Next Article in Journal
The Possible Impact of COVID-19 on Glycated Hemoglobin and Systolic Blood Pressure in Type 2 Diabetes and Obesity
Previous Article in Journal
Sociology of Obesity: How to Justify Fighting against the Development of the Obesity Epidemic
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Obesities
Volume 4
Issue 4
10.3390/obesities4040032
obesities-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Effectiveness and Side Effect Incidence in a Real-World Digital Weight-Loss Service Using Compounded Semaglutide: A Retrospective Comparative Study

by
Louis Talay
1,* and
Matt Vickers
2
1
Faculty of Arts and Social Sciences, University of Sydney, Camperdown, NSW 2050, Australia
2
Eucalyptus, Sydney, NSW 2000, Australia
*
Author to whom correspondence should be addressed.
Obesities 2024, 4(4), 399-411; https://doi.org/10.3390/obesities4040032
Submission received: 29 July 2024 / Revised: 3 September 2024 / Accepted: 2 October 2024 / Published: 3 October 2024
Browse Figure
Review Reports Versions Notes

Abstract

:
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) were originally developed in the late 1980s as a class of antidiabetic medication. However, research over the past decade has found them to be a safe and effective weight-loss agent, which has led to the approval of GLP-1 RAs such as Semaglutide as a supplement to lifestyle obesity interventions in multiple countries. When Semaglutide has become commercially unavailable, digital weight-loss services (DWLSs) have prescribed a compounded form of the medication—a practice in which health professionals formulate a replica of the commercial medication to serve ongoing patient needs. Although compounding has been relatively common over the past century, prominent medical bodies have argued that compounding a relatively novel medication such as Semaglutide represents a major safety risk. This study retrospectively compared the weight and side effect outcomes of patients from a large Australian DWLS whose lifestyle coaching was supplemented with either compounded or pure Semaglutide (both groups following the same titration schedule). All data were extracted from the service’s central data repository. To be included in the weight loss analysis, patients needed to have received a minimum of four monthly medication orders between June 2023 and May 2024 and have submitted weight data between 90 and 150 days after the arrival of their first order. All patients who received at least one medication order within the same period were included in the side effect analysis. The mean four-month weight loss percentage was statistically lower in the compounded Semaglutide group (N = 923, M = 9.11, SD = ±5.76) compared to those in the pure Semaglutide group (n = 1858, M = 9.87, SD = ±6.46), t (2032) = −3.15, p = 0.0017. A statistically lower proportion of patients in the compounded Semaglutide group (71.61%) reported at least one side effect than patients in the pure Semaglutide group (77.40%) during the study period, X2 (1, N = 7683) = 32.32, p < 0.001. When side effects were disaggregated into severity categories, a statistical difference was only observed in mild side effects, X2 (1, N = 7683) = 59.16, p < 0.001. A significantly higher rate of patients from the pure Semaglutide group achieved the ten (50.54% vs. 44.64%), X2 (1, N = 7683) = 10.34, p < 0.001, and fifteen (21.42% vs. 12.78%), X2 (1, N = 7683) = 30.43, p < 0.001, percent weight loss thresholds than patients from the compounded Semaglutide group. The findings indicate that compounded Semaglutide can be used as a component of tightly controlled DWLSs with slightly less effectiveness but with slightly lower side effect incidence when compared to pure Semaglutide.

