Scott Webb (Host): On today's podcast, I'm joined again by Dr. Ellie Chuang, endocrinologist and obesity medicine specialist with Southern New Hampshire Weight Management to catch up on weight loss medications, including some of the pill options that have hit the market.

This is On Call with Southern New Hampshire Health. I'm Scott Webb. Doctor, it's nice to catch up with you today. You know, I know we've spoken about this topic before. But, you know, here a year later, maybe you can briefly remind us what anti-obesity medications are and how they fit into an overall weight management plan.

Dr. Ellie Chuang: So, anti-obesity medications are basically medications that we utilize as tools to help facilitate weight loss and get to a healthier status. They can help in various ways, including decreasing appetite, promoting early sensation of fullness and, therefore, ability to control portions. They can decrease cravings help with binging issues.

But what's really important to know is that they should be used as just one component of a comprehensive weight management plan. That includes lifestyle, habit improvement, including nutrition, physical activity, mental health, and sleep. If you use anti-obesity medications alone without addressing any of those other issues, it can lead to unintended consequences like muscle loss, for example, and also will make it not as effective for weight loss if you just ignore lifestyle.

Host: Yeah, I see what you mean. Like, they are pretty amazing and I'm still learning about the benefits as everybody else is, but they're not magic per se. And we do need to do our part, right? Behavior, lifestyle, exercise, all that good stuff. And I know we talked before about the benefits of the medications. I just want to have you go back through the key pros and cons that people really need to understand, you know, before considering them.

Dr. Ellie Chuang: Well, the pros are, as I basically just kind of talked about, they can help you stick to the healthier lifestyles by, you know, lowering or getting rid of barriers that you may have, like very high hunger levels, cravings, tendencies to eat in the evening, low motivation, so that you are able to better implement and actually sustain the healthier habits.

There can be potentially some other benefits of the medications and, you know, the main pro, of course, is that they help you hopefully achieve, you know, a better health status so that you can improve any complications you might already have or prevent ones that could come in the future if you aren't proactive in managing your health.

In terms of cons, well obviously as with any medications that you might take, there are always potential side effects. And those should be discussed in detail with your prescriber. And it's a part of why it's important to be carefully evaluated by a reputable expert, first of all, to assess if you are even a good candidate for treatment, because you don't want to take a medication you don't really need and suffer a consequence. And then, what might be the best options for you personally. And, you know, going into all the potential side effects of the medications is way beyond the scope. You know, we could have a very long conversation about that.

But, you know, just to give a couple examples, Zepbound, for example, might not be a good option for you if you already deal with nausea frequently, because that's a common side effect of the medication, or phentermine, which is a pill option, might not be a good option for you if you already have uncontrolled anxiety, which that medication could potentially worsen. But again, that's a totally personalized decision that you and your provider, your prescriber will discuss after, you know, the full assessment.

Host: Right. Yeah. And we're talking here about injectable medications, these GLP-1s, and they've certainly gotten a lot of attention. But now, I'm hearing, and you mentioned there about oral or pill-based options. So, maybe you can go through some of the new pill medications that are available or they're emerging and, you know, explain, like do they work differently or is it basically the same, but you don't have to inject yourself? Like, take us through that.

Dr. Ellie Chuang: Well, there are a couple main GLP-1 pills that are either out or are coming out. First of all, it's interesting to note that the reason the GLP-1s have nearly all been injections up until now is that the drug molecules are easily broken down in the GI system and are poorly absorbed because of their large size. So, it was easier just to keep doing them as injections. However, the Wegovy pills just came out in January 2026. It is the same drug, same molecule as in the Wegovy injections. Instead of weekly injections though, you would be taking a daily pill. And the key here that enables it to be potentially effective, is that they added a coating that enhances the absorption and slows the breakdown of the molecule. Caveat, you do have to take it fasting on an empty stomach 30 minutes prior to any food or other pills.

Then, there's a newer oral medication, which is not yet approved, but it's expected to be approved later this year. It's called orforglipron. And that is also a daily pill. And this is a completely new type of GLP-1 molecule, which is much smaller and it's therefore resistant to breakdown and is much better absorbed than prior options. And what's nice about it is it is taken once a day, but it can be taken with or without food. So, you don't have any restrictions there.

Scott Webb: Nice. Yeah. So, lots of options and, as you've mentioned a couple times here, speak with your prescriber, your provider, get that personalized, you know, attention that we all need before we just start ordering things online and trying to, you know, self-medicate, if you will. Just wondering, Doctor, like how these newer pill options compare with injections when it comes to safety and effectiveness, and are there maybe certain people who may be better suited for pills versus injections based on their own, you know, health history, lifestyle, personal preference, that kind of thing.

Dr. Ellie Chuang: Well, first thing to just remind people or let people know about is that still, of all the options we have right now that are FDA-approved for weight loss, the most effective thing in the clinical trials was Zepbound, which showed about 20% total body weight loss. The next thing is Wegovy injections, which is about 15%.

And whenever I talk about these clinical trial data, I just want to stress the fact that that is not necessarily what you're going to see in real life in any individual patient. You can see, you know, a whole range, because we're all different. You know, you could see zero effect on Zepbound in someone, and then in someone else you might see about 20% like the trials. And in another person, you might see 30%. So, this is just, you know, an average. But in general, Zepbound is the most effective thing we have out right now for weight loss.

Oral Wegovy is pretty similar in effectiveness to the Wegovy injections with the highest dose in the trials showing about 13-14% total body weight loss at around a year. Orforglipron in the trials showed about 11% weight loss. So, slightly less than the oral Wegovy.

