The future of mounjaro?

[Legopotamus]

I know none of us have a crystal ball, but I'd love to know what developments you think there might be in the future in terms of how/ when people take it.

Could there be a pill for a maintenance dose? Maybe a longer lasting injection?
Any way of it supporting a healthier lifestyle indefinitely

(Asking hopefully as it's been so life-changing for me!)

I think ultimately there will be a pill form that can just be bought over the counter like viagra.

Completely agree with this

Pharmacists are highly educated, and in my 20 years nursing in hospitals, I often trusted them more than doctors. I would frequently contact them with concerns over doctors prescribing, and they would educate and advise the doctors. They came to the ward weekly to check charts and discuss patients needs with the nurses.

I can see it all going wrong if I’m honest. I’m already seeing people who have finished the course and reached their goal weight, now putting weight back on and “wanting to go again”. This is because whilst they may be eating better on M they are still not exercising maybe? Basically a quick fix is never the answer, you have to put in the work and this injection stops you having to do that. I can see people on and off this for life, that can’t be a good thing?

WLI bingo!

I really think some people drastically overestimate how much work GPs do in 'holistically managing' prescriptions! I mean you obviously can't fake a broken bone or something measurable like weight with your GP but beyond that? I've had numerous GPs (private and NHS) over the years and a multitude of health issues (mental and physical). According to my NHS health records I am 'formally diagnosed' with bipolar and CPTSD.

Now don't get me wrong, I'm am as sure as I possibly can be that I have these conditions and the meds I receive for them help immeasurably so I'm not about to question it, but my 'formal diagnoses' were a ten minute discussion with a psychiatrist after being discharged following a 24 hour section over a decade ago - they suggested it seemed likely I had these and suggested talking to my GP. From this some kind of misinterpretation/miscommunication between me and GP meant that I am now recorded as having gone through stringent tests via multiple panels of psychiatrists and am medicated and treated accordingly. Again, I am 99.99999% sure the diagnoses are accurate but it has never, ever been questioned and there was no referral etc, my GP wasn't even aware I was sectioned, this is all off the back of what I have told them! I could very easily have just...lied.

Similarly with Mounjaro I had some actual concerns about underlying health conditions and chose a decent/reputable pharmacy to discuss these. They were happy to diagnose but still sent a detailed letter to my GP setting out the issues and asking for feedback within a designated time frame. So far as I'm aware my GP never actually read the letter and certainly didn't speak to the pharmacy - this has been confirmed. I can understand this from my GP's perspective as my health records are lengthy but what on earth makes people think that the average GP would be more stringent, question more and spot any issues more? I'm sure as with anything that there will be some amazing GPs as well as some less great but again, my experience has been with probably close to ten separate practices/individuals and it's all been the same. Maybe I've just been unlucky (or lucky!) in that respect!

In terms of the future for MJ, I hope the price is reduced and that it is prescribed more widely. As well as weight loss the side benefits to me have been huge - I sleep properly for the first time, I'm less depressed and feel generally positive, have more energy and focus and can feel my physical health has improved. 2.5 months in I haven't come even close to having a mental health episode that were previously becoming more frequent and frankly terrifying for both me and my loved ones. And yet people want to make it harder to obtain?? Why? I am so incredibly lucky that I can afford this and when I look at some of my friends who can't and think what benefit it could be to them, I truly hope this drug is made more accessible to all.

On Friday a letter arrived asking if I want to take part in a trial of oral semaglutide, AKA Wegovy.

The trial lasts 5 years and they are trying to recruit 20 000 people with type 2 diabetes to see if it protects against cardiovascular disease.

Obviously I said 'yes' but there is a chance I will be in the control group or that they will reject me.

Don't forget these drugs started as treatment for diabetes, weight loss is a side effect.

On the pharmacist front, where I am, there’s a big push to have pharmacists doing more, so I actually think it’s likely that pharmacist prescribing powers will only increase over time, not decrease, to free up GPs from routine prescriptions. For example, the doctor surgery here now directs patients to the pharmacy as first port of call for a variety of things, urine infections for example. You can go directly to the pharmacy to be diagnosed and prescribed antibiotics.

