Astral Codex Ten

Novo Nordisk

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Novo Nordisk

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Novo Nordisk is a recurring brand in the Astral Codex Ten archive, appearing 4 times across 4 issues between November 24, 2022 and March 12, 2025. The archive places it in contexts such as “accusing Novo Nordisk of ‘charg[ing] people more for the same drug because of their obesity’”; “Novo Nordisk’s competitor Eli Lilly owns a closely related molecule”; “Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month”. It most often appears alongside FDA, Novo Nordisk, Eli Lilly.

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  • Category: Brands
  • Mention count: 4
  • Issue count: 4
  • First seen: November 24, 2022
  • Last seen: March 12, 2025

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Source Context

Recovered passages from the original issue text. When the raw archive preserved outbound links inside the source passage, they are listed directly under the quote.

Semaglutidonomics
November 24, 2022 · Original source
Semaglutide started off as a diabetes medication. Pharma company Novo Nordisk developed it in the early 2010s, and the FDA approved it under the brand names Ozempic® (for the injectable) and Rybelsus® (for the pill).
I think “Ozempic” sounds like one of those unsinkable ocean liners, and “Rybelsus” sounds like a benevolent mythological blacksmith. Patients reported significant weight loss as a side effect. Semaglutide was a GLP-1 agonist, a type of drug that has good theoretical reasons to affect weight, so Novo Nordisk studied this and found that yes, it definitely caused people to lose a lot of weight. More weight than any safe drug had ever caused people to lose before. In 2021, the FDA approved semaglutide for weight loss under the brand name Wegovy®. “Wegovy” sounds like either a cooperative governance platform, or some kind of obscure medieval sin. Weight loss pills have a bad reputation. But Wegovy is a big step up. It doesn’t work for everybody. But it works for 66-84% of people, depending on your threshold. (Source) Of six major weight loss drugs, only two - Wegovy and Qsymia - have a better than 50-50 chance of helping you lose 10% of your weight. Qsymia works partly by making food taste terrible; it can also cause cognitive issues. Wegovy feels more natural; patients just feel full and satisfied after they’ve eaten a healthy amount of food. You can read the gushing anecdotes here (plus some extra anecdotes in the comments). Wegovy patients also lose more weight on average than Qsymia patients - 15% compared to 10%. It’s just a really impressive drug. Until now, doctors didn’t really use medication to treat obesity; the drugs either didn’t work or had too many side effects. They recommended either diet and exercise (for easier cases) or bariatric surgery (for harder ones). Semaglutide marks the start of a new generation of weight loss drugs that are more clearly worthwhile. Modeling Semaglutide Accessibility 40% of Americans are obese - that’s 140 million people. Most of them would prefer to be less obese. Suppose that a quarter of them want semaglutide. That’s 35 million prescriptions. Semaglutide costs about $15,000 per year, multiply it out, that’s about $500 billion. Americans currently spend $300 billion per year total on prescription drugs. So if a quarter of the obese population got semaglutide, that would cost almost twice as much as all other drug spending combined. It would probably bankrupt half the health care industry. So . . . most people who want semaglutide won’t get it? Unclear. America’s current policy for controlling medical costs is to buy random things at random prices, then send all the bills to an illiterate reindeer-herder named Yagmuk, who burns them for warmth. Anything could happen! Right now, only about 50,000 Americans take semaglutide for obesity. I’m basing this off this report claiming “20,000 weekly US prescriptions” of Wegovy; since it’s taken once per week, maybe this means there are 20,000 users? Or maybe each prescription contains enough Wegovy to last a month and there are 80,000 users? I’m not sure, but it’s somewhere in the mid five digits, which I’m rounding to 50,000. That’s only 0.1% of the potential 35 million. The next few sections of this post are about why so few people are on semaglutide, and whether we should expect that to change. I’ll start by going over my model of what determines semaglutide use, then look at a Morgan Stanley projection of what will happen over the next decade. Step 1: Awareness I model semaglutide use as interest * awareness * prescription accessibility * affordability. I already randomly guessed interest at 25%, so the next step is awareness. How many people are aware of semaglutide? The answer is: a lot more now than when I first started writing this article! Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, says the headline. And here’s Google Trends: Semaglutide is now as searched-for on Google as Prozac or Viagra. Even if this is a temporary Musk-related spike, even pre-Musk it was getting a little above half their level. But Google Trends doesn’t exactly track awareness; few people search for Prozac these days precisely because everyone already knows what it is. So all this tells us is that there’s a lot of buzz around semaglutide. Suppose for the sake of argument that 5% of obese people have heard of this drug. Step 2: Prescription Accessibility The FDA says Wegovy is indicated for obesity, defined as BMI ≥ 30, or for people with BMI ≥ 27 and certain medical conditions. Does that mean that if you have that BMI, your doctor will give you a prescription? I think most doctors will want patients to try diet and exercise first. My experience as a doctor is that most obese people have already considered diet and exercise. Sometimes if you have a very compelling reason and a very well-thought out plan you can get them to try again. But usually they are obese because diet and exercise are hard for them, or don’t work for them, or some other reason besides “they never thought of it”. Still, I hear lots of stories about patient-doctor fights here. I assume this will happen with Wegovy too. Every doctor will have their own threshold for what amount of “already tried diet and exercise” is enough to justify a Wegovy prescription, and sometimes patients won’t meet that threshold. The history of medicine includes the following story many times: there’s some condition that doctors recommend lifestyle changes for. Then an exciting new medication comes out that treats the condition effectively. Over a generation or so, doctors go from demanding the lifestyle change, to gesturing at the lifestyle change before prescribing the medication, to mostly just prescribing the medication. We saw this with cholesterol and statins, with hypertension and ACE inhibitors, with depression and SSRIs. You can form your own opinion on whether this is good or bad, but we’re probably in the very beginning of this process with obesity. Opinions will be all over the map for a while before the inevitable pharma company victory makes everyone agree that semaglutide is first-line therapy. …except that this time, Silicon Valley is short-circuiting the process with fly-by-night telemedicine companies that guarantee you’ll get the drugs you want. For example, NextMed charges $138/month ($99 first month only!) for a guaranteed GLP-1 agonist prescription, plus “support and messaging with expert doctors”. The DEA sometimes shuts these groups down when