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By David Wallace-Wells
Opinion Writer
Last year was called the year of Ozempic, though it was also a year of Ozempic backlash and Ozempic shortages, which could persist for years. Even so, we appear very far from a peak for GLP-1 drugs, like Ozempic and Wegovy, which are powered by a molecule called semaglutide, and Mounjaro, which uses its cousin tirzepatide. It seems possible to imagine a future in which almost everyone is taking some variety of GLP-1 drug, and with a pretty good reason to do so.
Probably, you have heard about the game-changing impact of such drugs on obesity, a condition that affects 40 percent of Americans and increases the risk of heart disease, stroke and hundreds of other comorbidities. Patients on Ozempic and Wegovy can lose 15 to 20 percent or more of their weight in a little over a year, and if they stay on the drugs, the weight tends to stay off. That may not sound like a monumental effect, but consider that on average, an obese 210-pound man who loses 20 percent of his body mass generally passes quickly through the overweight stage all the way to a normal weight.
If anything, though, we’ve probably talked too much about cosmetic weight loss and Hollywood vanity — and certainly made too many comparisons to fen-phen, Botox and Viagra. The GLP-1 drugs have been shown to cut risk of heart attacks, strokes and death from coronary disease by 20 percent among overweight and obese patients, presumably through the salubrious effect of weight loss, though the researchers can’t yet say for sure. Semaglutide has been shown to eliminate or reduce the need for insulin among those with recent-onset Type 1 diabetes. In a clinical trial of people with Type 2 diabetes and moderate to severe kidney disease, the drug reduced the risk of kidney disease progression and cut the death rate from cardiovascular and kidney-related causes by 24 percent — such a clear result that the trial was ended early. Semaglutide has reduced fatty liver deposits in patients with H.I.V. and nonalcoholic steatotic liver disease. It has normalized the menstrual cycles of those with polycystic ovary syndrome. (It has also, somewhat mysteriously, seemed to produce a wave of unintended pregnancies among women taking birth control, at least if TikTok videos are to be trusted.)
Studies have shown promise in treating Alzheimer’s and Parkinson’s with GLP-1 drugs, perhaps by regulating insulin levels and reducing inflammation, and the drugs may yet prove useful in treating many other conditions made worse by chronic inflammation. Some studies have found large decreases in the risk of depression and anxiety; others found smaller but still positive effects. There are potential applications for schizophrenia and neurological dysfunction, thanks to the role that insulinlike hormones like GLP-1 play in the development of the central nervous system and the way semaglutide reshapes the brain’s chemical reward system. It seems to bend the curve on alcoholism and drug addiction and curb other addictive behaviors, as well — compulsive shopping and sex addiction, gambling and nail biting, smoking and skin picking. A compulsive nation has stumbled into what looks like a treatment for compulsion and one that happens to protect against some of the country’s biggest killers and curb some of its most pervasive pathologies and inner demons.
Americans love to dream of miracle drugs, but hardly anything ever seems to fill the bill. True, semaglutide has arrived with real questions trailing like bunting: Much of the weight loss is from lean muscle mass, which isn’t ideal, and there are reasons to worry over the possibility of thyroid problems, loss of bone density and sarcopenia, a weakness disorder associated with aging. There are potentially other serious long-term side effects, though millions of Americans have been taking Ozempic for Type 2 diabetes for years without serious issues. (Some of them do report more familiar side effects, like nausea.) The GLP-1 drugs aren’t a permanent fix in a single shot — whether the thing being addressed is body mass index or cardiac risk or the progression of Alzheimer’s — but a permanent disease-management program. They also haven’t exactly cured cancer, although more than a dozen cancers are linked to obesity, and in at least one case, colorectal cancer, there is reason to believe GLP-1 drugs may directly cut the chances of developing the disease.
All that means that semaglutide isn’t exactly a cure-all, in the vernacular sense. But it seems to be about as close as we’ve gotten, even in a time of racing biomedical progress, to that old science-fiction proposition — one pill for almost everything and almost everyone forever.