1. Introduction

Obesity is quickly becoming the world’s greatest preventable health threat [1]. In 2022, 2.5 billion (43%) adults worldwide were overweight, of whom 890 million (16%) were living with obesity [2]. These figures appear even more serious in Australia, with 66% of the adult population living with excess weight, including 32% with obesity [3]. The obesity rate among Australian adults is now over three times as high as it was in 1990 [4]. Whereas clinicians once considered weight regulation a matter of self-control [5], most experts now attribute the rising obesity trend to the disease’s complexity [6,7]. Multiple studies have demonstrated weight management’s association with socialization, disposable income, food security, and genetics [6,7,8]. Knowledge of obesity’s complexity also appears to extend to a significant portion of the Australian public, with research revealing widespread support for the regulation of food and beverage marketing and a ‘junk food’ tax [9,10]. One determinant that has arguably received a disproportionate amount of media attention, however, is the limited success people have with diet and exercise programs [11].
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged over the past decade as a promising solution to this problem, with several large-scale randomized controlled trials (RCTs) demonstrating their unprecedented efficacy as a supplement to diet and exercise [11,12,13]. Originally developed in the late 1980s as a class of medication to treat type 2 diabetes, research over the ensuing decades revealed that GLP-1 RAs also induce a significant amount of weight loss among patients with or without diabetes [14,15]. While bariatric surgery remains the most effective weight-loss intervention [16], GLP-1 RA-supported therapy represents a good alternative for patients who are apprehensive about invasive measures [17].
However, delivering GLP-1 RA-supported obesity care through a continuous multidisciplinary care team poses another large challenge to average people: access. People with significant work or family commitments struggle to attend and coordinate consults across a team of specialists (some of whom work out of separate clinics) on an ongoing basis [18,19,20]. A possible reason digital weight-loss services (DWLSs) have become increasingly popular in recent times is because they represent a solution to the comprehensive obesity care access problem [20]. Yet, several influential Australian medical bodies have questioned both the comprehensiveness and access of these services [21,22]. An ongoing concern is that many DWLSs simply increase access to GLP-1 RAs without upholding appropriate safety protocols. Most recently, Australia’s largest DWLS, Juniper, was criticized for prescribing compounded Semaglutide to patients when the service encountered GLP-1 RA supply constraints [23].
The evidence of structured diet interventions date back as early as 1862, when an English undertaker’s low-carbohydrate, high-fat eating plan was disseminated [24]. Multiple varieties of diet interventions having been studied since then, including low-fat, vegetarian, and periodic fasting diets; however, the macronutrient composition seems to be less important than caloric restriction [25]. Nevertheless, research has consistently shown that diet-only interventions are largely unsuccessful or unsustainable [26,27]. Combined diet and exercise interventions tend to fare slightly better, but most studies report a mean weight loss of less than five percent from baseline [28,29]—the widely accepted threshold for ‘clinically meaningful’ weight loss [30]. Many experts attribute this lack of success to obesity’s genetic component, highlighting the neural integration of satiety and the food-reward feedback loop [31,32]. GLP-1 RAs regulate neural pathways involved in satiety, which likely explains their unprecedented weight-loss efficacy reported in numerous RCTs [33]. However, GLP-1 RAs should only be used by weight-loss patients under a strict set of conditions.
The World Health Organization (WHO) and other major global health institutions stress that GLP-1 RAs should only be taken as a supplement to diet and exercise therapy, and under the guidance of a continuous and coordinated multidisciplinary care (MDC) team [34,35]. Although the Australian Therapeutic Goods Administration (TGA) guidelines for obesity pharmacotherapy are generally less detailed and do not mention MDC, they too emphasize that Liraglutide should always be limited to an ‘adjunct’ to behavioral interventions [36]. These recommendations are likely based on the relative novelty of GLP-1 RA-induced weight loss and the consequent absence of knowledge around the sustainability of such interventions. At present, there is no evidence to suggest GLP-1 RA therapy increases the safety risk for overweight and obese patients, yet some studies have reported significant reductions in fat-free mass and post-intervention weight regain [37,38]. Prominent Australian medical bodies have raised regular concerns that various DWLS care models are designed to write as many GLP-1 RA scripts as possible rather than prescribing them safely as an adjunct to comprehensive obesity care [21,22].
