As a pharmacist I’ve seen a lot of weight loss drugs come and go.  As a rule, and I think I speak for many pharmacists, I view such remedies with pessimistic eyes. 

Amphetamines and thyroid medications became popular in the 1930’s, but were banned for this use in the late sixties due to sudden death.  The now infamous fenfluramine—phentermine combinations of the 80s (called fen-phen) turned out to cause fatal heart and lung complications and were withdrawn from the market in 1997.  Not much appeared until Roche launched Orlisat (Xenical) in 1999.  This curious drug reduced absorption of fat and had a modest effect but came with many gastrointestinal side effects that made it intolerable for most.

So as clinicians, it’s fair to say we didn’t see a lot of success and we saw a whole lot of failure. 

Which brings us to the present, when investigators and clinicians are falling over themselves to praise the most potent weight reducing drugs ever discovered.   There are a few on the market, and several waiting in the wings.  You may have heard about Ozempic, Wegovy, and Mounjaro. Some are only approved for use in Type 2 diabetes, but it’s common to prescribe medications “off label” for other uses, in this case weight loss. 

Louis Aronne, a long time researcher in metabolic health and obesity at Cornell University waxed “Something we have sought for decades, we have finally been able to achieve.  I still remember exactly where I was when I saw these results for the first time last April. I knew something big was happening.” 

He was commenting on the previously unheard of weight loss of up to 22.5% in pivotal trials by Eli Lilly of tirzepatide or Mounjaro. 

Even us reluctant pharmacists must admit they work. No serious side effects seem to have emerged yet.  They are so successful that Novo Nordisk, a manufacturer,  recently stopped advertising in the US because supplies were not sufficient to meet demand.  They are a pharmaceutical company’s dream – expensive, patentable, chronic, and when you stop taking them, the weight returns. 

Are they a patient’s dream? For sure, patients are flocking to physicians to get a prescription, grateful for a chance at an effective weight loss option.  However, according to many public payers for medications, like our provincial drug plans, or Medicaid in the US, the answer is “no”.  Weight loss drugs, like pro-fertility or erectile dysfunction drugs are classed as “lifestyle” medications.  Patients must resort to paying cash or rely on private insurance plans which may or may not pay for the prescription.  They are not the only dissenters.  I have spoken to many physicians and pharmacists who hold the view that that obesity is a self-inflicted condition, and that we should not encourage the use of drugs to treat it.  The advice is: heal thyself.  Healing thyself consists of the effective application of diet and exercise.  Unless you’re living under a rock, you’ve heard about reducing sugars, carbohydrates and calories and getting 10,000 steps per day.  The truth is, it’s not working.  Humans are facing our own evolutionary heritage and what has been called a “paleolithic gut with a space age diet”.  One in three Canadians today are classed as obese. 

To be sure, we have encountered this dilemma before in medicine.  A few examples come to mind: offering liver transplants to those who have alcoholic liver disease; offering safe injections of narcotics to addicts; offering morning after pills to those who have had unprotected sex.  In each of these cases, an argument could be, and has been made that the condition is self-inflicted and that “medical” treatment should not be offered.  In each case, society has chosen to ignore, or at least suspend, the cause and focus on treatment. 

In probing more deeply, I have found that the objections to weight loss treatment conflate two things: the slightly moral finger wagging about self-responsibility and the economic issue of treatment cost.  These drugs are expensive.  But we readily leap to treat the downstream sequelae of obesity such as diabetes, hypertension, cardiovascular disease, kidney disease, cancer and fatty liver, in many cases lifelong diseases.  I suspect, in the long run, treating obesity with drugs is a less costly approach. 

The issue of cost is real and needs creative solutions.  Public-pharmaceutical industry population based health management strategies and risk sharing are possible, as is more involvement of individuals themselves in bearing a portion of costs. 

Obesity is the next pandemic in all western countries and indeed many others.  We defeated the last pandemic with resolve and investment, setting aside causes.  Let’s do the same with this one.