And pretty soon, it won’t be just one. Technically, Ozempic hasn’t even been approved yet for weight loss, though Wegovy and Mounjaro (under the new brand name Zepbound) have, and there are almost 100 new GLP-1 obesity drugs in various stages of development. Roughly 70 percent of American adults are obese or overweight, and while not everyone who might benefit from GLP-1 drugs is likely to take them, it’s also hard to have confidence in projections that the market will grow only 26 percent annually over the next five years, when over the past five alone, semaglutide use has grown fortyfold. When we talk about GLP-1 drugs as a major breakthrough or even potential solution to obesity, it raises questions about health care access, the social determinants of health and the political determinants of health inequality, the pathologies of the United States and the modern world. (Not to mention the unpredictability of putting so many people on what may need to be lifelong drug regimens.) But it also means, very simply and straightforwardly, that the drug could help a couple of hundred million Americans right now.
At the moment, getting those drugs to those people would be remarkably expensive. A single month’s worth of Ozempic or Wegovy is today priced at around $1,000 or more, which is more than private companies currently pay per employee into employer-based insurance in total, and at present few private insurers cover these drugs for weight loss. A group of researchers recently calculated that at current prices, the cost of providing GLP-1 drugs to all Americans who could benefit from them could grow past $1 trillion annually: more than the full annual cost of Medicare or even than that of the U.S. military.
But miracles don’t have to be this expensive, and in fact, they aren’t elsewhere in the world, where Ozempic costs one-fifth as much as it does here or even less. A month of doses can be manufactured for less than $5, which means that American customers are paying a 200-fold markup or more, with many of them paying it out of pocket. That suggests one additional way that semaglutide could reshape American health and health care: The price of marginal production has never determined American medication costs, but the sheer magnitude of Ozempic demand may force a belated reckoning with the mess of U.S. drug pricing. Perhaps it will also refocus our approach to health care away from crisis treatments and toward underlying conditions and preventive care, as reformers have advocated for decades.
If this is the beginning of a health revolution, we are still in its early days. We don’t know how many Americans would like to avail themselves of GLP-1 drugs or how many of them will find an unending course sustainable and helpful. (Though we do know that a majority of those who took the medications over the past several years have already stopped.) We don’t know whether the costs will be brought down to manageable levels, for individuals and for insurers, and we don’t know what that might mean for the government’s role in setting drug prices generally. We don’t know how quickly, if at all, obesity rates will fall. We don’t know what medical complications might follow from the sudden uptake of weight-loss meds by a conspicuously obese nation. We don’t even really know everything about how these drugs work or what else they might do.
What we do know is that treatment for obesity has been called for decades a holy grail. All of a sudden, we have several, with many more to come.
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Subscriber-only Newsletter
By David Wallace-Wells
Opinion Writer
Last year was called the year of Ozempic, though it was also a year of Ozempic backlash and Ozempic shortages, which could persist for years. Even so, we appear very far from a peak for GLP-1 drugs, like Ozempic and Wegovy, which are powered by a molecule called semaglutide, and Mounjaro, which uses its cousin tirzepatide. It seems possible to imagine a future in which almost everyone is taking some variety of GLP-1 drug, and with a pretty good reason to do so.
Probably, you have heard about the game-changing impact of such drugs on obesity, a condition that affects 40 percent of Americans and increases the risk of heart disease, stroke and hundreds of other comorbidities. Patients on Ozempic and Wegovy can lose 15 to 20 percent or more of their weight in a little over a year, and if they stay on the drugs, the weight tends to stay off. That may not sound like a monumental effect, but consider that on average, an obese 210-pound man who loses 20 percent of his body mass generally passes quickly through the overweight stage all the way to a normal weight.
If anything, though, we’ve probably talked too much about cosmetic weight loss and Hollywood vanity — and certainly made too many comparisons to fen-phen, Botox and Viagra. The GLP-1 drugs have been shown to cut risk of heart attacks, strokes and death from coronary disease by 20 percent among overweight and obese patients, presumably through the salubrious effect of weight loss, though the researchers can’t yet say for sure. Semaglutide has been shown to eliminate or reduce the need for insulin among those with recent-onset Type 1 diabetes. In a clinical trial of people with Type 2 diabetes and moderate to severe kidney disease, the drug reduced the risk of kidney disease progression and cut the death rate from cardiovascular and kidney-related causes by 24 percent — such a clear result that the trial was ended early. Semaglutide has reduced fatty liver deposits in patients with........
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