Warning doctors not to prescribe Ozempic for weight loss is morally problematic

Monday, May 22nd was a bad day at the office for staff in our obesity clinic. Every doctor in the country received an email from the Medical Council, our regulatory body, stating that using the drug semaglutide – better known to the public by its brand name Ozempic, and which is both a diabetes treatment at low doses and an obesity treatment at high doses – for patients with obesity but without diabetes was an “off-label” misuse of scarce resources.

The warning – which came from the Medical Council in an email featuring the logos of the Dept of Health, HSE, Health Products Regulatory Authority and Pharmaceutical Society of Ireland – said this would compromise the availability of the drug for patients who need it most – those with diabetes. Given that most obesity specialists have been using semaglutide in non-diabetic patients with obesity for some time, it felt really uncomfortable to be on the wrong side of Council guidance on appropriate prescribing.

There are serious global challenges with demand exceeding supply of semaglutide, and the communication from the Medical Council, which also went to all pharmacists, was undoubtedly sent in good faith. But it is problematic for several reasons. Firstly, the drug has been licensed for the treatment of obesity here since January 2022, just at a higher dose than is currently available. The fact that Novo Nordisk has chosen not to market the higher dose version here does not mean the lower dose isn’t licensed. Drawing semantic distinctions between marketing authorisations for different strengths and brand names of what is the same drug is misleading and unhelpful.

A second problem with the Medical Council communication is the inference, however unintentional, that obesity is a lower priority for treatment as a disease than diabetes. This negates Government policy that obesity is a disease, it makes a mockery of specialist treatment services for obesity and, most importantly, it serves to stigmatise and demean patients with obesity. The communication epitomises the bias and discrimination faced by them at every turn in our healthcare system.

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Doctors and specialist groups have written individually and collectively to express these concerns to the Medical Council in the strongest possible terms. Their response to media representatives has been disappointing because it doesn’t recognise the validity of those concerns, it hasn’t clarified that semaglutide is in fact licensed for obesity, and it denies that the communication discriminates against people with obesity – when it patently does. Every moment that the communication remains current guidance on drug prescribing creates a worsening crisis for patients with obesity, whose doctors won’t prescribe semaglutide and whose pharmacists won’t dispense it.

The average man, woman or child in Ireland still consumes the equivalent of five packets of Skittles, three Mars bars, 10 digestive biscuits and seven packets of crisps every single week

This communication is symptomatic of wider dysfunction in how the healthcare and regulatory establishments are addressing the problem of obesity. Government policies don’t emphasise the overconsumption of unhealthy food as the primary driver of the obesity crisis. Overly optimistic but scientifically unsound reports on “progress” with the reformulation of unhealthy food are written by the food industry and warmly endorsed by policymakers, while the average man, woman or child in Ireland still consumes the equivalent of five packets of Skittles, three Mars bars, 10 digestive biscuits and seven packets of crisps every single week, not to mention energy drinks, ice cream and all the other stuff.

Meanwhile, we allow a charity associated with a fast-food chain to sponsor the accommodation for the parents of our sickest children in the new children’s hospital. Then we lament the burden of too many people with obesity, an entirely predictable consequence of inadequate policies to limit the overproduction, aggressive marketing and overconsumption of unhealthy food products.

We need the Government to take obesity as seriously as they’ve taken other public health problems, like smoking and alcohol misuse. Instead, we trickle resources to desperately underserved clinical services for obesity, while tinkering around with partnerships with the food industry to see how much salt they can take out of a tub of crisps without them tasting like the cardboard package they come in. Compared with the compassionate, urgent and adequately resourced response to Covid, which included difficult and unpalatable population health measures that were nonetheless proportionate to the severity and gravity of the threat posed to the most vulnerable in society, our response to obesity is a farce.

We need a radical change of thinking when it comes to obesity. Let’s start with the enormous costs of these drugs, which is estimated on RTÉ’s Prime Time this week to be in the region of €100 million a year. Given this is an epidemic, predicted to cost north of a billion euro, and that we already spend €2.3 billion a year on drugs in Ireland, we’re going to have to get our heads around the fact that effective drugs are going to cost a lot of money and drug companies are going to make profits from their use. But there are simple if radical solutions that we could deploy to address this challenge.

For starters, we could halve the cost of treatment by not using Saxenda (liraglutide) – currently used for obesity – which is twice as expensive as Ozempic. Both are manufactured by the same company, Novo Nordisk.

Secondly, we could pay for these drugs through hypothecation – ring-fencing – of the money raised from the sugar tax, more than €30 million per year since 2018, as Donal O’Shea suggested on Prime Time this week. It would address the population-level drivers of obesity, while simultaneously helping those most in need of help – because of their biology, not their personality. We did this for the plastic bag tax, using it to fund other environmental initiatives such as recycling facilities. A no-brainer for some; too radical for others.

Thirdly, we could ask – politely – that the drug companies reduce their prices for these drugs, which are much cheaper in other parts of Europe.

This is so much more than a drug shortage. We have to stop framing the therapeutic solution for obesity in terms of effort, personality and motivation. Treatment of obesity requires the modification of a disease process. That’s going to cost a lot of money. In the meantime, the Medical Council needs to make an urgent follow-up statement to all doctors and pharmacists that semaglutide is an appropriate drug for obesity and should be dispensed to patients irrespective of their diabetes status, when available.

Francis Finucane is a Consultant Endocrinologist at Galway University Hospitals and an Honorary Full Professor in Medicine at the University of Galway