This concern is yet to be conclusively refuted by any Australian DWLS. Indeed, several care models appear to provide little more than access to a previously unknown doctor who prescribes eligible patients GLP-1 RAs without any follow-up care or specialist referrals [21]. It needs to be mentioned, however, that GLP-1 RA prescribing and follow-up care from Australian face-to-face (F2F) general practitioners is yet to be investigated. At present, Eucalyptus (Juniper for women; Pilot for men) appears to be the only Australia DWLS to have published peer-reviewed research. Although the service’s studies have covered the program’s effectiveness, side effect incidence, program adherence, and patient satisfaction, none have categorically demonstrated that the service’s practitioners are not irresponsibly prescribing GLP-1 RAs [19,39,40]. Moreover, a recent study indicated that a significant portion of the Eucalyptus patients are simply subscribing to the service to facilitate their access to weight-loss medications [19]. The skepticism regarding Eucalyptus arguably intensified when the service began prescribing off-label Semaglutide (Semaglutide is approved for weight-loss in Australia in the form of Wegovy, but not Ozempic, which is what Eucalyptus Australia has been prescribing patients.) to patients in 2023 [23]. When the supply of this medication became constrained, a large portion of Eucalyptus patients indicated a preference for compounded Semaglutide over Liraglutide, which the service subsequently provided. This led to further criticism and the eventual ban of compounded Semaglutide by the TGA [41].
Pharmaceutical compounding signifies the preparation of customized medications for patients whose specific needs cannot be met with mass-produced products. Although mass production significantly reduced the role of pharmaceutical compounding in the early 1900s, it has continued to remain commonplace throughout the world as a means of providing a necessary medication when the commercial supply is exhausted [42,43]. However, compounding medications typically comes with the risk of limited regulatory oversight [42]. The TGA states that compounded medicines ‘can be an option when a medicine that has been approved by the TGA is not currently available’ if a pharmacist possesses a TGA manufacturing license [44]. In response to concerns from various medical bodies about the large numbers of people using compounded GLP-1 RAs, the Australian government announced in May 2024 that such medications would be banned from 1 October 2024 [41].
Research on compounded Semaglutide is scarce. Only two studies appear to have generated quantitative data on compounded Semaglutide [45,46]. One of these was a case series that reported the dispensing of syringes not intended for Semaglutide, which resulted in 10-fold dosing errors [45]. The other was an evaluation of two compounding pharmacies undertaken by Semaglutide manufacturer Novo Nordisk, which detected impurities of up to 33% in one of the tested samples and a product containing a Semaglutide concentration 19% lower than what was stated on the label [46]. Among the detected impurities was Body Protection Compound 157—a peptide with the potential for immunogenicity and life-threatening reactions. A perspective article that commented on these findings asserted that compounding pharmacies need to be accredited with a national pharmacy board, comply with national standards, source active pharmaceutical ingredients from accredited facilities, and perform periodic testing of compounded medications through an independent lab [47]. To the knowledge of the authors, the literature is yet to generate any data on the use of compounded Semaglutide in a DWLS.
The mechanisms through which pure (commercial) Semaglutide induces weight loss include the stimulation of insulin secretion, the inhibition of glucagon secretion, the delay of gastric emptying, and the activation of glucose-like peptide-1 receptors in the brain [15,48,49]. The synergy of these mechanisms results in an overall reduction in appetite. Research has revealed that Semaglutide therapy increases a patient’s risk of diabetic retinopathy complications, hypoglycemia, acute kidney injuries, and acute gallbladder disease [49,50]. Although there does not appear to be any evidence of an association between Semaglutide and the development of thyroid C-cell tumors, such as medullary thyroid carcinoma (MTC), the drug is contraindicated in patients with a personal of family history of MTC [49]. The literature is yet to generate any safety outcomes data on compounded Semaglutide.
This study’s objective is to retrospectively compare the weight-loss and tect outcomes of Juniper DWLS patients who supplemented their health coaching with compounded Semaglutide versus those who were prescribed pure Semaglutide.

