The Skinny on GLP-1s

If you’ve turned on the TV, opened social media, or chatted with anyone about health lately, chances are you’ve heard about GLP-1 medications. Everyone talks about Ozempic, but these also include Wegovy, Mounjaro and Zepbound. All the influencers, personal trainers, your coworkers, and maybe even your neighbor seem to have an opinion. I get asked all the time what I think about them. Let’s unpack it together.

Before we delve into GLP-1 talk, think about this…When someone has high blood pressure or high cholesterol, we work to make sure they are getting exercise and eating well. But if that doesn’t do the trick, or if that is not sustainable for whatever reason, we add medication. The reason for medication? To improve someone’s health and prevent the associated long term stuff that goes along with it. Same concept when it comes to using medication to help someone manage their weight.

Enter GLP-1s…GLP-1 medications have changed the game in so many ways, whether you’re talking about diabetes, obesity, heart disease, liver disease…I would even go so far as to say mental health in a lot of cases…the list goes on and on. I’ve seen them truly change lives. Really powerful stuff. 

I’ve prescribed these for a lot of people, and I have a lot of insight into the impact they have on them. Many people say that they didn’t realize they had constant background thoughts about food in their brain until they were no longer there. People call this “food noise.” I remember one person who told me that she had never experienced the feeling of fullness until she was on a GLP-1. She literally had no idea what people were talking about when they said they were full. This is not a willpower thing. This is malfunctioning hormone signals. 

But they’re too new…we don’t know enough about them, right?

Wrong!

GLP-1s first entered the chat as a diabetes medication 20 years ago. That means we have 20 years of data on them (not including the years of data collected in clinical trials before they came to the market).

Yes, you only started to hear about them a couple of years ago when Ozempic and Wegovy went viral. First we had Byetta, then it was Victoza and Trulicity. These are great, but they keep on getting better and better. Ozempic was FDA approved for diabetes in 2017. It’s twin, Wegovy (same drug, just a different name for a different indication) was FDA approved for weight loss in 2021. While the buzz is new, the meds are not. So yeah, we have over 20 years of safety data on these, and the data shows they are A-OK for long term use. 

GLP-1s first changed the game when it comes to managing diabetes. They lower blood sugar without causing dangerous dips. Historically, our blood sugar goals for someone with diabetes were above the normal range, because going too low even once is more dangerous than being a little high all the time. Now, thanks to GLP-1s, so many more people with diabetes are able to have NORMAL blood sugars without the fear of it going too low. Wild.

As people were taking these for diabetes, it became clear that they were also losing a lot of weight. Naturally the next step was to study them specifically for weight management. 

Here’s the quick rundown of what’s out there right now approved for weight management.

Liraglutide (Saxenda for weight loss / Victoza for diabetes)

This was the OG of GLP-1s as a weight loss drug, and good, but not as effective as the others. It’s a daily injection that has been around since 2010. I checked out the cash price of this when I was writing this, and my mind was blown 🤯…the generic version is now available through Mark Cuban’s Cost Plus pharmacy for $210 for a 54 day supply. Wait, what?!  

(Pro tip: always check places like Cost Plus or GoodRx for lower prices for any of your meds if insurance doesn’t cover or if they are pricey — the only downside is they don’t count against your deductible if you opt for the cash price).

Semaglutide (Wegovy for weight loss / Ozempic for diabetes)

The most famous of the GLP-1s in the news and social media. It’s a once-weekly injection that’s super effective and widely studied. If not covered by insurance, the manufacturer’s cash price is about $499/month.

Tirzepatide (Zepbound for weight loss / Mounjaro for diabetes)

If semaglutide is amazing, this is even better for both blood sugar control and weight management. Another once-weekly shot. Cash price if not covered by insurance: about $349/month for the starting dose or $499/month for higher doses.

If insurance does cover it but it’s pricey, manufacturer savings cards may bring it down to as little as $25/month.