they start playing around with controlled substances (eg addictive drugs like Adderall), but Wegovy isn’t controlled, and the government probably doesn’t care that much here. These services guarantee that people with money will be able to circumvent conservative doctors and access a prescription. Only 75% of Americans have PCPs at all. If we assume half of them will eventually be able to get a Wegovy prescription from their doctor, that’s 37.5%. Step 3: Affordability Semaglutide costs $15,000/year. Well-off people like Elon Musk might be able to pay that out-of-pocket, but most people will probably need insurance coverage. Right now this is spotty. Medicare doesn’t cover obesity drugs. This isn’t a reaction to the threat of semaglutide-related cost explosions - they’re not that smart. I think Medicare laws were just written in the old days when people were less likely to think of obesity as a disease. Is it time for change? Some Congressmen have proposed a very noble-sounding law telling Medicare and Medicaid to start covering weight loss drugs. I‘m sure this is out of deep compassion for America’s obese population and not because it would make pharma companies one billion zillion dollars. One of the Congressmen even has the last name “Kind!” Some pharma lobbyist probably got a bonus for that one. Private insurers mostly have to cover whatever Medicare does, but they can choose whether or not to include extra non-Medicare-covered drugs. Some have chosen to cover semaglutide under some conditions. Others would prefer not to cover it, but can be scared into covering it by the magic words “medical necessity”. Overall I don’t understand the laws here beyond that maybe they’ll cover it and maybe they won’t. Here, too, it might be time for change. The New York Times is publishing articles trying to convince us that private insurances not covering semaglutide is an outrage. Here in the tiny gray text, I want to take a second to complain about this article. It notes that Wegovy (semaglutide for obesity) costs more per prescription than Ozempic (semaglutide for diabetes), and calls this “a gross inequity”, accusing Novo Nordisk of “charg[ing] people more for the same drug because of their obesity”. But the obesity prescription is higher dose than the diabetes prescription! Milligram per milligram, Wegovy costs *less* than Ozempic! A steelmanned version of the NYT might object - don’t most of the costs come from the intellectual property and not the manufacturing, so that dose shouldn’t matter? Yes, but if you made the obesity version cost too much less per milligram than the diabetes version, then diabetics would cheat the system by buying the obesity version and splitting it into smaller doses! Insurances that do cover it may require extra documentation that the patient has tried lots of diet and exercise, maybe including some official diet-and-exercise program like WeightWatchers. They might also want documentation that patients have tried cheaper earlier-generation weight loss drugs without success. Even when insurances do cover semaglutide, copays may be very high. I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my out of pocket limit. Harsh. People with better insurances might get hit less hard, but I don’t think anyone will be picking this up for cheap. Let’s say only 5% of people who clear all previous hurdles can afford the drug. How Many People Get Semaglutide? 140 million obese Americans * 25% interested * 5% know of semaglutide’s existence * 37.5% can get prescriptions * 5% can afford it = 33,000, which is a pretty good match for the 50,000 estimated prescriptions. I didn’t even fudge the numbers to come out right, it just happened. The Coming Decade As a service to pharma investors, Morgan Stanley modeled the economic future of obesity medications over the next decade. Their headline result: semaglutide and various semaglutide-copycat-drugs will be a $30 billion market by 2030. That’s less than the $500 billion disaster I was afraid of! But still almost 10% of all US drug spending! Here are two core analyses from the report: The first analysis asks “what if doctors medicalized obesity as comprehensively as they’ve medicalized hypertension and high cholesterol?” That is: what if we put in a society-wide effort to get every obese person to a doctor, and after only a little diet and exercise, the doctor puts them on a medication? They find that the US obesity market would multiply by a factor of 25, to about $87 billion/year. The second analysis is a more realistic projection for the next decade. Two things stand out. First, the number of patients on Wegovy or related medications goes from an estimated 46,910 now (pretty close to my 50,000 estimate!) to 11.3 million in 2030. Second, the cost per prescription goes from $15,000/year to about $4,000 year. Let’s look at this second change in more detail. Right now semaglutide is literally in a class of its own for weight loss. But remember, it started as a GLP-1 agonist diabetes drug. And there are other GLP-1 agonists already in use for diabetes. Novo Nordisk’s competitor Eli Lilly owns a closely related molecule, tirzepatide (Mounjaro®). They’ve already done studies showing it also works very well for weight loss - if anything even better than semaglutide - and they’re expected to get FDA approval to market it as a weight loss medication next year. Although capitalism fans might expect the presence of two competing drugs to immediately drive down prices, this is mysteriously not how things work in health care and prices will probably stay the same in the short term. But several other companies are working on semaglutide-like drugs, some will be cheaper to produce than semaglutide, and Morgan Stanley expects that this stronger level of competition will eventually drive costs down to $350/month ($4,000/year) by 2030. “Mounjaro” sounds like the playful animal sidekick in a Disney movie. From a purely economic perspective, semaglutide costs the health system money (because it’s expensive) but also saves the health system money (because we don’t have to pay for obesity consequences like diabetes and heart attacks). Which effect wins out? According to the Institute for Clinical and Economic Review, benefits would outweigh costs if semaglutide cost less than about $8,000/year. Since it costs $15,000 year now, it’s not cost effective. But if Morgan Stanley’s model comes true and it costs $4,000/year in 2030, then it will be cost effective. So at some point, Medicare (and so insurance companies) may start covering it more out of self-interest. I can’t tell whether the model takes this into account or not. (there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.) 11.3 million prescriptions at $4,000/year comes to $45 billion, but Morgan Stanley expects that not everyone will fill their prescriptions consistently or stay on the medication the same amount of time, leading to their $31 billion figure. Towards The Glorious Post-Obesity Transhuman Future The Morgan Stanley report shows that even the greediest pharma investors, openly plotting to medicalize obesity, can’t bring themselves to believe in more than 11 million US semaglutide patients by 2030. That’s less than 10% of the US obese population. Isn’t that kind of disappointing? We’ve got > 100 million people dealing with a condition that not only makes them unhealthy, but also causes them psychological distress, and makes lots of people low-grade disappointed in and repulsed by our society. And we’ve got an effective drug that treats the condition. And we’re going to use it on less than 10% of the people involved? In 2032, semaglutide goes off-patent. It will probably take a few years to sort out legal issues and ramp up generic production, but by the mid-2030s, its price will go way down. I don’t think there are technical barriers to getting it down as low as $10 - $100 per month. By then, maybe there will be even more exciting branded weight loss drugs for wealthy people to choose from. But at the very least, semaglutide itself should become much more widely available even to poor or uninsured patients. I’m not sure what will happen. Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo? Or will semaglutide end up disappointing us in some way, like so many promising drugs have before? I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want. I’m not sure this will happen, but for the first time I can see a clear path to how it might. Postscript 1: Should You Take Semaglutide? I can’t answer this, please ask your doctor. But I do want to add that there are potential side effects I haven’t mentioned in this post, including nausea, gastrointestinal problems, pancreatitis, and kidney problems. Semaglutide has been accused of slightly increasing risk of pancreatic and thyroid cancers. Studies have found trends in this direction, but these conditions are so rare that even over thousands of patients over many years, the increase hasn’t yet reached clear statistical significance. The current consensus position is that it may increase thyroid cancer by a tiny amount not relevant to most patients, and that it probably doesn’t increase pancreatic cancer. I think my father has looked over these data more and is less sure than other people about the lack of pancreatic cancer risk, but he can’t get the resources he needs to prove anything, and I can’t remember his exact argument. More broadly: like all medications, semaglutide has benefits and risks, and you shouldn’t blindly take it after reading one blog article. Postscript 2: Is There A Way To Cheat The System To Get Semaglutide For Lower Cost? Health care is much like airline tickets: everyone pays a different price for everything and there’s usually a secret way to get what you want for much less money. Is this true of semaglutide? Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month. I’m a little suspicious of this - pharma company offers are rarely as good as they sound - but I don’t notice any obvious tricks in this one and it should probably be your first bet. This startup claims that they can get insured people semaglutide for a $25/month copay “after their deductible is met” by negotiating with the insurance company very effectively. I can’t imagine how that works or what they have to negotiate with, but they seem pretty convinced, so I would welcome more information. Otherwise, you don’t have many great options. Although there are two older forms of semaglutide not FDA-approved for weight loss - Ozempic and Rybelsus - these are both more expensive, milligram per milligram, than Wegovy itself. Canada is also of no help. The usual Canadian pharmacies don’t seem to carry Wegovy, and charge about the same amount for Ozempic as American pharmacies do. This article in Drug Discovery Trends says that compounding pharmacies have been selling semaglutide for $300/month, less than a quarter of the sticker price. This is a bit confusing: compounding pharmacies are small local operations permitted to dispense unusual medications by mixing existing ones together in nonstandard ways. They’re arguing that they can legally dispense the semaglutide because they’re mixing it with vitamins, which, fine, but how are they getting it in the first place? Everyone else seems as confused as I am: "Nobody knows how [compounding pharmacies are] getting it," said Karl Nadolsky, an endocrinologist at Spectrum Health. "Who's making it? [The pharma company that makes it] Novo [Nordisk]'s not giving it to them. They're the ones with the rights to the molecule, so how is anybody getting semaglutide?" Has nobody asked compounding pharmacists about this? Do they have a conspiracy of silence? Does the FDA sometimes send their goons in to extract the information, but the compounding pharmacists compound sleeping gas / smoke grenades and vanish into the night? Anyway, the usual authorities warn you not to take compounded semaglutide under any circumstances, but they’re the same people who tell you never to buy drugs from a Canadian pharmacy because they might be adulterated. You can decide how much you want to trust them. Postscript 3: What About Europe And The Rest Of The World? Countries that are not the US usually negotiate with pharmaceutical companies over price. Because of some combination of “negotiation works” and “they are free-riding off Americans’ hard work”, they usually get much lower prices. What does semaglutide cost elsewhere? This is hard to find out because government health agencies sometimes keep their prices secret, plus Wegovy mostly isn’t available in other countries yet. The only information I could find was from Britain, which is in the process of making Wegovy available to patients. It looks like NHS will “restrict the expensive drug’s availability to very obese people attending specialist weight-loss clinics”, but that it might be possible to get it from private clinics for £199/month = £2400/year. Wegovy has been approved in the EU but doesn’t seem to have made it there yet. I can’t find any information about any other country. Non-weight-loss-indicated versions of semaglutide are available in many countries, but I wouldn’t expect their health care systems to be flexible about redirecting it for weight. Canadian regulators have approved Wegovy, but it doesn’t seem to be available there yet. I haven’t seen any evidence that Ozempic costs less in Canada than it does in the US, and I’m not sure why. Maybe the pharma companies have figured out that anything that happens in Canada gets imported into the US, and they’re playing hardball this time. I don’t know whether Canadians will be able to get it for cheaper than Americans or not. Postscript 4: Predictions (all predictions are conditional on no singularity or global catastrophe) 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%
Inline links: studied this, https://substackcdn.com/image/fetch/$s_!Pnzm!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F13ec390a-e8fd-4680-8da1-eace4f42ba74_1159x645.png, https://substackcdn.com/image/fetch/$s_!gShh!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fe4b4ffd4-3d5b-445c-961d-f562ca14ac0f_818x220.png, Source, here, in the comments, lose more weight, this report, Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, https://substackcdn.com/image/fetch/$s_!RABx!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F366df26d-e420-431d-8034-e2c4a6a8de60_1149x471.png, NextMed, a very noble-sounding law, https://substackcdn.com/image/fetch/$s_!l_X7!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F1dbb9e98-6e07-4237-988e-3b7a61af3e5a_1381x834.png, is publishing articles, https://substackcdn.com/image/fetch/$s_!R-zS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0f24b293-27de-462a-84fd-bed2ba7cf07f_1723x831.png, https://substackcdn.com/image/fetch/$s_!zSOS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0906b28a-1ad4-421d-a055-87ed95db59ce_918x261.png, https://substackcdn.com/image/fetch/$s_!QJj9!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fb966f730-6b24-48e1-98b1-e710cda9264c_903x656.png, this is mysteriously not how things work in health care, https://substackcdn.com/image/fetch/$s_!5poy!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fc201f05a-7d1f-4738-911f-11d0d051adf9_2880x1562.png, Institute for Clinical and Economic Review, don’t think there are technical barriers, offers a Savings Card, This startup, about the same amount for Ozempic, This article in Drug Discovery Trends, Everyone else seems as confused as I am, NHS will, private clinics