2. Materials and Methods

2.1. Study Design

The study retrospectively analyzed weight-loss and side-effect outcomes of two cohorts of patients who used the Juniper Australia DWLS between 15 June 2023 and 15 May 2024. Both cohorts received personalized health coaching via the Juniper app. Cohort one was prescribed compounded Semaglutide as a supplement to their health coaching, whereas cohort two was prescribed pure Semaglutide. All study data were retrieved from the Eucalyptus (Juniper parent company) central data repository on Metabase. The Bellberry Human Ethics Committee approved the study on 22 November 2023 (No. 2023-05-563-A-1). The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE) guidelines.

2.2. Program Overview

Prospective Juniper DWLS patients complete a pre-consultation questionnaire that a doctor or nurse practitioner (NP) uses to determine their eligibility for the service. Questionnaires contain up to 100 questions and often doctors and NPs request additional information such as blood test results, medical imaging, photos, and reports from previous clinicians. Eligibility decisions are largely based on GLP-1 RA product information documents that detail body mass index (BMI) ranges, contraindications, and drug interactions. Inclusion criteria include a BMI of 27 kg/m2 for patients with at least one weight-related comorbidity (e.g., hypertension, symptomatic cardiovascular disease) or patients of Asian, African Caribbean, Indigenous Australian, or Pacific Islander ethnicity, and a BMI of 30 kg/m2 for everyone else. Key exclusion criteria included the following contraindications: a personal or family history of MTC, multiple endocrine neoplasia syndrome type 2, acute pancreatitis, acute gallbladder disease, hypoglycemia, known hypersensitivity to Semaglutide or any of the product components, a severe mental health condition, and type 1 or type 2 diabetes.
All prescribing decisions and patient interactions from Juniper clinicians are automatically uploaded to the Eucalyptus clinical auditing repository on Jira, which uses data analytics to alert auditors whenever an incorrect decision or safety error has been committed. Each Juniper Australia DWLS patient is allocated a multidisciplinary team (MDT), consisting of a doctor or nurse practitioner, a university-qualified health coach, a pharmacist, and a medical support officer. Patients communicate with all members of their MDT through the Juniper app to facilitate care coordination and data management.
The Juniper Australia DWLS has only ever provided GLP-1 RA-supported therapy, i.e., it has never offered standalone lifestyle or GLP-1 RA treatment. Upon payment of their first monthly subscription fee, patients receive a month’s supply of GLP-1 RA medications and access to personalized lifestyle coaching. Coaching is delivered via the Juniper app and includes access to multimodal educational materials, progress trackers, and meal and exercise plans. Patients can request changes to the diet and exercises plans at any stage of their care journey. Patients continue to receive a box of GLP-1 RA medications at monthly intervals up until (and including) month 4 unless they respond to payment reminder messages and opt out. Prescribing doctors and NPs are required to assess patients at the 5-month point of their care journey. Patients do not receive their 5th GLP-1 RA order and ongoing lifestyle coaching until they are approved by their doctor or NP to continue the Juniper program at their 5-month follow-up consult. While patients are encouraged by their MDT to upload weight data to the app on a fortnightly basis, the follow-up consult represents the first moment since program initiation when weight data are a requirement for continuing the program. Patients are instructed to report side effects to their MDT whenever they arise.
Throughout the study period, all patients (pure and compounded Semaglutide) followed the same medication titration schedule, unless their prescribing clinician considered it unsafe, e.g., as a result of a side effect. The schedule was as follows: 0.25 mg once weekly for 4 weeks, increasing to 0.5 mg for weeks 5 to 8, and 1.0 mg from week 9 and beyond. The adjuvant ingredients used in compounded Semaglutide were identical to the ingredients listed in the product information for the commercial (pure) Semaglutide product [39]. All compounded Semaglutide used in the Juniper DWLS was prepared according to the Pharmacy Board of Australia’s quality and safety guidelines [51]. These guidelines require compounding pharmacists to obtain a certificate of analysis from the manufacturer when sourcing raw ingredients and to produce evidence of the sterility, stability and physicochemical properties of the medicine. Three samples of the formulation were tested the Monash University Medicines Manufacturing Innovation Centre before the service began prescribing compounded Semaglutide. Thereafter, monthly tests were conducted by independent experts at a University of Sydney laboratory.

2.3. Participants

To be included in the weight-loss analysis, Juniper patients had to receive at least four monthly medication orders (pure or compounded Semaglutide) between June 2023 and May 2024, and submit weight-loss data between 90 and 150 days after the arrival of their first medication order. The analysis of side effect incidence included all patients who received a minimum of one medication order. This separate criterion was used to compare side effect data as many patients could feasibly discontinue the program due to side effects experienced from the first order.

2.4. Endpoints

Coprimary endpoints were (comparative) mean weight-loss percentage and side effect incidence. Secondary endpoints included the proportion of patients who achieved 5, 10, and 15 percent weight-loss milestones. A two-sample t-test was used to compare the mean weight loss of the two groups. Chi-square tests were used to conduct all analyses with categorical dependent variables, such as side effect incidence and weight-loss percentage milestones, in which contingency table rows were organized into ‘yes’ and ‘no’ binaries.

2.5. Statistical Analysis

Investigators assessed data distribution normalcy using quantile-quantile plots and Shapiro–Wilk tests. Parametric descriptive data are presented as means with standard deviation scores. The mean weight loss values of the study’s two groups were compared using an independent samples t-test. Binary outcomes among the two groups, such as side effect incidence (yes/no) and weight-loss milestone achievement (yes/no), were compared using Chi-Square tests. All visualizations and statistical analyses were conducted using RStudio, version 2023.06.1+524 (RStudio: Integrated Development Environment for R, Boston, MA, USA).