Who qualifies? The FDA says you’re eligible if:

• Your BMI is 30 or higher, or

• Your BMI is 27+ and you have a related condition (like high blood pressure, high cholesterol, sleep apnea, prediabetes, or diabetes).

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Wegovy is also approved to reduce heart attack/stroke risk in people who have heart disease and a BMI > 27. Zepbound is approved for treating sleep apnea in people with a BMI >30.

Those are the FDA indications, and the only chance you have at getting them covered by insurance. However, sometimes they may be useful even if these don’t necessarily apply to you.

Pro tip — if your doctor has to renew your insurance approval (aka Prior Authorization), they should note your starting BMI and the percentage of total starting weight you’ve lost in their note, so coverage doesn’t get denied just because you’re now in a normal BMI range.

So how do they work?

They mimic certain hormones produced in the gut. These hormones do the following:

• Help the body make more insulin when needed

• Reduce the amount of sugar made by the liver

• Slow down digestion of food

• Act on hunger and fullness hormones to reduce appetite.

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The part where they slow down digestion of food is responsible for some of the side effects, such as nausea, diarrhea, constipation, and reflux. (Anecdotally, I’ve seen this side effect work out really well for people with chronic diarrhea).

A few pro tips:

• Vitamin B12 can help with nausea

• Fiber helps with constipation

• Stay hydrated and don’t skip meals

• Avoid large meals, and fatty or greasy meals

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Not only do they help people lose weight, but they also help with sleep apnea, heart disease, fatty liver, high cholesterol/high triglycerides, etc, etc, etc.

GLP-1s are being studied for all kinds of things — from fatty liver disease, chronic kidney disease and heart disease to addiction, arthritis, migraines, autoimmune arthritis, PCOS,  Alzheimer’s and other neurological conditions just to name a few. 😅 The list is long and growing.

If someone opts for a GLP-1, don’t they have to stay on it forever?

Well, it depends.

Let me ask you this…if someone has high blood pressure, do they go off the medication when their blood pressure is normal? Do they go off their cholesterol medication when their cholesterol is normal? No! Their blood pressure and cholesterol are normal because they are on medication. Same deal here.

For some people, their hunger hormones need lifelong support or they find that quieting the food noise is a game changer, so they choose to stick with it for the long term. Many folks may decide to reduce their dose or even stop completely at some point. It’s all individualized, and it’s important to work with someone who with tailor your plan to your needs.

GLP-1s aren’t magic in isolation. They work best when you also:

• Eat a balanced, high-protein diet

• Do resistance training (to help prevent muscle loss)

• Stay active

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Yes, muscle loss can happen with weight loss — that’s true no matter how you lose weight. We don’t know for sure yet whether there is accelerated muscle mass loss due to using the medication or if it’s just because people are so successful with weight loss so quickly. Strength training and eating enough protein help keep your muscle mass intact.

Don’t They Cause Cancer?

Well, probably not. They come with the warning that they may cause a rare type of thyroid cancer called medullary thyroid cancer. This came out of the studies done on rats. Here’s the thing –- rats have a lot more of these medullary or GLP-1 receptors on their thyroid than humans do. There hasn’t been an increased risk of medullary thyroid cancer observed in humans who take these. If you have a family history of MEDULLARY thyroid cancer (this is very rare - only 1% to 4% of thyroid cancers are medullary), or if you have MEN (multiple endocrine neoplasia) syndrome, you should not take them.  

A more common complication is pancreatitis (inflammation in the pancreas), which could land someone in the hospital for a few days. Less than 1% of people taking these get pancreatitis. The risk of this is increased in people who have diabetes or chronic kidney disease stage 3 or higher and smokers.

So… what do I think?

Honestly? These are life-changing medications for a lot of people.

They’ve helped people improve blood sugar, lose weight safely, lower cholesterol and triglycerides, sleep better, and reduce heart disease risk among other things.

This is just the beginning. We’re likely to see GLP-1s being used for even more conditions in the near future.