The Top 5 Ways Ozempic and Friends Has Changed My Medical Practice

Most pancreatitis patients in the hospital are there because of alcohol. This varies with the surrounding demographics of any given hospital. Other reasons include gallstone issues, fatty meals and famously for board exam takers — scorpion stings, but I remember the first time Ozempic was identified as the cause of pancreatitis. The patient was in the ICU which is kind of impressive for a pancreatitis admission. They did fine eventually but it was a brutal case of pancreatitis — a very painful experience.

Specialists are usually the first adopters when it comes to new medications. I had not prescribed a GLP-1 type of medication before I took care of the that pancreatitis patient in the ICU. Since then, I’ve prescribed these type of medications more times than I can count.

I have become incredibly interested in this class of medications. I’ve done some deep dives so I can feel competent with management of these medications. Here are the top 5 ways this medication and the demand for them have changed my practice:

• Number 5

From the saliva of the gila monster comes the medication being pushed by Kim Kardashian on IG. Ozempic and Wegovy are both brand names for semaglutide, which is in the glucagon-like-peptide agonist category, otherwise known as GLP-1 medications. In 2017 Ozempic was approved for the treatment of diabetes. Soon it was recognized that this medication had potential as a weight loss drug. This dynamic, a so-called “side effect” of a medication that is then recognized as a separate treatment option reminds me of a story I regularly tell patients in the clinic. Viagra is a medication (sildenafil) which was developed for angina and pulmonary hypertension — both issues improved with the dilation of arteries — in other words, the medication relaxes arteries allowing for more blood flow. More blood flow in the right place, and voila, we have pulmonary hypertension patients telling their doctor about their improved erections.

By the way, the origins of these medications does come from the gilla monster -- this article will tell the story better than I can.

While that story is interesting, it allows me to go into the discussion of possible side effects of Viagra when we understand that arterial dilation is what the medication does in the body. The GLP-1 story is less sexy, in a way, but if one is losing weight and getting great erections, then, I guess, it is still kind of sexy. I have plenty of patients who want to or are already taking Viagra, or one of the others (my favorite name of a medication is tadalafil — Tada! The fill!) and I have a way were patients can get these medications cheap and for now, there is no major supply issue with these medications. This is not the case for GLP-1s. Supply is extremely short and without insurance, it’s an easy $1600 per month for an injectable GLP-1. In the past year, I think I’ve had more people interested in these medications than I have for the “magic boner” pills. In June of 2008 a clinical, phase II trial began for the medication called semaglutide — which, in brief, is a glucagon-like-peptide-1 receptor agonist. This means semaglutide is very similar in structure to the actual GLP-1 our own bodies make, and binds to the receptors our body also makes that GLP-1 molecules attach to, and this is like a switch in the body which then, in turn causes something else to happen.

Ideally, any medical provider knows very well the mechanism of action of any given medication they are prescribing. The demand for this medication has had me reviewing and learning about how exactly this medication works in a way I haven’t had to do in the recent past.

This includes learning about the ways this medication may help with more than just reducing average blood sugars and obesity. A recent trial is showing that it helps with fatty liver disease — which, in my mind is one of those “well, duh” situation as we know that in NAFLD (non-alcoholic-fatty-liver-disease) improves when one loses weight and average blood sugars are decreased. But, we do these studies anyway and I’m glad we do, as we are often surprised at the results these endeavors reveal.

I’m really excited about the idea that these medications can help with all kinds of addictions. I think, in some ways, many of us humans are addicted to eating — perhaps at a “sub-clinical” level but nevertheless, most of us eat for more than mere sustenance. If we ate just to exist, spices would not exist. And, what is spice, if not the spice of life?

I suspect that this medication will help with addictions that don’t involve exogenous compounds — think heroin, nicotine, alcohol — anything you put in your body. The addictions that involve a certain behavior and not using a substance are in some ways, more insidious and difficult to resolve than those with a needle in one’s arm. A gambling addict is looking for that neurotransmitter fix — that dopamine hit, so to speak. This medication may very well help us do what we’ve struggled to do our selves — be better people for ourselves and our loved ones.

There is a current Oxford trial looking at helping with dementia — Alzheimer’s Disease in particular. There will be more coming soon, in terms of ideas and explorations of what these medications can do for us.

The 5th most impactful way Ozempic and friends has changed my medical practice is having to realize that this may end up being the biggest revolution in my prescribing practices since I started my career as a doctor. A salve for any given itch? Better living through chemistry, as they say.

• Number 4

In 2012, Novo Nordisk, a Danish pharmaceutical company developed this medication into a once per week injectable medication. Semaglutide binds closely to albumin in the blood, allowing the half-life of the medication to be approximately seven days., making injection an ideal route of administration.

The clinical trial looking at how this medication worked in the diabetic population was completed in 2017 and later that same year, it was brought to the US market for this very purpose — to treat diabetes.

In 2021 a trial was started looking how it could treat obesity. And in June, 2021, Wegovy, identical in structure to Ozempic but coming in a little higher top dose was approved for the treatment of obesity. It didn’t take long for people to see the benefit.

