A class of prescription weight-loss drugs is transforming weight management to the point that manufacturers are struggling to keep up with demand. big pharma continues to bet big on it and the market could be worth $150 billion by 2030.
When Johannesburg-based Kendi (name changed to protect privacy) was pregnant with her second child, she developed gestational diabetes. She didn’t have a family history of the disease so learning how to manage her sugar while nursing a newborn was a mine- field. After years of interchanging injections, patches and pens, her endocrinologist recommended Ozempic to go along with her insulin. Kendi wasn’t on Ozempic for weight loss although in the beginning, she did lose a few kilograms. Her doctors were happy because the drug was working as it was meant to and her blood glucose levels were signifi- cantly lower. The only problem was that when she went to collect her prescription, the pharmacy had no stock. Even the diabetic center was struggling to keep up with scripts, eventually creating a rule that they would only dispense medication if you were a patient at the center. “There are still times when I can’t get the right dosage and only the smaller pens are available,” she says. “You end up injecting double the amount; the pen finishes much quicker and then it’s back to the beginning…”
Welcome to the Ozempic era. A drug originally devel- oped to help treat adult-onset diabetes by stimulating insu- lin resistance is now being used to fight the global obesity epidemic. Novo Nordisk’s Ozempic (and Wegovy) belong to a class of drugs known as GLP-1 receptor agonists and they’re transforming weight management to the point that manufacturers are struggling to keep up with demand, something that hasn’t happened since anti-HIV drugs launched in the 1990s. But it’s not only injectable sema- glutide, the active component in Ozempic and Wegovy, there’s liraglutide (or Saxenda, also from Novo Nordisk) and tirzepatide (Eli Lilly’s Mounjaro and Zepbound) on the market which also target GLP-1 receptors, though they work through different mechanisms and have varied dos- ing schedules.
It’s a lot to take in. To say anti-obesity medicine is big business is an understatement, with Goldman Sachs ana- lysts predicting that the market could be worth $150 billion by the early 2030s.
Shares for both Eli Lilly and Novo Nordisk are also booming, with the two pharmaceutical giants controlling around 80% of the obesity market. And while global spend- ing on obesity medications hit $24 billion last year, Ameri- can multinational company IQVIA’s estimation is that it should reach $131 billion by 2028. It’s no wonder that big pharma and biotech companies like Viking Therapeutics, Pfizer, Amgen and AstraZeneca are all hoping to break the weight-loss duopoly and launch their own GLP-1-based treatments.
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In the United States (U.S.), a month’s supply of Ozem- pic costs around $1,000 (R18,000), depending on insurance coverage and dispensing pharmacy. Each box of Ozem- pic contains four weekly doses, administered by a pen. In South Africa, the price is significantly lower, starting at R1,500 ($85) for the minimum weekly dose. According to SAHPRA (South African Health Products Regulatory Au- thority), Ozempic is not registered for weight-loss use in South Africa. Saxenda, which is the same product as Vic- toza when used for diabetes, costs between R2,500 ($141) to R4,000 ($226), depending on the dose required.
Satiety and sugar control
First approved by the U.S. Food and Drug Administration in 2005, GLP-1 drugs like Ozempic or Wegovy, an injectable form of the drug semaglutide, was approved for adults with type 2 diabetes back in 2017. Semaglutide mimics a natural hormone in the body known as GLP-1 that plays a key role in controlling blood sugar and appetite. When blood sugar levels rise, these drugs help the body produce more insulin to lower it, while also reducing the amount of glucose re- leased by the liver.
Dr Brad Merwitz, a Johannesburg-based endocrinolo- gist, sees a number of patients every week that enquire about Ozempic. Of course, not everyone who comes to him is looking for a weight-loss miracle. Some people have pre- existing medical issues like diabetes or other co-morbidities and have read up about the drug. But with Ozempic, there’s something that he has never experienced before as a doctor – people asking for a drug by its name. “There’s been a shift. People used to ask about weight-loss drugs [in general] but not to this extent,” says Merwitz. “People now know the names of the drugs but not necessarily the side-effects, the cost or indications. They just know that there is this ‘wonder drug’ out there that can help them lose an enormous amount of weight in a short amount of time.”