In terms of safety, they're all like fairly similar with their side effects. They're all in terms of the GLP-1s, they're mainly GI side effects with nausea being a very common one. For both of the Wegovy formulations, nausea is probably higher than the other choices. Zepbound and orforglipron showed a little less frequency in the nausea. But in all cases, the rate of people stopping the trial because of side effects was somewhere around 7%. Now, in real life, that's probably higher, but just to tell you in an ideal setting.

Host: Yeah.

Dr. Ellie Chuang: Now, in terms of who might be better suited for pills versus injections, I would say the most common consideration is probably preference. You know, certainly a lot of people are out there saying, you know, "No way am I taking injections," whether that's just a preference or some people have a true needle phobia, or maybe they like the idea of daily over weekly or vice versa. I have some people who would rather take a weekly medication than have to remember to take something every day.

Another category of patients who might want to consider the oral are people who have had a serious skin reaction to the injectables that they've already tried. Also cost. Now that's going to be particularly true if you're cash paying, which unfortunately that would be a whole nother talk about insurance coverage issues right now. But there are some relatively, and, you know, relatively with large air quotes, cheaper also, you know, cheaper with air quotes.

Host: Cheaper in the air quotes, right? Yeah.

Dr. Ellie Chuang: Yeah, cheaper, in air quotes, cash options, which right now and also projected to be for orforglipron, the orals are at least slightly cheaper than getting the injectables cash price, so that could be a consideration as well.

Host: Right.

Dr. Ellie Chuang: Also, something to mention, a couple peoplemso, who would not be a good candidate for some of these oral medications in particular? If you have had a history of bariatric surgery, whether it is the gastric sleeve or the bypass, gastric bypass, we would not use the Wegovy pill in you. So, they did not study it in those patients, but it is absorbed in the stomach, which is greatly decreased in size in both of those surgeries. So, where this medication already has issues with absorption, you would probably want to create another barrier. So, we would not use that in those patients.

If you are not able to adhere to the administration restrictions for the Wegovy pill, then that's not a good choice for you either. Remember, you have to take it fasting at least 30 minutes prior to food or other pills. They do have some, you know, recommendations for like, if you take a thyroid hormone pill to take that 30 minutes after is fine or take it at night. But, you know, some people aren't going to be able to adhere or won't want to try that. And then for both of the pills, they're daily. So, if you're not able to stick to a daily schedule, then that's also not the best option for you.

Host: Yeah, you know, I'm learning from you, Doctor. There's just so much to consider. And, thankfully, we have experts, providers like yourself to help us through all this. And as we finish up here today, Doctor, there's so many ads, so many ads, online programs, non-medical providers offering their weight loss medications. You know, I just get a sense from you, like who should people really trust for advice and prescriptions? And what would you recommend their first step be?

Dr. Ellie Chuang: Certainly, it's always good to start with a trusted medical provider that you are seeing, such as your PCP, who can potentially provide evaluation and treatment for obesity or, you know, refer you to a reputable weight management clinic. Now, how would you assess such a clinic or service? And this could be online or in-person, because you know, certainly there's many online options. I would say there are a few points to think about.

Number one, are there actual medical providers involved, of course? And ideally, are there obesity medicine, board-certified physicians involved in some way? You know, whether they are supervising, are the prescribers, whatever, just someone you know who is really specialized in this field.

Number two, before they prescribe the medication, are they doing a full assessment of you, including getting your medical history, your weight history, your medication list, et cetera. If they're just prescribing the medication without doing any of that that would certainly make me be a little worried as to what this program is like.

Number three, are they prescribing FDA approved medications when it comes to, especially the GLP-1 agents? There's a lot of websites still out there, or even local places too that are prescribing compounded versions of things like Zepbound and Wegovy. And what people need to know is that compounded versions are not FDA-approved. You know what you're getting in there and there are certainly a lot of risks involved. So, it is not recommended to use the compounded versions.

And then, number four, are the medications being prescribed in the context of a comprehensive weight management program, which would include, you know, advice about the lifestyle habits like we talked about before, and could potentially include consulting with the nutritionist or other specialists. And are you receiving regular follow-up visits? Not like they prescribe the medication and they're like—

Host: "Have a nice day." Yeah, right.

Dr. Ellie Chuang: Yeah, exactly. So, those are important things to know. And then, also just, you know, in terms of taking the first step, like I said, you could talk to your primary care provider or even, you know, increasingly, there are a lot of specialists who treat conditions that are associated with or worsened by obesity, who are also talking to their patients about seeking obesity care. And they can also give you a referral. I get patients from their cardiologist or gastroenterologist.

And then, just to leave you with a website that people can check out for more information about obesity and obesity treatment, and it includes some really useful articles and videos, it's the Obesity Action Coalition. And they provide information as well as advocacy and other support. And the website is www.obesityaction.org. So, I would definitely encourage people to check that out.

Host: That's great. It's always great to catch up with good guests, and you are one of them, you're in that category. And yeah, there's just so much information out there, information, misinformation, questions, concerns. And as you're saying here today, put your faith, put your trust in your providers, in your doctors, in your specialists and get those referrals if you need them. There are answers and help available. Thank you so much.

Dr. Ellie Chuang: You are welcome, Scott.

Host: That's Dr. Ellie Chuang. And for more information, go to snhhealth.org/weightmanagement. And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is On Call with Southern New Hampshire Health. I'm Scott Webb. Stay well, and we'll talk again next time.