“Wegovy” sounds like either a cooperative governance platform, or some kind of obscure medieval sin. Weight loss pills have a bad reputation. But Wegovy is a big step up. It doesn’t work for everybody. But it works for 66-84% of people, depending on your threshold. (Source) Of six major weight loss drugs, only two - Wegovy and Qsymia - have a better than 50-50 chance of helping you lose 10% of your weight. Qsymia works partly by making food taste terrible; it can also cause cognitive issues. Wegovy feels more natural; patients just feel full and satisfied after they’ve eaten a healthy amount of food. You can read the gushing anecdotes here (plus some extra anecdotes in the comments). Wegovy patients also lose more weight on average than Qsymia patients - 15% compared to 10%. It’s just a really impressive drug. Until now, doctors didn’t really use medication to treat obesity; the drugs either didn’t work or had too many side effects. They recommended either diet and exercise (for easier cases) or bariatric surgery (for harder ones). Semaglutide marks the start of a new generation of weight loss drugs that are more clearly worthwhile. Modeling Semaglutide Accessibility 40% of Americans are obese - that’s 140 million people. Most of them would prefer to be less obese. Suppose that a quarter of them want semaglutide. That’s 35 million prescriptions. Semaglutide costs about $15,000 per year, multiply it out, that’s about $500 billion. Americans currently spend $300 billion per year total on prescription drugs. So if a quarter of the obese population got semaglutide, that would cost almost twice as much as all other drug spending combined. It would probably bankrupt half the health care industry. So . . . most people who want semaglutide won’t get it? Unclear. America’s current policy for controlling medical costs is to buy random things at random prices, then send all the bills to an illiterate reindeer-herder named Yagmuk, who burns them for warmth. Anything could happen! Right now, only about 50,000 Americans take semaglutide for obesity. I’m basing this off this report claiming “20,000 weekly US prescriptions” of Wegovy; since it’s taken once per week, maybe this means there are 20,000 users? Or maybe each prescription contains enough Wegovy to last a month and there are 80,000 users? I’m not sure, but it’s somewhere in the mid five digits, which I’m rounding to 50,000. That’s only 0.1% of the potential 35 million. The next few sections of this post are about why so few people are on semaglutide, and whether we should expect that to change. I’ll start by going over my model of what determines semaglutide use, then look at a Morgan Stanley projection of what will happen over the next decade. Step 1: Awareness I model semaglutide use as interest * awareness * prescription accessibility * affordability. I already randomly guessed interest at 25%, so the next step is awareness. How many people are aware of semaglutide? The answer is: a lot more now than when I first started writing this article! Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, says the headline. And here’s Google Trends: Semaglutide is now as searched-for on Google as Prozac or Viagra. Even if this is a temporary Musk-related spike, even pre-Musk it was getting a little above half their level. But Google Trends doesn’t exactly track awareness; few people search for Prozac these days precisely because everyone already knows what it is. So all this tells us is that there’s a lot of buzz around semaglutide. Suppose for the sake of argument that 5% of obese people have heard of this drug. Step 2: Prescription Accessibility The FDA says Wegovy is indicated for obesity, defined as BMI ≥ 30, or for people with BMI ≥ 27 and certain medical conditions. Does that mean that if you have that BMI, your doctor will give you a prescription? I think most doctors will want patients to try diet and exercise first. My experience as a doctor is that most obese people have already considered diet and exercise. Sometimes if you have a very compelling reason and a very well-thought out plan you can get them to try again. But usually they are obese because diet and exercise are hard for them, or don’t work for them, or some other reason besides “they never thought of it”. Still, I hear lots of stories about patient-doctor fights here. I assume this will happen with Wegovy too. Every doctor will have their own threshold for what amount of “already tried diet and exercise” is enough to justify a Wegovy prescription, and sometimes patients won’t meet that threshold. The history of medicine includes the following story many times: there’s some condition that doctors recommend lifestyle changes for. Then an exciting new medication comes out that treats the condition effectively. Over a generation or so, doctors go from demanding the lifestyle change, to gesturing at the lifestyle change before prescribing the medication, to mostly just prescribing the medication. We saw this with cholesterol and statins, with hypertension and ACE inhibitors, with depression and SSRIs. You can form your own opinion on whether this is good or bad, but we’re probably in the very beginning of this process with obesity. Opinions will be all over the map for a while before the inevitable pharma company victory makes everyone agree that semaglutide is first-line therapy. …except that this time, Silicon Valley is short-circuiting the process with fly-by-night telemedicine companies that guarantee you’ll get the drugs you want. For example, NextMed charges $138/month ($99 first month only!) for a guaranteed GLP-1 agonist prescription, plus “support and messaging with expert doctors”. The DEA sometimes shuts these groups down when they start playing around with controlled substances (eg addictive drugs like Adderall), but Wegovy isn’t controlled, and the government probably doesn’t care that much here. These services guarantee that people with money will be able to circumvent conservative doctors and access a prescription. Only 75% of Americans have PCPs at all. If we assume half of them will eventually be able to get a Wegovy prescription from their doctor, that’s 37.5%. Step 3: Affordability Semaglutide costs $15,000/year. Well-off people like Elon Musk might be able to pay that out-of-pocket, but most people will probably need insurance coverage. Right now this is spotty. Medicare doesn’t cover obesity drugs. This isn’t a reaction to the threat of semaglutide-related cost explosions - they’re not that smart. I think Medicare laws were just written in the old days when people were less likely to think of obesity as a disease. Is it time for change? Some Congressmen have proposed a very noble-sounding law telling Medicare and Medicaid to start covering weight loss drugs. I‘m sure this is out of deep compassion for America’s obese population and not because it would make pharma companies one billion zillion dollars. One of the Congressmen even has the last name “Kind!” Some pharma lobbyist probably got a bonus for that one. Private insurers mostly have to cover whatever Medicare does, but they can choose whether or not to include extra non-Medicare-covered drugs. Some have chosen to cover