Side effects may include: How GLP-1 agonists push the boundaries of medical treatment

During one of his clerkship rotations, fourth-year UBC medical student Mohit Sodhi had a patient come in with complaints of excessive vomiting — up to 15–20 times in a day.

After running the appropriate tests and realizing that there was no clear medical cause, he noticed that the patient had recently started taking Ozempic for weight loss.

Ozempic, like Wegovy and Rybelsus, is part of a group of drugs used to treat type 2 diabetes called glucagon-like peptide 1 (GLP-1) agonists, which help regulate hunger and satiety signals and facilitate the production of hormones like insulin.

Semaglutide, the active ingredient in these drugs, has been prescribed under the name Ozempic as a type 2 diabetes treatment in Canada since 2018. It was indeed successful in helping diabetics control their blood sugar levels, but users noticed another unexpected effect during clinical trials: they were experiencing significant weight loss.

Sodhi began sifting through past case studies and relevant literature and his findings eventually evolved into a study on potential adverse effects of GLP-1 agonists that was published in the Journal of the American Medical Association in 2023.

In the study, researchers compared users of one of two main GLP-1 agonists, semaglutide or liraglutide, to users of bupropion-naltrexone, a weight loss agent that is not related to GLP-1 agonists.

Researchers’ primary goal was to quantify the risk of taking GLP-1 agonists in a demographic that uses it for weight loss rather than blood sugar regulation. Diabetic individuals were not included, as Sodhi noted that they are already at a higher risk for conditions such as diabetic gastroparesis.

Researchers found that those who used GLP-1 agonists experienced increased risk of pancreatitis, gastroparesis and bowel obstruction compared to the other type of weight loss drug.

Because GLP-1 agonists make people feel full for longer, they eat less — naturally, the drug began garnering a lot of attention as a potential treatment for obesity.

In 2021, Health Canada approved Wegovy, a drug containing a higher dose of semaglutide for obesity and weight-related conditions like hypertension, diabetes or obstructive sleep apnea.

Due to its rising popularity as a weight loss method, Wegovy quickly went into shortage. Although Ozempic hasn’t been approved for weight loss by Health Canada, health care professionals have been prescribing it off-label — the practice of using a drug to respond to a condition outside of its intended purpose. The resulting ongoing global shortage of Ozempic has left doctors scrambling to support diabetics, for whom this treatment could be a matter of life and death.

At $200–300 per month in Canada, Ozempic isn’t just difficult to get hands on — it’s financially unviable for many. It’s not a one-and-done treatment; it’s designed as a drug therapy to be used for an extended period of time, so costs add up quickly.

The unreasonable expenses and limited supply anxieties that come with GLP-1 agonists are undesirable impacts on their own — but what toll could the drugs also be taking on users’ physical well-being?

Although they determined that the side effects observed by the study are rare, Sodhi urged anyone planning to use these drugs — regardless of their reasons for doing so — to take this possibility into consideration. The study assumed that diabetics may be more willing to endure the risks given the urgency of their situation, but notes that those taking it for weight loss may also be willing to disregard the potential side effects.

“[For] people who do choose to take these medications for weight loss, we just ask and recommend that they get it prescribed from a licensed practitioner who they can sit down and have a conversation with, and who can monitor any potential side effects associated with these medications,” said Sodhi.

Aside from societal pressures to lose weight, Sodhi believes that weight loss can sometimes be beneficial for maintaining physical health.

“People who have high BMI [(body mass index)] can benefit from the weight loss side effect that was found with GLP-1 agonists,” said Sodhi. “As we know, obesity is one of the leading causes of morbidity in the world. It’s always good to help people along their weight loss journeys to help them become healthier.”

But do we really know if being thinner actually is healthier? And can high BMI actually be linked to some of the most common fatal conditions, or are we approaching this research with bias?

Gerry Kasten, a UBC food, nutrition and health lecturer, believes the latter.

“There are a lot of conditions that, in medical research, have been associated with ill health and with higher body weights, but we have to remember that association is not causation,” Kasten said. “We certainly need to question weight bias and weight stigma as contributing to that deferral of health care.”

Weight stigma is a term used to describe the judgment of and discrimination against people due to their weight or size. It’s consistently present in health care settings, where individuals of higher body weights are often perceived as being noncompliant with treatment, or lacking willpower to maintain certain diet or exercise habits.

It’s a factor medical professionals often overlook when treating patients with heavier body weights. Since patients know that their health issues will most likely be attributed to their weight and not investigated further, they might defer treatment or preventative care, letting illnesses progress further than if the initial concerns had been properly addressed.

Weight loss is typically not a sustainable solution to many health issues. People are good at losing weight, but not at maintaining it, and Kasten believes that GLP-1 agonists are the same as other weight loss interventions — once you stop, you’ll gain it right back.

“I don’t see how it’s any different than people talking about keto, or clean eating, or intermittent fasting or any of the ill-constructed weight loss strategies that never work,” said Kasten.

“Within two to five years, pretty much everyone regains weight, and many people regain more weight than was originally lost. Products like these drugs or these food restriction regimens all ratchet people’s weight upwards, and one hears a lot about the crisis around body weight,” Kasten said. “Maybe that crisis has to do with the constant, ineffective interventions that are being prescribed and proscribed to deal with it.”

Set-point theory is a common case against diets and other weight loss methods — it suggests that each body has a set weight range where it functions best, and will consistently employ mechanisms to return to this range.

Kasten pointed out that weight bias and stigma are branches from the same tree of discrimination that includes racism, misogyny and homophobia. Other studies show women and Queer people bearing the brunt of this judgment.

“I think it keeps coming back to [how] we have, more or less, an unattainable body ideal. People are willing to sacrifice their health to achieve that socially constructed, idealized body, and this is just one of many ways that they’re doing that,” said Kasten.

For some, GLP-1 agonists truly are a miracle drug, because they have revolutionized the way we treat certain life-threatening conditions. But like any other form of medical intervention, they don’t come without side effects.

But frenzies around weight loss methods are not new, and doctors are just beginning to deconstruct beliefs surrounding weight and body size in health care settings.

“I don’t see the drugs as being a new thing. It’s just this current iteration, and it will quite possibly have a peak and then a decline,” said Kasten.