“Ozempic Face” has become a thing — with rapid weight loss, the skin of the face doesn’t have time to adjust and the skin can look as it if is sagging off of the skull itself. It has spawned a whole industry focused on using fillers to treat this condition. The endless Tik-Toks, Youtube videos, IG posts and all the hype surrounding this medication stems from a hope that we can be thin.

I’m not discounting the health benefits that come from losing weight — they are real and very important. But there is no doubt that the push for these medications, at times, comes from a desire to be thin. To be attractive. To be a person who is easier to love. To be a person that people wish to be.

Okay, there is a lot to unpack with this and this will be done in other offerings but we’re staying more surface level with this one. The emotional toll of being overweight in this culture is something that runs deep. A seminal memory of mine is one of the older kids calling me a “fat farmer”on the school bus on the way home and letting it get me so angry that I attacked these kids and basically lost my shit — I remember rage crying and telling my mom she needed to kill these kids for me, after all they humiliated me. I was probably six or seven. I remember one kid trying to give me the nickname “bakery” as he said I had a lot of rolls, afterall.

The 4th most impactful way Ozempic and friends has changed my medical practice is having to confront my own insecurities and deep seated feelings of shame and inadequacy when my own body is not in great shape. This can be helpful in the clinical setting, afterall, empathy is usually a good thing.

• Number 3

Most of the insurances will deny payment for these medications, especially Wegovy, which, again is the one used for obesity alone. Some patients will go above and beyond to find a pharmacy that has supply, but that is a lot of work and can involve calling dozens of pharmacies, if not more. Some patients are willing to pay out of pocket for these medications (always check for that sweet manufacturer’s coupon) — if they can find it, of course.

I’ve had to tell my patients that if the medication is not covered by their insurance we will do one pre-authorization claim. Most patients have no idea how much time behind the scenes a pre-authorization process can take and how frustrating the insurance companies make the process. These kind of time sinks are nearly impossible to do with a skeleton crew. My day, depending on the schedule, is eaten by form completion and inbox replies that often would be taken care of by staff. Somebody still needs to communicate with the patient.

The 3rd most impactful way Ozempic and friends has changed my medical practice is having to have a discussion regarding how many pre-authorization attempts we are able to do. I try to frame this in a way so the patient understands our limitations and the nature of this fruitless endeavor.

• Number 2

Many patients will have a BMI that is above 30 but be below 5.6% with their A1c, have great blood pressure and a decent lipid profile.

Not long ago there were reports of insurance companies investigating doctors who were fraudulently using a diagnosis of type 2 diabetes so the medication would be paid for by their insurance companies. This is medical fraud. I’ve had to take a hard stance with my patients, in that I will not use a diagnosis that is not true to get a medication covered. After all these years of education and the debt associated, I basically have one way to make a living and support my family — and that is to have an active and unrestricted medical license. Most patients understand this.

The 2nd most impactful way Ozempic and friends has changed my medical practice is dealing with patients who are upset they are not prediabetic or even diabetic — they are too healthy to qualify for the medication. Kind of like the middle class of the medical world. There have been times I’ve almost felt bad telling a patient their A1c is in a fantastic range. What a world.

• Number 1

And the most impactful way Ozempic and friends has changed my practice is by looking at obesity, more than ever before, as more than a just a will-power issue. We know this, most of us know this. I may know this. more than most, with my own history, my family’s history and of course, being a doctor.

But the dynamics that have trapped us — as US citizens — but also as obese people also applies to our overall health — mental health perhaps as intertwined with obesity as anything else could be. Decisions and influence coming from private industry to set public policy is nothing short of corruption and has led us to a place where “fat free” was a goal. I at the tail end of Generation-X — born in 1978. I was born into a very different world than exists now. But the idea of dietary fat being what to avoid at all costs was a thing in the family, at large, that I bought into in my ignorance well into my adult years. See how I avoided using a pun for my large family — I’m proud of myself, I hope you are proud of me.

I don’t know what percentage of my appointments involve anxiety and/or depression. It is a lot and while there are those of us who have clinically lower thresholds of spiraling into depressive states or deal with constellation of symptoms we sum up as “generalized anxiety disorder.” There are those of us who are in really shitty situations and to have distress, even sever distress is understandable at a human level if not at a clinical level.

Companies with more money than God have record profits and stock prices yet have wave after wave of layoffs. Many of my patients, if they lose their job, may not be able to stay in the US. Their children — their lives upended. This is stressful. This is anxiety inducing. An economy built on endless growth is as the enemy of good is perfect.

An economy that found itself with an excess of corn turned to using high fructose corn syrup as a common dietary additive and then went on to put it in every edible good imaginable. Why is our bread sweet here in the States? Why is there HFCS in our bread? Why is it in our ketchup? McDonalds uses a 49–51% ratio of sugar to salt on their french fries and the sugar is there to create dependency, beyond the deliciousness of an honest fry. That dopamine fix via the drive-thru dollar menu.

Food deserts. Packaged food. Fast Food. Obesity approaching 50%. Atherosclerosis in the young. Many can’t qualify for military service. Expense of fresh produce. Scarcity of fresh produce.

Ozempic and friends is an answer for a question that never should have had to be answered in the first place. We need a way out of this late stage capitalism nightmare.