Weight loss is not only the positive side-effect of Ozempic. Once the drug is in your system and the common, gastrointestinal side-effects like nausea, vomiting and diarrhoea dissipate, there are long-term benefits like improved liver function and lower stroke rates. A study published in The New England Journal of Medicine found that semaglutide reduced the risk of cardiovascular diseases (CVDs), including events like heart attacks and strokes, by around 20%.
Professor John Deanfield, the study’s lead author, said that semaglutide should be routinely prescribed to treat CVDs — a significant breakthrough, given that no previous weight-loss drugs have demonstrated similar cardiovascular benefits.
This is especially impactful for Africa, where car- diovascular disease is a major cause of death. What makes this finding even more remarkable is that the benefits extend beyond weight loss; participants with only mild obesity or limited weight loss still saw signifi- cant improvements in cardiovascular health.
A mental shift
Another unexpected side-effect links to the brain and has neuroscientists excited about the connec- tion between GLP-1 and substance abuse disorders and behavioral issues. There are already signs that drugs in this category could treat neurological con- ditions like Parkinson’s disease, Alzheimer’s or even be repurposed as anxiety, depression or eating dis- orders’ medication. One of the most common pa- tient responses to taking semaglutide is that it helps to reduce ‘food noise’, a term often used to describe cravings or continual thoughts about eating. In the European Journal of Clinical Nutrition, they refer to GLP-1 as a ‘satiety hormone’. This is because sema- glutide works by mimicking the hormone GLP-1, which affects multiple areas in the brain responsible for appetite regulation and fullness.
Merwitz says that what’s important to remember is that these drugs don’t work as a stimulant, like am- phetamines which were used in the past for medical weight loss. “They don’t have those central, neurologi- cal side-effects like the older weight-loss formulations. There is no addictive potential to them,” he adds. That said, Merwitz’ advice is that patients with diabetes should take precedence because there are multiple deleterious effects to uncontrolled sugar. That said, not every diabetic needs Ozempic – the ideal candidate for the drug should also be obese and have cardiovascular issues. “Moving forward, should funding and public health models allow it, these will probably become drugs that are used a lot earlier because of their cardio- protective effects and cardiovascular benefits,” he says.
A silver bullet?
For off-label use, it’s recommended that patients fol- low strict, calorie-controlled diets alongside other healthy habits like regular low-impact workouts. In fact, research from the Diabetes Care journal found that people who used Ozempic in conjunction with exercise lost significantly more weight than those who used Ozempic alone. “It’s not a silver bullet,” adds Merwitz, who says that what the literature says is that a third of people will have a very good response to GLP- 1, the next third will have an average response, and the last third of people will have no response. “Anecdot- ally, it’s not been my experience that as many as a third have no response.” While these drugs are designed for chronic disease, and the guideline is that you should be on them for a minimum of 12 weeks, people do stop for a number of reasons ranging from that they haven’t seen any weight loss to simply not being able to afford the treatment long-term.
The question really is – is the weight loss worth the cost? And when you stop a drug like Ozempic, have you put enough lifestyle modifications in place that the weight doesn’t return? In a CNBC interview with a senior executive from Novo Nordisk, it was said that most people will recover most of their weight within five years of stopping an obesity drug.
Some individuals may actually gain more weight after stopping an obesity drug than they initially lost. ‘Ozempic rebound’ is common, without the right life- style interventions in place.
But unlike bariatric surgery, which is a permanent procedure (and that comes with post-operative com- plications), GLP-1 drugs are a well-tolerated and re- versable solution.
Goldman Sachs estimates that GLP-1 agonist drugs could be used by up to 70 million consumers world- wide by 2028. In South Africa, where obesity is wide- ly prevalent, Ozempic could be revolutionary. “It’s a very exciting space,” says Merwitz. “Hav- ing these drugs available has really changed the way we manage obesity. It’s given us options we’ve never had before.”
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