3. Results

In total, 7683 patients received a minimum of one Semaglutide order via the Juniper DWLS between 15 June 2023 and 15 May 2024, including 4819 who were prescribed the pure version and 2864 who received the compounded variant. Of these patients, 2781 were included in the weight-loss analysis—1858 and 923 from the pure and compounded cohorts, respectively. 4172 patients were excluded because they did not receive a minimum of four orders and a further 122 were excluded because they did not submit weight data within the specified window (Figure 1).
The average BMI was 33.66 (±5.18) kg/m2 in the pure Semaglutide group, versus 33.46 (±5.87) kg/m2 among patients who used the compounded variant (Table 1). The average age was slightly higher in the compounded cohort (43.58 (±10.20) vs. 40.46 (±10.11) years). Patients of Caucasian ethnicity accounted for a little over 84 percent of both cohorts.
Compounded Semaglutide patients submitted follow-up weight data at a mean of 132.43 (±9.82) after program initiation, compared to 130.77 (±11.24) days in the pure Semaglutide group. At these respective points, patients whose coaching was supplemented with pure Semaglutide (M = 9.87, SD = ±6.46) tended to lose more weight than those who were prescribed the compounded variant (M = 9.11, SD = ±5.76). A two-sample t-test revealed that this difference was statistically significant, t (2032) = −3.15, p = 0.0017.
A statistically lower proportion of patients from the compounded Semaglutide cohort (71.61%) reported at least one side effect compared to the pure Semaglutide cohort (77.40%) during the study period, X2 (1, N = 7683) = 32.32, p < 0.001 (Table 2). In accordance with these results, the observed frequencies of 3730 and 2051 patients who reported at least one side effect from the pure and compounded Semaglutide groups, respectively, were higher (3626) and lower (2155) than their corresponding respective frequencies. When side effects were disaggregated into severity categories, a statistical difference was only observed in the presence of mild side effects (yes/no), X2 (1, N = 7683) = 59.16, p < 0.001. Of the 168 severe side effects reported in the compounded Semaglutide group, 133 pertained to gastrointestinal disorders, 24 to hepatobiliary disorders, and 11 to cardiovascular events. In the pure Semaglutide group, two hundred and seven severe side effects were of a gastrointestinal nature, forty-two affected the hepatobiliary system, twenty-eight were cardiovascular issues, and eight were related to mental health. No thyroid issues, carcinoma or deaths were recorded at any stage of the study period.
Chi-square tests revealed that there was no statistically significant difference between the proportion of patients from each group who achieved the five percent weight loss milestone (pure = 81.70% vs. compounded 81.15%), X2 (1, N = 2781) = 0.12, p < 0.72 (Table 3). However, a significantly higher rate of patients from the pure Semaglutide group achieved the ten (50.44% vs. 44.64%, X2 (1, N = 2781) = 10.34, p < 0.001) and fifteen percent (21.42% vs. 12.78%, X2 (1, N = 2781) = 30.43, p < 0.001) weight loss thresholds. Whereas the observed frequencies of 939 and 398 pure Semaglutide patients achieving 10 and 15 percent weight loss, respectively, were higher than the corresponding expected frequencies of 902 and 344, the opposite was true of the compounded Semaglutide cohort (expected frequency 10% weight loss = 448–observed frequency = 412; expected frequency 15% weight loss = 171–observed frequency = 118).