semaglutide under some conditions. Others would prefer not to cover it, but can be scared into covering it by the magic words “medical necessity”. Overall I don’t understand the laws here beyond that maybe they’ll cover it and maybe they won’t. Here, too, it might be time for change. The New York Times is publishing articles trying to convince us that private insurances not covering semaglutide is an outrage. Here in the tiny gray text, I want to take a second to complain about this article. It notes that Wegovy (semaglutide for obesity) costs more per prescription than Ozempic (semaglutide for diabetes), and calls this “a gross inequity”, accusing Novo Nordisk of “charg[ing] people more for the same drug because of their obesity”. But the obesity prescription is higher dose than the diabetes prescription! Milligram per milligram, Wegovy costs *less* than Ozempic! A steelmanned version of the NYT might object - don’t most of the costs come from the intellectual property and not the manufacturing, so that dose shouldn’t matter? Yes, but if you made the obesity version cost too much less per milligram than the diabetes version, then diabetics would cheat the system by buying the obesity version and splitting it into smaller doses! Insurances that do cover it may require extra documentation that the patient has tried lots of diet and exercise, maybe including some official diet-and-exercise program like WeightWatchers. They might also want documentation that patients have tried cheaper earlier-generation weight loss drugs without success. Even when insurances do cover semaglutide, copays may be very high. I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my out of pocket limit. Harsh. People with better insurances might get hit less hard, but I don’t think anyone will be picking this up for cheap. Let’s say only 5% of people who clear all previous hurdles can afford the drug. How Many People Get Semaglutide? 140 million obese Americans * 25% interested * 5% know of semaglutide’s existence * 37.5% can get prescriptions * 5% can afford it = 33,000, which is a pretty good match for the 50,000 estimated prescriptions. I didn’t even fudge the numbers to come out right, it just happened. The Coming Decade As a service to pharma investors, Morgan Stanley modeled the economic future of obesity medications over the next decade. Their headline result: semaglutide and various semaglutide-copycat-drugs will be a $30 billion market by 2030. That’s less than the $500 billion disaster I was afraid of! But still almost 10% of all US drug spending! Here are two core analyses from the report: The first analysis asks “what if doctors medicalized obesity as comprehensively as they’ve medicalized hypertension and high cholesterol?” That is: what if we put in a society-wide effort to get every obese person to a doctor, and after only a little diet and exercise, the doctor puts them on a medication? They find that the US obesity market would multiply by a factor of 25, to about $87 billion/year. The second analysis is a more realistic projection for the next decade. Two things stand out. First, the number of patients on Wegovy or related medications goes from an estimated 46,910 now (pretty close to my 50,000 estimate!) to 11.3 million in 2030. Second, the cost per prescription goes from $15,000/year to about $4,000 year. Let’s look at this second change in more detail. Right now semaglutide is literally in a class of its own for weight loss. But remember, it started as a GLP-1 agonist diabetes drug. And there are other GLP-1 agonists already in use for diabetes. Novo Nordisk’s competitor Eli Lilly owns a closely related molecule, tirzepatide (Mounjaro®). They’ve already done studies showing it also works very well for weight loss - if anything even better than semaglutide - and they’re expected to get FDA approval to market it as a weight loss medication next year. Although capitalism fans might expect the presence of two competing drugs to immediately drive down prices, this is mysteriously not how things work in health care and prices will probably stay the same in the short term. But several other companies are working on semaglutide-like drugs, some will be cheaper to produce than semaglutide, and Morgan Stanley expects that this stronger level of competition will eventually drive costs down to $350/month ($4,000/year) by 2030. “Mounjaro” sounds like the playful animal sidekick in a Disney movie. From a purely economic perspective, semaglutide costs the health system money (because it’s expensive) but also saves the health system money (because we don’t have to pay for obesity consequences like diabetes and heart attacks). Which effect wins out? According to the Institute for Clinical and Economic Review, benefits would outweigh costs if semaglutide cost less than about $8,000/year. Since it costs $15,000 year now, it’s not cost effective. But if Morgan Stanley’s model comes true and it costs $4,000/year in 2030, then it will be cost effective. So at some point, Medicare (and so insurance companies) may start covering it more out of self-interest. I can’t tell whether the model takes this into account or not. (there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.) 11.3 million prescriptions at $4,000/year comes to $45 billion, but Morgan Stanley expects that not everyone will fill their prescriptions consistently or stay on the medication the same amount of time, leading to their $31 billion figure. Towards The Glorious Post-Obesity Transhuman Future The Morgan Stanley report shows that even the greediest pharma investors, openly plotting to medicalize obesity, can’t bring themselves to believe in more than 11 million US semaglutide patients by 2030. That’s less than 10% of the US obese population. Isn’t that kind of disappointing? We’ve got > 100 million people dealing with a condition that not only makes them unhealthy, but also causes them psychological distress, and makes lots of people low-grade disappointed in and repulsed by our society. And we’ve got an effective drug that treats the condition. And we’re going to use it on less than 10% of the people involved? In 2032, semaglutide goes off-patent. It will probably take a few years to sort out legal issues and ramp up generic production, but by the mid-2030s, its price will go way down. I don’t think there are technical barriers to getting it down as low as $10 - $100 per month. By then, maybe there will be even more exciting branded weight loss drugs for wealthy people to choose from. But at the very least, semaglutide itself should become much more widely available even to poor or uninsured patients. I’m not sure what will happen. Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo? Or will semaglutide end up disappointing us in some way, like so many promising drugs have before? I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want. I’m not sure this will happen, but for the first time I can see a clear path to how it might. Postscript 1: Should You Take Semaglutide? I can’t answer this, please ask your doctor. But I do want to add that there are potential side effects I haven’t mentioned in this post, including nausea, gastrointestinal problems, pancreatitis, and kidney problems. Semaglutide has been accused of slightly increasing risk of pancreatic and thyroid cancers. Studies have found trends in this direction, but these conditions are so rare that even over thousands of patients over many years, the increase hasn’t yet reached clear statistical significance. The current consensus position is that it may increase thyroid cancer by a tiny amount not relevant to most patients, and that it probably doesn’t increase pancreatic cancer. I think my father has looked over these data more and is less sure than other people about the lack of pancreatic cancer risk, but he can’t get the resources he needs to prove anything, and I can’t remember his exact argument. More broadly: like all medications, semaglutide has benefits and risks, and you shouldn’t blindly take it after reading one blog article. Postscript 2: Is There A Way To Cheat The System To Get Semaglutide For Lower Cost? Health care is much like airline tickets: everyone pays a different price for everything and there’s usually a secret way to get what you want for much less money. Is this true of semaglutide? Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month. I’m a little suspicious of this - pharma company offers are rarely as good as they sound - but I don’t notice any obvious tricks in this one and it should probably be your first bet. This startup claims that they can get insured people semaglutide for a $25/month copay “after their deductible is met” by negotiating with the insurance company very effectively. I can’t imagine how that works or what they have to negotiate with, but they seem pretty convinced, so I would welcome more information. Otherwise, you don’t have many great options. Although there are two older forms of semaglutide not FDA-approved for weight loss - Ozempic and Rybelsus - these are both more expensive, milligram per milligram, than Wegovy itself. Canada is also of no help. The usual Canadian pharmacies don’t seem to carry Wegovy, and charge about the same amount for Ozempic as American pharmacies do. This article in Drug Discovery Trends says that compounding pharmacies have been selling semaglutide for $300/month, less than a quarter of the sticker price. This is a bit confusing: compounding pharmacies are small local operations permitted to dispense unusual medications by mixing existing ones together in nonstandard ways. They’re arguing that they can legally dispense the semaglutide because they’re mixing it with vitamins, which, fine, but how are they getting it in the first place? Everyone else seems as confused as I am: "Nobody knows how [compounding pharmacies are] getting it," said Karl Nadolsky, an endocrinologist at Spectrum Health. "Who's making it? [The pharma company that makes it] Novo [Nordisk]'s not giving it to them. They're the ones with the rights to the molecule, so how is anybody getting semaglutide?" Has nobody asked compounding pharmacists about this? Do they have a conspiracy of silence? Does the FDA sometimes send their goons in to extract the information, but the compounding pharmacists compound sleeping gas / smoke grenades and vanish into the night? Anyway, the usual authorities warn you not to take compounded semaglutide under any circumstances, but they’re the same people who tell you never to buy drugs from a Canadian pharmacy because they might be adulterated. You can decide how much you want to trust them. Postscript 3: What About Europe And The Rest Of The World? Countries that are not the US usually negotiate with pharmaceutical companies over price. Because of some combination of “negotiation works” and “they are free-riding off Americans’ hard work”, they usually get much lower prices. What does semaglutide cost elsewhere? This is hard to find out because government health agencies sometimes keep their prices secret, plus Wegovy mostly isn’t available in other countries yet. The only information I could find was from Britain, which is in the process of making Wegovy available to patients. It looks like NHS will “restrict the expensive drug’s availability to very obese people attending specialist weight-loss clinics”, but that it might be possible to get it from private clinics for £199/month = £2400/year. Wegovy has been approved in the EU but doesn’t seem to have made it there yet. I can’t find any information about any other country. Non-weight-loss-indicated versions of semaglutide are available in many countries, but I wouldn’t expect their health care systems to be flexible about redirecting it for weight. Canadian regulators have approved Wegovy, but it doesn’t seem to be available there yet. I haven’t seen any evidence that Ozempic costs less in Canada than it does in the US, and I’m not sure why. Maybe the pharma companies have figured out that anything that happens in Canada gets imported into the US, and they’re playing hardball this time. I don’t know whether Canadians will be able to get it for cheaper than Americans or not. Postscript 4: Predictions (all predictions are conditional on no singularity or global catastrophe) 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%
Inline links: https://substackcdn.com/image/fetch/$s_!gShh!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fe4b4ffd4-3d5b-445c-961d-f562ca14ac0f_818x220.png, Source, here, in the comments, lose more weight, this report, Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, https://substackcdn.com/image/fetch/$s_!RABx!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F366df26d-e420-431d-8034-e2c4a6a8de60_1149x471.png, NextMed, a very noble-sounding law, https://substackcdn.com/image/fetch/$s_!l_X7!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F1dbb9e98-6e07-4237-988e-3b7a61af3e5a_1381x834.png, is publishing articles, https://substackcdn.com/image/fetch/$s_!R-zS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0f24b293-27de-462a-84fd-bed2ba7cf07f_1723x831.png, https://substackcdn.com/image/fetch/$s_!zSOS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0906b28a-1ad4-421d-a055-87ed95db59ce_918x261.png, https://substackcdn.com/image/fetch/$s_!QJj9!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fb966f730-6b24-48e1-98b1-e710cda9264c_903x656.png, this is mysteriously not how things work in health care, https://substackcdn.com/image/fetch/$s_!5poy!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fc201f05a-7d1f-4738-911f-11d0d051adf9_2880x1562.png, Institute for Clinical and Economic Review, don’t think there are technical barriers, offers a Savings Card, This startup, about the same amount for Ozempic, This article in Drug Discovery Trends, Everyone else seems as confused as I am, NHS will, private clinics
Highlights From The Comments On Semaglutide
November 30, 2022 · Original source
First, the low volume for semaglutide that you are observing is at least partially due to supply shortages. The drug has been in serious shortage for a while. Novo Nordisk also sells Saxenda (liraglutide) for weight loss. Over the last 2 quarters, Saxenda sales are up 59%, while Wegovy sales are down 18%. Saxenda is priced similarly, and Wegovy is a better product. So I suspect a lot of the Saxenda spending would be going towards Wegovy in the absence of the semaglutide supply shortage.
Inline links: supply shortages, sales
Sixth, this post focuses on GLP-1 agonists, which makes sense, because those drugs are starting to have an impact today. But the Morgan Stanley report also notes that amylin analogue cagrilintide may be approved for weight loss as soon as 2025. This drug has a completely different mechanism than semaglutide, but likely offers similar weight loss benefits. The crazy thing is that the weight loss benefits stack. So Novo Nordisk hopes to sell Cagrisema, which combines amylin analogue cagrilintide with semaglutide, and hopes to offer a ~30% average weight loss. This is roughly double what semaglutide offers, and is getting closer to bariatric surgery efficacy.