For ‘lifestyle’ medication which doesn’t tend to have severe side effects in any great number or bad interactions with other medication or health conditions, I think it’s pretty sensible to allow pharmacists to take the lead. Pharmacists are often far more knowledgeable about the specifics of medication anyway, that’s their job.

The drug treats the symptoms of the disease in this case it fixes the excessive hunger that obese people face due to dysregulation of satiety signalling. Ie. In obese people the systems that tell you when you are full don't work properly so you feel hungry more, therefore eat more.

So if you compare it to statins, the statins will get your blood pressure under control. Once your blood pressure is within the normal range we don't then go ok let's just stop the drug. In some individuals diet and lifestyle is sufficient to come off the drug however in a large amount of cases it is not.

WLI are the same, some individuals will be able to come off them with diet and lifestyle changes but others will not and will require lifetime or certainly more prolonged treatment. They do not have a time limit on how long it can be taken and the long term trials from diabetes patients show the benefits significantly outweighs the side effects when taken over a prolonged period.

The eat less, more more, just try harder, you are a failure for being fat.... has been around a long time. It does not work on a societal level. If anything this drug shows that fixing your gut hormones and reducing that constant hunger is the answer to obesity rather then shame or assuming all fat people eat nothing but chips and cake.

I say this as someone who has been obese since early childhood. I exercise more then my slim frinds, I know more about nutrition then most of my slim friends but decades of yo yo dieting and fasting in my teens has ficked my metabolism to the point that calorie restriction sends me into a hypoglycemic state. Even after my healthy balanced breakfast with fibre and protein and healthy fats I am staring 2 hours later and if I don't ha e a snack am visibly shaking from low blood sugar by lunch. Just try harder is not the answer.

??? Pharmacists can prescribe certain medications.
Pharmacist prescribers are a central strategy to reduce demands on GPs. https://healthmedia.blog.gov.uk/2024/02/01/pharmacy-first-what-you-need-to-know/#:~:text=The%20pharmacist%20will%20be%20able%20to%20recommend%20the%20best%20course,antibiotics%20or%20antivirals%20where%20necessary.

Or here

https://www.nhs.uk/nhs-services/pharmacies/how-pharmacies-can-help/

Also- NHS information about pharmacist prescribers https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA-01426/en-us

I expect it will become a long-term drug that people take to maintain their health if they are prone to obesity - the same as people who take blood pressure or asthma medication. So long as that doesn't cause more potential problems than being obese, that is a sensible public health strategy.

People put weight back on when they come off Mounjaro because the insatiable hunger comes back. That's because some people are genetically prone to that state.

I have a friend who has been slim/skinny all her life. She eats quite normally, but small portions compared to me. She says she doesn't ever really feel hungry - she just realises she needs to eat something when she feels tired and weak. When she was breastfeeding she felt properly hungry and found it really unsettling. That is a million miles from my experience of hunger.

This is complete nonsense.
Pharmacists (and nurses) can complete a Masters level qualification to become an independent prescriber.

With the shortage of GPs in many areas, it’s the future of prescribing, where a doctor is not needed to make a diagnosis.
If a person is overweight it’s easy to diagnose visually. Same for urine/blood tests where a result may clearly indicate a need for a specific medication.

assets.pharmacyregulation.org/files/document/guidance-to-support-the-implementation-of-the_standards-for-the-education-and-training-of-pharmacist-independent-prescribers-october-2022.pdf

Agreed.

Even taking the arguments people are making about risks at their highest, the NHS in the long term needs MJ for the population.

Not disimilar to ND children or those with dyslexia etc - decades ago they were thrown on the scrap heap by the education system and a society that failed them before our understanding developed - now we can make environmental changes or medicate where appropriate and everyone (frustrated teachers / parents as well as the child) - the answer was not to try harder. Anyone with one leg cant actually physically walk without a crutch.