4. Discussion

4.1. The Significance of the Comparative Weight- and Side-Effect Outcomes

This is the first study to assess the impact of replacing pure Semaglutide with compounded Semaglutide as a supplement to health coaching in a real-world obesity service. It found that patients from the compounded Semaglutide cohort lost an amount of weight that was, on average, significantly lower than patients from the pure Semaglutide cohort. However, the degree to which the difference between 9.11 (±5.76) and 9.87 (±6.46) percent might be considered ‘meaningful’ is open to debate. The analysis of secondary endpoints revealed that the difference between the two cohorts existed in the proportion of patients who achieved the 10 and 15 percent weight-loss milestones. Stakeholders who share the widely held view that 5 percent constitutes ‘meaningful’ weight loss may consider the weight outcomes of the two cohorts comparable given that no significant difference was observed between the two groups for that measure.
To enable a comprehensive comparison of side-effect outcomes, the study expanded both cohorts to include all patients who had received a minimum of one Semaglutide (pure or compounded) order in the analysis. This analysis revealed that compounded Semaglutide patients were statistically less likely to experience at least one side effect than pure Semaglutide patients. However, once again, the real-world implications of a difference between 77.40 and 71.61 percent may be considered inconsequential, especially when taking into account that this outcome stemmed from a disparity in mild side effect incidence. Arguably, the most salient discovery regarding side effects was that over five percent of patients in each group reported severe adverse events.

4.2. Public Health Implications

These findings have significant implications for providers and patients of real-world obesity programs. Since the widespread acceptance of obesity’s complexity, GLP-1 RAs have become an essential component of weight-loss services. Multiple studies have demonstrated their unprecedented effectiveness as a supplement to lifestyle therapy, and thus, their potential as a key factor in the global fight against obesity. However, in recent times, GLP-1 RA manufacturers have struggled to keep up with the rising demand for these medications. During such periods, obesity patients who can no longer access GLP-1 RAs are feasibly at a greater risk of regressing and/or discontinuing their program. This study provides preliminary evidence that real-world services have the potential to safely prescribe compounded Semaglutide when access to commercial GLP-1 RAs is limited without compromising program effectiveness to a meaningful extent. However, it needs to be emphasized that the service assessed in this study used compounded Semaglutide that was prepared under strict guidelines from the Pharmacy Board of Australia and tested at monthly intervals at an independent laboratory. Any future need for the temporary replacement of commercial GLP-1 RAs with compounded products should consider the tight regulation of such protocols.

4.3. Strengths and Limitations

The study’s strengths included its novelty and topicality, its non-interference with patient experience, and its sample size. The study also had several limitations. Firstly, it could only assess weight-loss outcomes for compounded Semaglutide patients after four months (M = 128.1 (18.1±) days), as Juniper Australia only prescribed the variant over a period of six months (until the supply of pure Semaglutide was restored). Although GLP-1 RA RCTs have demonstrated that most weight loss occurs in the first few months of therapy, it is possible that the difference observed between the two cohorts in this study would have been greater if data were collected over a longer period. Secondly, all side effect data were patient reported and therefore may not have been as accurate as events assessed by independent clinicians. Thirdly, Juniper Australia patients are not required to state their reason for discontinuing the service, so investigators could not determine the percentage of patients from each group who dropped out as a direct result of their side effects. It is important to note that a higher proportion of compounded Semaglutide patients (64.7%) discontinued the program before receiving their fourth medication order than pure Semaglutide patients (60.7%). Previous adherence studies of the Juniper DWLS have indicated that only a small proportion of patients discontinue the service due to reasons associated with side effects [33,40], but cohorts were restricted to pure GLP-1 RA medications. A dedicated adherence study of a compounded Semaglutide-supported DWLS would be needed to determine whether such medication tends to increase early program discontinuation relative to those using pure GLP-1 RAs. Finally, over four-fifths of patients from the two cohorts were of Caucasian ethnicity, rendering the sample relatively unrepresentative of Australian society.

4.4. Future Research

Future research should consider a comparable analysis of other real-world obesity services, in both digital and F2F settings. The literature could also benefit from focused investigations of DWLS responses to moderate and severe side effects.