I think those numbers might be "over one year", and they could stay on it longer than a year. I was kind of lazy just asserting “drugs might get better”, but I think the upcoming CagriSema combination and AMG-133 are good examples of how this might play out. Max Görlitz has done the proper thing and made Manifold markets for each of my predictions - see here, here, here, here, and here. Despite the problems with prediction markets for decades in the future, the “will obesity be cut in half by 2050” one seems popular: 5. Do You Have To Stay On Semaglutide Forever Or Else Gain The Weight Back? Biff_Ditt writes: I saw on the 1 year follow-up to the STEP-1 trial that most of the participants gained all of their lost weight back. Biff is probably thinking of Weight Regain And Cardiometabolic Effects After Withdrawal Of Semaglutide, which finds people gained back 2/3 of the lost weight after a year. The graph looks like it’s in the process of plateauing but not quite there, so I don’t know if we should expect them to regain the other third later. This matches what I would expect from my understanding of other diets and weight loss drugs. Still, some people disagree. Maximum Liberty writes: Anecdote is not the singular of data, but my better half lost 25 pounds on it, then had to get off it for reasons unrelated to the drug. She has not regained the weight yet -- and consistently eats less now that she had for years. So in at least one case, the drug helped with a successful change in eating habits. Lauren Thomas writes: So there's been a lot of research on dieting and losing weight, etc., and one of the things that has been found is that your body has a "set" point weight wise that it will try REALLY hard to return you to. If you lose weight, your body will slow its metabolism until you return to that weight. If you gain weight, your body will rev up metabolism. That's why you might gain 10 lbs over Christmas and then lose it in January without purposefully trying to lose weight. (this is all in the short term, ofc, as people do tend to naturally gain weight as they age). This seems to imply that semaglutide would need to be taken forever. However, there seems to be an important caveat: you *can* reset your set point, it just takes a long time at the new weight. When most people go on diets and lose weight, they end up regaining the new weight quite quickly after they "end" their diet, so they don't have a chance to reset their set point. Speaking from personal experience, I had kind of an accidental natural experiment with this: I once lost 40 lbs over the course of a year and a half, where I began with a very strict low carb diet that very very slowly trailed off to a normal diet, mostly because I got progressively more tired of being on the low carb diet. So by the time I had gotten back to my normal diet, I had been losing weight for a long time. I ended up regaining 10 lbs of the weight, but no more, and am still ~30 lbs below my peak even today (5 years later). Something like this has been my experience with dieting too so far. And something like set point reset has to exist in order to explain things like why so many obese people fail to lose weight after they start eating healthy, and maybe other things like anorexia. And maybe it works for some people. Still, the evidence suggests that most people who stop semaglutide will regain the weight, at least for the protocol used in the study. Maybe some other protocol that had them on it for more than a year would have done better? 6. Personal Anecdotes Edgehopper writes: I couldn’t get Wegovy at a reasonable price when it was approved, and then Novo Nordisk started having huge supply chain problems with their injectors. Fortunately, Eli Lilly’s coupon for Mounjaro was less restrictive at first, though they’ve had to crack down as they have trouble meeting demand for both off-label weight loss use and for the approved T2D use. I am what the doctors call “morbidly obese,” and it’s been more effective than anything else I’ve ever tried. Down about 35 lbs in the first three months, and unlike with other diets I’ve tried, I’m not feeling miserable or hungry all the time. Assuming there aren’t scary side-effects in the future, these really are miracle drugs. I do expect the price to come down relatively quickly due to competition, which is a good thing. Education Realist (blog) writes: I am on Mounjaro, and have been for four months. Lost 20 pounds so far, and I'm not yet on full dosage. Occasional mild nausea but real issue for me is....tiredness. Not fatigue or exhaustion. I'm a former insomniac who can now hit the sack at 9:00 and sleep happily to 6 am, which is insanely weird. I have been trying to lose weight for 6 years, and for most of that time been in a 20 pound range that is 100 pounds over what someone of my height should weigh. I've eaten 1500 calories a day and not lost a pound, have to drop to 1100 to lose weight verrry slowly (that's with intermittent fasting and low carbs, around 50 grams). Last year before Mounjaro I started intermittent fasting and lost 20 pounds very quickly and then stopped cold. I do not have eating issues. I don't binge. I cut out the "four white foods" six years ago because I learned that I do better on meat and cheese and vegetables than I do on pasta or bread or potatoes and vegetables. I put on weight despite walking two and in some cases four miles a day, which I can do easily. I am ridiculously healthy and do not have an obesity diagnosis. Stone cold normal readings in A1c, glucose, cholestrol. My doctor sent me to an endocrinologist after I lost 20 pounds and then stopped cold despite the same behavior (which I still do today) because she agreed I might be insulin resistant. Endocrinologist shrugged, said it's multifactorial, but agreed that anyone with my numbers, appearance, and obvious good health was clearly doing everything right and put me on Mounjaro with no further questions. Diagnosis: insulin resistance. My insurance pays around $500 but I'm on the $25 coupon. I didn't change a single thing about my eating habits and lost ten pounds in 2 months on the low dosage. Higher dosages have finally reduced my appetite somewhat, but my endocrinologist and I have decided to stop the increases at 12.5 (15 is the top) and then maybe even reduce, since my appetite is decreasing but the weight loss rate is constant. Because I lost weight doing the same behavior and no drop, I'm quite convinced that something far different than appetite suppressing is also going on (fwiw, I was on phentarmine back in the day and liked it fine). Mounjaro is supposed to increase insulin production and reduce the liver's sugar production, although what that means I dunno. I have no idea what's up with obesity but the idea that it's all about cutting intake and exercise is just stupid. I should have been losing weight for all of the past six years and haven't. Plenty of people eat healthily and are still obese. We're probably the descendants of famine survivors. Anyway, I wrote about it here: https://educationrealist.wordpress.com/2022/10/09/weight-loss-and-mounjaro Eliezer Yudkowsky writes: I tried semaglutide and it did nothing to slow rate of weight gain, just produced stomach upset, going up to 2.4mg injectable. I know one other person trying semaglutide and they reported something similar. I wonder if they played some clever games with their choice of patients. My expectation of how the news goes here is a whole lot of people who try semaglutide, maybe after fighting really hard to get on it, and find that it does nothing. That said, I know at least one friend of a friend, if not a friend per se, who claims that semaglutide was their miracle drug. So maybe still worth that hard fight, even if I'm guessing that the real proportion who get nothing out of it will prove to be over 50% in real populations. Further fun fact: Semaglutide comes heavily recommended with diet and exercise and many stern injunctions about that! The actual insert sheet includes a graph for how much weight people lose with and