Sunday, November 26, 2023

Weight loss drugs - are they for me?

Last year, Denmark published statistics on its Gross Domestic Product with and without Novo Nordisk, the giant Danish pharmaceutical company that markets Wegovy – that is how much money is rolling in to the manufacturer of the wildly successful obesity drug.

Why are Wegovy and friends such a hit? What should you know about these drugs?

America is suffering an epidemic of overweight and obesity – some 70% of us are either overweight (BMI>27) or obese (>30). Excess weight contributes to the development of hypertension, diabetes and heart disease and losing 5% or more of body weight has been demonstrated to lower the risk of cardiovascular disease.

The problem is that losing weight is hard. For most of us it goes well beyond “will power.” The determinants of weight are complex, and include genetics, environment and habits. The food industry with its high fructose additives and advertising are also culprits.

Enter the holy grail – the search for a safe and effective drug that will help people lose weight.

Drugs for weight loss have been around for a while, and include phentermine, orlistat and Contrave.

Phentermine is an amphetamine that has been shown to produce about 6% of body weight loss after 6 months of use, but has the expected side effects of anxiety, racing heart and insomnia. Orlistat decreases the body’s absorption of fat and leads to about a 5% weight loss; it has a number of bowel side effects including leaking of stool, though is otherwise safe. Contrave combines naltrexone, an opioid blocker, and bupropion, an antidepressant. About half of those using it lose at least 5% of body weight after a year. Side effects include seizures, behavior changes and suicidal thoughts.

So, modest weight loss and serious or annoying side effects with these older agents.

The new kids on the block are GLP-1 agonists – drugs that mimic the effects of glucagon-like-peptide-1. They send a signal to the brain that you are full and also slow the stomach emptying. These drugs have been used to treat diabetes since 2005. Because they must be injected, they never captured much of the diabetes market.

What has turned the GLP-1 agonists into blockbusters is their dramatic effects on weight. In different trials with different products, subjects lost 12-20% of their body weight after a year. Most recently, a trial of semaglutide in very high-risk patients – in their 60’s with established cardiovascular disease – showed that those on the drug had 20% fewer events (heart attack, stroke or cardiovascular death).

There are now three products on the market: Wegovy (semaglutide), Saxenda (liraglutide) and Zepbound (tirzepatide – a GLP-1 agonist plus another). Given the vast market potential, more will follow.

What is the downside? First is cost. Wegovy retails for $1349/4 weeks; Zepbound for $1060/4 weeks; Saxenda about $1300/4 weeks. And note that these drugs must be taken indefinitely! In trials, those who stopped the drug after a year regained most of the weight they had lost by a year after stopping.

Nuisance side effects including nausea, diarrhea and constipation are common. More serious side effects including inflammation of the pancreas or gallbladder, kidney injury and suicidal thoughts have been reported in less that 1% of people taking them.

Are they for you? If you are seriously overweight and have other conditions such as diabetes, high blood pressure and/or heart disease, and if you have made your best effort at losing weight without medication, definitely discuss their use with your doctor.

Remember that weight is a life-long issue, and commit to using dietary changes and exercise as part of your life.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, November 19, 2023

I am sick. Where should I go?

In the “old days,” say the 1950’s and 60’s, getting sick was much simpler. If you did not feel well, you called your doctor and either went to his (and 90%+ were male) office or he made a house call. Now, the set of choices is overwhelming – but where you decide to go can have a major impact on your health and your wallet. Your choices include:

The Emergency Department (ED). Pros: always open, prepared to handle just about anything acute that you may have. Cons: usually no idea who you are or your underlying health issues; very expensive – even if you have good insurance, there is usually a high co-pay; little continuity of care, and, unless you are critically ill, a long wait, often a very long wait.

Urgent care center. Pros: extended hours including weekends; can handle most minor emergencies; usually have X-ray and lab; less expensive than ED. Cons: Not 24/7, so be sure to check if they are open; no continuity of care; moderately expensive.

Pharmacy-based drop-in clinics, usually nurse-staffed. Pros: weekend hours; can handle most “minor” illnesses well; usually less expensive that the prior two. Cons: limited diseases that can be handled; little continuity; limited lab or X-ray available.

Your doctor’s office: Pros: they know you and can generally avoid over-testing; continuity of care automatic; least expensive. Cons: limited hours; may not be able to see you quickly.

So, what should you do?

As the ubiquitous phone message says, if you are having a medical emergency, hang up and dial 911. If you are experiencing chest pain, sudden shortness of breath, severe abdominal pain or are bleeding profusely, you belong in the ED. Calling 911 will get you there more safely than driving and will assure you are seen more promptly. Ambulance patients are almost always seen before those who drive themselves or are driven. Most insurance covers emergency ambulance transport (but not “convenience” rides).

If you need urgent attention but are not severely ill – think foreign object in your eye, a deep cut that will need suturing or a red swollen arm on a Saturday – the closest Urgent Care Center is probably your best bet.

For the myriad other “minor emergencies” that need prompt attention such as a bad sore throat, an earache, a possible urinary infection or a very itchy rash, try your doctor’s office first. If they are unable to see you, a convenience clinic at the local pharmacy will probably be able to help you at lowest cost and least waiting. These are the kinds of problems that do NOT belong in the ED.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, November 12, 2023

Medical Bills and how to fight them

Years ago, when I would visit with my in-laws, after the initial pleasantries, my mother-in-law would bring out a shoebox full of paper and say “Edward, do I owe anyone any money?” In the box were dozens of undecipherable pieces of paper, many of which were marked “This is Not a Bill,” even though they looked like bills. Things have not gotten better.

Medical billing is notorious for being very hard to understand and full of errors. The average person, faced with a gigantic bill, is likely to throw up their hands and pay it, but do not be in too much of a hurry to do so.

The first step is to request an itemized bill, to which you are entitled. This will list all the things the doctor or hospital is charging you for. While the bill should list the items, sometimes you will just get a listing of CPT (Current Procedural Terminology) codes – 5-digit numbers that are medical shorthand for the things done. It is very easy to use Google to get the English translation of, say, 99285 into “Emergency Visit, high complexity.” Very often you will see things listed that were simply not done, and a call or letter should ask to have these removed.

You should also use your common sense to evaluate how well the service for which you are billed matches the service you received. Using the same example, if you are being charged $800 for a 99285 and you went to the Emergency Department with a swollen ankle that was wrapped in an elastic bandage, you should insist the charge be reduced. A high complexity visit is meant to cover caring for a victim of a major auto accident or a patient in coma, not a 10-minute visit for a simple problem.

If the billing department will not reduce the charge, demand a copy of your visit. If the notes reflect a simple visit, repeat your demand and threaten to take the issue to your insurance company or the state department of consumer affairs.

Finally, it is always worth asking for a discount. Uninsured patients are usually charged the “list price” for a service while Medicare, Medicaid and every commercial insurance company gets a substantial discount off these prices. You will very often get a discount of 25% or more just by asking.

It is your money. Don’t part with it without a fight.

Prescription for Bankruptcy. Buy the book on Amazon