Also if your eyesight fails you wear glasses - for life - its not a case of 'trying harder' - squint more!

I think this is a really valid point @Dinglydelll about eyesight and the comparison to MJ. I truly believe something in me is wired differently in regards to food as since starting mj 3 weeks ago I keep saying to DH is this how normal people feel around food, like I'm just not fussed about it anymore.

Just like I wear contacts to correct my vision, perhaps I need mj for long term to correct what ever it is that makes my relationship with food a bit skewed

I don't think it will become that ubiquitous as there is emerging evidence of psychiatric risk in some individuals using the semaglutide family. I understand some people's MH symptoms improve whereas for others they experience depression or anxiety, so I think it will need to be managed or monitored and not used as a panacea. NB mounjaro isn't specifically mentioned in this study as it's newer, but there is anecdotal evidence for that too.

https://www.nature.com/articles/s41598-024-75965-2?fbclid=IwY2xjawJgWc1leHRuA2FlbQIxMQABHhyY5J0HP7judG9uRMZy3ZvMY3VqTTuY_sEZhYYykzw3cY2RkL7Lja6nVDhM_aem_fDhZKkMihTBmn17C6MvlTQ

The mental health effects are really interesting. Thanks for sharing the paper I hadn't seen that one.

It seems in the study you linked they excluded anyone with preexisting conditions. But when the studies included those with preexisting psychiatric conditions the overall effect is more beneficial in terms of depression scores.

https://www.ajgponline.org/article/S1064-7481(23)00394-9/fulltext

https://www.sciencedirect.com/science/article/pii/S1064748123003949

So mabey the side effects need to be updated with this new information to allow informed consent

What work do you think those on WLI are neglecting to put in?

Thank you for your concern. I'm planning to stay on it for the long haul so it's nice to know I can help with your worry that it'll all go wrong for me. I'm sure that you were really worried about the risks of my obesity too. It's really a miracle to be heading towards slim and healthy at no cost to the nhs. You're welcome.

I don’t understand the problem with online pharmacists. I’ve been getting everything from prescription migraine medication to birth control from them for years because my GP surgery is useless. Didn’t see anyone worrying about it all then.

Your study seems to be on patients with type 2 diabetes rather than those who were not diabetic but seeking to use the meds just for obesity. I wonder if it works differently in a diabetic cohort.

There's a lot we don't know about these meds yet I suppose. For some they are an absolute miracle but for others they cause intolerable side effects, like any med I suppose.

I don’t think the side effects are worse than those of the contraceptive pill in either frequency or severity, but that has become easily available. It would have been so earlier, except for the reluctance to allow women so much control over their own fertility. Where it isn’t available in some countries, the concern isn’t our health, but our autonomy.

Yeah alot of the studies are done in diabetes patients just because that's where they have been prescribed in the longer term.

Diabetes does increase rates of depression, they are about twice that seen in the rest of the population so definetly something to consider. It is worth noting thir is a link between obesity and drpression. Their is a linear relations ship between bmi and depression with high rates of depression seen in those with higher bmis. But interestingly depression makes you more likely to be obese so there is a bit of a chicken and an egg argument to be had there.

It would be really interesting to see the outcome in a population with depression without diabetes and weather or not it is effective in reducing rates. While preclinical studies show it may be I am not aware of any clinical trials in that population.

Edited to add all drugs have side effects including WLI but even the most commonly used class of drugs for the use of depression , SSRIs, increase risk of suicidal thoughts and attempts in adolescent populations where they are widely used.

https://pmc.ncbi.nlm.nih.gov/articles/PMC9178080/

I was actually shocked that they removed that ad a side effect on the list on the NHS website.

Most people who lose weight by any means will put it back on. But oddly you never see all those warnings on a regular weight loss board, in keto or slimming world or whatever other weight loss threads. 'Why are you counting your calories, you'll lose muscle and will just put it back on afterwards and have to do it again!'