without "lifestyle interventions" added. The two graphs are roughly the same. Lan writes: I wonder about the adoption of the medication, though. I took victoza (=saxenda, but approved for diabetes) and the absence of the desire to eat lead to some unforeseen lifestyle side effects. Given that 5 almonds made me full for the day, I was not interested in having dinner with the family or going out with friends. There is the reality that some restaurants would probably not be happy if you only ordered the smallest appetizer. In addition, alcohol was also very difficult, because the drug slows down gastric emptying and your stomach ends up absorbing alcohol for hours. I got really, really drunk for an entire night from a single glass of wine once. Before taking this drug I had not fully appreciated how much of one's (social) life revolves around food; lunch break with colleagues, dinner with family or friends, drinks on the weekend, a sweet treat, snacks and a movie etc. But once I was not interested in food anymore, combined with the tiredness that comes with eating little, a lot of those activities also lost their appeal. (On the upside, I slept like a log.) Walter Sobchak, Esq writes: I have been taking Wegovy for 14 months. When I began I weighed 275 lbs and my BMI was 39.9. I have hypertension, albeit well controlled by medicines. Diet and exercise phaaahhh. I could eat faster than I could exercise. And no, I eat very little fast food and little candy and soda. I worked with my doctor to be prescribed Wegovy. It was only approved by the FDA in June 2021. My doctor was reluctant because he was unfamiliar with the class of compounds. He does not like to prescribe off label so he was not willing to to start me on Ozempic. But, the FDA solved that problem. I knew to ask for the drug because my daughter was pre-diabetic and had been put on Metformin and Ozempic. She lost 100 lbs. in 2019 and 2020. I started on Wegovy in September 2021. I now weigh 220 and my BMI is 31.5. That represents a 20% reduction in my original weight. 220 was my original goal. To get a BMI under 30 I would have to be under 209. I doubt that I will get there. I am back in 40 in. trousers which I had not been able to wear in 30 years. 220 was my original goal. I have had no major side effects other than constipation. Even that is a little hard to tease out. I am on 7 Rx drugs and at least 5 of them are constipating. I have been pounding Metamucil and Colace for years. I have been able to fill my prescriptions using a GoodRx coupon at $1328 for a box with 4 injectors. A year requires 13 boxes. The total cost for 15 boxes has been about $20,000. I can afford it and it has been worth while. I call it a bargain, the best I've ever had. I understand that it still way too expensive for the American health care system to afford. But given the bonanza size of the market. There will be lots of competition starting with the Lilly's tirzepatide. There are several other pharma's with GLP-1 agonists in development. I am sure that the cost will come down. My doctor tells me that I can expect to stay on semaglutide for the long term. He is proposing that I switch to Ozempic 2 mg for maintenance as I can buy that for less than $1,000 for a four dose pen. My only sadness is that semaglutide wasn't invented 40 years ago when i would have saved me from a lot of damage. But, I am grateful that it exists now and that it has helped my daughter so much. Also from Walter, and I was wondering about this: I was very concerned with the injections before I started Wegovy. My experience is that the injector is fast and almost painless. My pharmacist was important because he showed me how to do it correctly before I started. 7. Tangents That I Find Tedious, But Other People Apparently Really Want To Debate Why can’t people just diet and exercise? (142 comments)
Inline links: here, here, here, here, here, writes, Weight Regain And Cardiometabolic Effects After Withdrawal Of Semaglutide, writes, writes, anorexia, writes, Education Realist, blog, https://educationrealist.wordpress.com/2022/10/09/weight-loss-and-mounjaro, writes, writes, from Walter, Why can’t people just diet and exercise?
The Compounding Loophole
August 22, 2024 · Original source
They say it’s through the same factories that make the official version for Big Pharma. If I understand the situation, nameless Chinese factories1 make the chemical itself, and Novo Nordisk (the pharmaceutical company that owns the official patent) does some fancy encapsulation work at their own plants. But they have a permanent capacity problem because of logistical and regulatory issues, so the nameless Chinese factories sell the extra to the compounding pharmacies on the side.
Inline links: They say, 1
Don’t get me wrong, this does probably take a big chunk out of Novo Nordisk’s profits. But Novo Nordisk’s stock price currently looks like this:
…and they’re now the most valuable company in Europe. So they can probably eat the loss. What happens when the shortage ends? Compounding pharmacies are only allowed to do this because of a law that suspends some drug regulations during a “shortage”, ie when the drug is on the FDA’s drug shortage list. At some point, Novo Nordisk will build enough factories to meet capacity and there won’t be a shortage anymore. What then? Will the fun be over? Will GLP-1 agonists go back to costing $1,200/month again? Will most of the current users have to stop the drug and regain the lost weight? This would make tens of thousands of people really mad. I don’t know if the FDA has the guts to offend that many people. Their style is more to crush drugs before they ever come out, before anyone knows what they’re missing. During COVID, the DEA said that telemedicine was allowed to be cheap and convenient so patients could get care during lockdown. After the pandemic died down, they tried making it hard and expensive again, but so many patients protested that they backed off. The uproar we’ll get if the FDA tries to make GLP-1 drugs expensive again will make that one look like a tempest in a teapot. But Big Pharma will be even angrier if they don’t. And besides, they can’t keep the drug on their shortage list if everyone knows there’s no shortage. I really don’t know what will happen, and I don’t envy whichever FDA official is in charge of setting a policy on this. I did see one proposed solution somewhere or other (sorry if it’s yours and I’m not crediting you). Compound pharmacies are always allowed to make compounded medications for specific patients who have a “medical necessity” for a non-FDA-approved product. So in theory, you could try something like: Tell the patient to say that Ozempic causes them nausea.
Inline links: the most valuable company in Europe, they tried making it hard and expensive again
The Ozempocalypse Is Nigh
March 12, 2025 · Original source
But the compounders aren’t the only ones boxing clever. Novo Nordisk and Eli Lilly, the pharma companies behind semaglutide and tirzepatide respectively, have opened consumer-facing businesses about halfway between a traditional doctor’s appointment and the telehealth/compounder model that’s getting banned. So for example, Lilly Direct offers to “find you a doctor” (I think this means you do telehealth with an Eli Lilly stooge who always gives you the meds you want) and “get medications delivered directly to you”. The price depends on dose, but an average dose would be about $500 - so about halfway between the cheap compounding price and the usual insurance price. Not bad.
Inline links: Lilly Direct
Some people are stocking up. GLP-1 drugs keep pretty well in a fridge for at least a year. If you sign up for four GLP-1 telehealth compounding companies simultaneously and order three months from each, then you can get twelve months of medication. Maybe in twelve months the FDA will change their mind, or the pharmacies’ insane legal strategies will pay off, or Trump will invade Denmark over Greenland and seize the Novo Nordisk patents as spoils of war, or someone will finally figure out a diet that works.