– There are many who describe it as »oh, how nice that I don’t have to be hungry«, says Helena Dreber, general practitioner at Vårdcentralen Hökarängen south of Stockholm, who a few years ago defended her thesis on obesity in young adults.
She herself is currently only using Ozempic in patients with diabetes, waiting for Wegovy, with the same substance – but approved for weight loss – to become available in Sweden.
– Then I know that there are colleagues who do differently, but I hold very tightly to the indications we have.
Both she and several other doctors who deal with overweight or obese patients in various ways believe that the pressure will only increase as the new popular weight loss drugs approach the clinic.
– Certainly there is increased pressure. Many people would prefer not to have surgery, says Joanna Uddén Hemmingsson, senior physician and operations manager at the Obesity Center at Capio St. Göran’s Hospital in Stockholm and chairman of the Swedish Association for Obesity Research.
According to Claude Marcus, pediatrician and professor at the Karolinska Institute, who for many years has researched overweight and obesity in children and young people, the new effective drugs are a major and long-awaited break from trends.
As the proportion of people with overweight and obesity has steadily risen, the desire for good drug treatment has also increased. Over the years, a number of drug candidates have emerged, but in the end, they have not turned out to be as amazing as many had hoped.
– This is a revolution, but like all revolutions it must be handled with reason. These are potent drugs that should be used for the disease obesity and not for beach slimming or the like, says Claude Marcus, who has been a tester of semaglutide for obesity in clinical studies.
Helena Dreber agrees. Above all, she believes that more people will come to the realization that obesity is a chronic disease where drugs are part of the treatment arsenal, just like with other major public diseases.
– But drug treatment must always be combined with lifestyle treatment, she emphasizes.
Who will ultimately get access to the new drugs remains to be seen. It also remains to be seen who will pay.
Since last year, Wegovy has been approved for treatment in adults with a BMI of 30 or more, as well as in adults with a BMI between 27 and 30 and, for example, diabetes, high blood pressure or high blood fats.
Very recently, it was also approved for the treatment of obesity in children over 12 years of age.
There are currently four medicines with the indication obesity available in Sweden. Only one – Xenical – is subsidized. It is also the only drug that is currently recommended in the national guidelines for obesity care.
As recently as 2020, the Dental and Pharmaceutical Benefits Agency rejected the benefit application for the weight loss drug Saxenda because the cost was not deemed reasonable in relation to the benefit.
The authority pointed, among other things, to the risk of indication slippage, i.e. prescription of benefits outside the subsidy, which would be costly for society.
In light of that, many are anxiously waiting to see how Wegovy—and eventually tirzepatide, which has shown even better efficacy but is still not approved for weight loss treatment—will be handled.
Claude Marcus thinks it is obvious to subsidize Wegovy for people with the disease obesity.
– It would be deeply unethical and illogical if it doesn’t happen that way, he says.
Peter Ueda, who is an ST doctor at the Center for Diabetes in the Stockholm Region and researches diabetes drugs, recently spoke about the spectacular weight effects of the new drugs during a lecture at the AT meeting. He, too, is hoping for a subsidy.
– An argument against subsidies that I often hear is that weight is a personal responsibility. Then there are many other things to which the same argument could be applied, for example blood pressure and diabetes, but I don’t see the same discussion there.
Joanna Uddén Hemmingsson would like to see Wegovy as well as Saxenda and Mysimba – two drugs that patients today have to pay for themselves – subsidized. Considering today’s rules, however, she finds it difficult to imagine that a broad group will have their treatment with Wegovy paid for.
– If there is any subsidy, I think it will be very narrow, only for some of those with established sequelae. The others will probably have to pay out of their own pockets, she says.
None of those whom Läkartidningen spoke to think that everyone who has a BMI over 30 should automatically receive treatment with Wegovy.
– I don’t think any of us who work with obesity think that 1.3 million Swedes should be treated. We need more efficient ways to diagnose obesity so that we can see who needs treatment and who can work on self-care, says Joanna Uddén Hemmingsson.
Both she and Helena Dreber point out that a high BMI is not enough to diagnose obesity.
– One should not stare blindly at BMI limits. It is only when you see the medical or psychological consequences of a BMI over 30 that you can diagnose obesity, says Helena Dreber.
Joanna Uddén Hemmingsson emphasizes that you can have good health despite a high BMI and that you cannot assume that everyone must receive treatment, whether with medication or something else.
Nor does Claude Marcus think it is reasonable to give Wegovy to everyone with a BMI over 30. However, he emphasizes that there is no reason to be very restrictive with prescription.
– If you don’t already have sequelae when you have a BMI over 30, the risk is high that you will get it. After all, we don’t wait to treat high blood pressure until a patient has had a stroke. We treat so that the patient does not get it.
Peter Ueda notes that there are still some question marks. There is a lot of evidence that you gain weight again when you stop taking the medicine and that you may need to be treated for a longer period of time. Then there is a risk of previously unknown side effects appearing.
– The question is whether any long-term side effects of semaglutide can be worse than the long-term side effects of too much weight. If I were a patient, I would probably take a chance that it is better to take semaglutide. What we know for sure is that being overweight is bad for health and for the quality of life, says Peter Ueda.
Claude Marcus states that medication must be combined with other supportive measures to prevent the patient from gaining weight again. However, he believes that there are those who see the new drugs as a »quick fix«.
– There is of course a risk that the medicines are used incorrectly. But I think there is just as much risk that doctors don’t want to prescribe the treatment because they see it as a moral issue. I think we will have to struggle with that for a long time, he says.
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