Navigating the Ups and Downs of Weight loss Medications: Beyond the Social Media Success Stories

Introduction

In the age of social media, success stories of celebrities shedding pounds with cutting-edge medications like semaglutide (Ozempic and Wegovy) and tirzepatide (Mounjaro) fill our feeds. These medications, designed for treating obesity and type 2 diabetes, have become transformative tools for weight loss, sparking both enthusiasm and concerns within the medical community. As our offices witness unprecedented success stories, a critical question emerges: what happens when patients discontinue these medications, and why are they compelled to stop in the first place?

The Effectiveness and Challenges

Undoubtedly, incretin medications have shown remarkable effectiveness in not only promoting weight loss but also improving cardiometabolic health and overall quality of life. However, the journey with these drugs is not without challenges. Gastrointestinal side effects, primarily nausea, pose a common hurdle, albeit one that often diminishes with time and careful management.

Acute pancreatitis, although rare, stands as a potential reason for discontinuation, affecting around 0.2% of individuals in clinical trials. Despite their efficacy, the high cost of medications like liraglutide (Saxenda) and semaglutide (Wegovy), hovering around $1400 per month, can render them financially prohibitive. Limited insurance coverage, changing employment circumstances, or alterations in insurance plans can abruptly halt treatment, leaving patients grappling with the consequences.

The Domino Effect: Stopping Equals Weight Regain

Stopping these medications isn't just a matter of interrupting a treatment plan; it's often associated with a domino effect. A patient's regained appetite, diminished satiety, and the inevitable weight regain can reverse the progress made during the course of treatment. The alarming truth is that obesity, much like hypertension, is a chronic condition that necessitates ongoing management.

Insights from Trials and Real-World Experiences

Insights from trials like STEP-1, which demonstrated an initial body weight reduction of 17.3% with semaglutide over one year, underline the positive impact of these medications. However, when participants stopped semaglutide and the accompanying lifestyle intervention, two-thirds of the lost weight was regained within a year, accompanied by a reversion of improvements in key cardiometabolic variables.

Real-world scenarios further emphasize the challenges faced by patients. A change in employment or insurance coverage led a patient, who initially lost over 30 pounds with semaglutide, to experience a 10-pound regain within three months. Transitioning to tirzepatide off-label brought further success until shifts in the discount card caused the pharmacy to halt prescription fills, leaving her in search of alternative options.

Chronic Therapy for Long-Term Success

These data together demonstrate that medications are effective for durable weight loss if they are continued. However, this is not how obesity is currently treated. Anti-obesity medications are prescribed to less than 3% of eligible people in the US, and the average duration of therapy is less than 90 days. This treatment length isn't sufficient to see the full benefits most medications offer and certainly doesn't support long-term weight maintenance.

In addition to maintaining weight loss from medical therapies, a recent study showed that incretin-containing anti-obesity medication regimens were effective for treating weight regain and facilitating healthier weight after bariatric surgery.

Chronic therapy is needed for weight maintenance because several neurohormonal changes occur owing to weight loss. Metabolic adaptation is the relative reduction in energy expenditure, below what would be expected, in people after weight loss. When this is combined with physiologic changes that increase appetite and decrease satiety, many people create a positive energy balance that results in weight regain. This has been observed in reality TV shows such as The Biggest Loser: It's biology, not willpower.

Unfortunately, many people — including healthcare providers — don't understand how these changes promote weight regain and patients are too often blamed when their weight goes back up after medications are stopped. This blame is greatly misinformed by weight-biased beliefs that people with obesity are lazy and lack self-control for weight loss or maintenance. Nobody would be surprised if someone's blood pressure went up if their antihypertensive medications were stopped. Why do we think so differently when treating obesity?

The prevalence of obesity in the US is over 40% and growing. We are fortunate to have new medications that on average lead to 15% or greater weight loss when combined with lifestyle modification.

However, these medications are expensive and the limited insurance coverage currently available may not improve. From a patient experience perspective, it's distressing to have to discontinue treatments that have helped to achieve a healthier weight and then experience regain.

People need better access to evidence-based treatments for obesity, which include lifestyle interventions, anti-obesity medications, and bariatric procedures. Successful treatment of obesity should include a personalized, patient-centered approach that may require a combination of therapies, such as medications and surgery, for lasting weight control.

Disclaimer: Not Medical Advice. The information provided in this blog is for informational purposes only and should not be construed as medical advice or a substitute for professional medical expertise.