as other life-altering drugs remain high.

As with all innovative approaches to widespread conditions, the pharmaceutical industry is poised to make windfall profits. The list price of a month’s treatment with these drugs will range from about $1,000 to $1,300.  How long the patient takes the drugs will be decided by the physician and the patient, but it is likely that people with robust weight loss on the drugs will urge their doctors to continue the drugs indefinitely or will shop for a doctor who is accommodating. 

The drug companies will argue that these highly inflated prices are still much less than the cost of bariatric (weight loss) surgery or liposuction. That competition will reduce the cost of these drugs is unlikely, since demand is high and price inflation is more likely than price reductions. Drug companies will report ‘rebates’ and ‘assistance plans,’ but experience with other block-buster drugs indicates that the manufacturers will charge whatever the market will bear for the next ten to twenty years, limiting competition by legislation from a friendly U.S. Congress and payoffs to potential competitors.

The benefits of semaglutide and tirzepatide look real so far, especially for obese individuals with type II [aka, adult onset] diabetes mellitus. Weight loss alone may diminish or eliminate many of the complications of adult-onset diabetes mellitus.  The obvious disadvantage with these drugs is that people without obesity, including people with anorexia nervosa, a condition in which the affected individual may starve to death, may abuse the drugs with fatal consequences.

As with innumerable drugs that appeared safe and effective when they were first marketed, these new weight loss drugs may surprise us in the months and years to come with side effects overlooked [or even concealed] in their development. Alternatively, they may provide longterm benefits for those of us perpetually losing the battle between our appetite and our waistline. We shall soon know if this brave new world of injectable appetite and gut motility suppressants fulfills our dream of weight loss ‘without tears.’

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan.  He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the U.S., as well as in England, Germany, and France.

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