Fresh questions are being asked about the use of weight loss injections after pharmacists demanded a clampdown.
Millions of Brits are now eligible for the appetite-suppressing jabs which can come with unpleasant side effects but NHS rationing means only a tiny fraction will be prescribed them. This has led to huge demand for expensive private purchases of the weekly injections which slow digestion by mimicking a hormone called glucagon-like peptide 1 (GLP-1) which regulates hunger and feelings of fullness. However many patients have complained of side effects such as vomiting and stomach cramps.
Amid a new year boom in demand the National Pharmacy Association (NPA) has urged regulators to require greater consultation with patients before dispensing them. The problem is that without ongoing tailored support from clinicians and dietary experts, users of GLP-1s do not tend to transform their diets and exercise habits. They simply eat less of the poor diet they have always ate.
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If this happens users will still lose a lot of weight initially – but importantly they lose muscle mass as well as fat. If they stop the injections because the side effects become too much, or they can no longer afford what is an expensive treatment, then they pile the fat back on. But muscle mass does not return. This leaves people much weaker and with less muscle with which to burn calories. This means losing weight in future will be much harder.
NHS leaders know this and are grappling with how to fund the essential support people taking these weight loss jabs will need. It is far from certain whether remote monitoring and the occasional video call via an app – currently being trialled – will be enough to help people make the necessary lifestyle changes. Despite these problems some in government have suggested GLP-1 jabs could be key to getting people on sickness benefits back to work.
Prof Sir Stephen O’Rahilly, director of the Medical Research Council Metabolic Diseases Unit at Cambridge University, has said: “The genie is out of the bottle here. Safe and effective drug treatment for obesity is not going to go away. We must continue to work on making our environment less promoting of obesity. But that will take political will and time. Even if we do so, there will still be people who develop obesity because they have a very strong inherent predisposition. Medicines such as tirzepatide will become a central plank of how we help people living with obesity to live longer and healthier lives.”
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Tirzepatide, also known by its brand name Mounjaro, was shown to help obese people lose 21% of their body weight in 72 weeks during trials. It was dubbed the “King Kong” of weight loss drugs by US expert Dr Julio Rosenstock after its effect size emerged , compared to the “gorilla” of Wegovy.
The two biggest selling GLP-1 drugs are branded as Wegovy or Ozempic – both the same drug semaglutide but sold at different doses. Semaglutide was originally designed to tackle Type 2 diabetes but was repurposed for obesity and trials showed its stronger dose form, branded as Wegovy, could help users lose 15% of their body weight in 68 weeks. Ozempic is only prescribed on the NHS for diabetes.
The semaglutide drugs, manufactured by Novo Nordisk, saw global shortages after celebrities including Sharon Osbourne, Elon Musk and even ex-PM Boris Johnson boasted about buying them privately for weight loss.
After semaglutide came Mounjaro which, as well as mimicking GLP-1, also targeted a hormone called GIP to boost this effect on appetite suppression. Mounjaro will start being given to the most dangerously obese from the end of March. But the NHS spending watchdog has announced it will only be given to 220,000 people in England during the first three years – despite 3.4 million people being eligible for it.
Lack of NHS capacity to provide this counselling support from clinicians is the reason millions of those eligible will have to wait up to 12 years to be offered the appetite-suppressing jab. Those already accessing this support will be prescribed Mounjaro in the first tranche.
Announcing the rollout plan last month, Dr Kath McCullough, NHS England’s national specialty advisor for obesity, said: “Obesity is one of the greatest public health issues facing the NHS and weight loss drugs, such as tirzepatide, are an important tool in helping people lose weight while also reducing the risk of other serious long-term conditions such as diabetes, strokes and heart attacks. However, on their own, weight loss drugs are not a magic bullet. They need to be prescribed by a healthcare professional alongside programmes that help people lose weight and live healthier lives by making changes to their diet and physical activity – and it’s also crucial that they are prioritised for those who need them most.”
Earlier NICE guidance stated anyone with a body mass index (BMI) of more than 35 – considered class 2 and class 3 obesity – and at least one weight-related illness would qualify for Mounjaro. Examples of weight related illnesses are hypertension, dyslipidaemia, obstructive sleep apnoea, cardiovascular disease, prediabetes, or type 2 diabetes.
In common with all new medications, we simply do not know the long term consequences of mimicking our hormones which regulate hunger. Many experts who are in favour of GLP-1 argue that the dangerously obese patients who need these drugs will not live long enough to find out if they don’t take them.