5. Conclusions

After 4 months on the Juniper Australia DWLS, patients from both the compounded Semaglutide and pure Semaglutide cohorts lost, on average, more than nine percent of their baseline weight. The mean figure of 9.87 percent recorded among patients whose health coaching was supplemented with pure Semaglutide was found to be statistically higher than the mean of 9.11 observed in patients who were prescribed compounded Semaglutide instead. Conversely, patients in the compounded Semaglutide group were statistically less likely to report side effects than those in the pure Semaglutide group. Although the differences across these two markers were found to be statistically significant, their real-world impact may be inconsequential. No significant differences were detected in the proportion of patients from each group who achieved the five percent weight-loss milestone—widely considered a ‘meaningful’ amount of weight loss. Similarly, the side effect incidence disparity could be attributed to the higher proportion of patients in the pure Semaglutide group who reported mild adverse events, with the difference of 72.50 (pure Semaglutide) versus 64.14 (compounded Semaglutide) percent arguably being of minimal significance.
Ultimately, this study found that patients from the Juniper Australia DWLS who were prescribed compounded Semaglutide rather than pure Semaglutide as a supplement to their online personalized health coaching experienced marginally inferior weight-loss outcomes and marginally better side-effect outcomes than patients who were prescribed pure Semaglutide. This discovery does not suggest anything about the general safety of compounded Semaglutide, as compounding can vary from pharmacy to pharmacy. It does, however, indicate that compounded Semaglutide can be used as a component of tightly controlled DWLSs with slightly less effectiveness and slightly lower side effect incidence to pure Semaglutide.

Author Contributions

Conceptualization, L.T. and M.V.; methodology, L.T. and M.V.; validation, L.T. and M.V.; formal analysis, L.T. and M.V.; investigation, L.T.; resources, L.T. and M.V.; data curation, L.T.; writing—original draft preparation, L.T.; writing—review and editing, L.T. and M.V.; supervision, L.T.; project administration, L.T.; software, L.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki and approved by the institutional review board (or ethics committee) of the Bellberry Ethics Committee (No. 2023-05-563-A-1, 22 November 2023).

Informed Consent Statement

Eucalyptus patients consented to the service’s privacy policy at subscription, which includes permission to use their de-identified data for research.

Data Availability Statement

The data presented in this study are available from the corresponding author on reasonable request.

Acknowledgments

The authors would like to thank all patients, clinicians, and auditors involved in the Eucalyptus weight loss program over the study period.

Conflicts of Interest

LT and M.V. are paid a salary by Eucalyptus.

Correction Statement

This article has been republished with a minor correction to resolve spelling and grammatical errors. This change does not affect the scientific content of the article.

References

  1. NCD Risk Factor Collaboration. Worldwide trends in underweight and obesity from 1990 to 2022: A pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults. Lancet 2024, 403, 1027–1050. [Google Scholar] [CrossRef] [PubMed]
  2. World Health Organization. Obesity and Overweight. 1 March 2024. Available online: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (accessed on 1 June 2024).
  3. Australian Bureau of Statistics. National Health Survey 2022. 2023. Available online: https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey/2022 (accessed on 1 June 2024).
  4. Australian Institute of Health and Welfare. A growing problem: Trends and patterns in overweight and obesity among adults in Australia, 1980 to 2001. Bulletin 2003, 1, 19. [Google Scholar]
  5. Hall, K.; Heymsfield, S.; Kemnitz, J.; Klein, S.; Schoeller, D.A.; Speakman, J.R. Energy balance and its components: Implications for body weight regulation. Am. J. Clin. Nutr. 2012, 95, 989–994. [Google Scholar] [CrossRef] [PubMed]
  6. Javed, Z.; Valero-Elizondo, J.; Maqsood, M.; Mahajan, S.; Taha, M.B.; Patel, K.V.; Sharma, G.; Hagan, K.; Blaha, M.J.; Blankstein, R.; et al. Social determinants of health and obesity: Findings from a national study of US adults. Obesity 2022, 30, 491–502. [Google Scholar] [CrossRef] [PubMed]
  7. Hall, K.; Farooqi, I.; Friedman, J.; Klein, S.; Loos, R.J.F.; Mangelsdorf, D.J.; O’rahilly, S.; Ravussin, E.; Redman, L.M.; Ryan, D.H.; et al. The energy balance model of obesity: Beyond calories in, calories out. Nutrition 2022, 115, 1243–1254. [Google Scholar] [CrossRef]
  8. Verde, L.; Frias-Toral, E.; Cardenas, D. Editorial: Environmental factors implicated in obesity. Front. Nutr. 2023, 10, 1171507. [Google Scholar] [CrossRef]
  9. Sainsbury, E.; Hendy, C.; Magnusson, R.; Colagiuri, S. Public support for government regulatory interventions for overweight and obesity in Australia. BMC Public Health 2018, 18, 513. [Google Scholar] [CrossRef]
  10. Humphreys, L.; O’Flaherty, C.; Ambrosini, G. Public support for obesity prevention policies in Western Australia from 2012 to 2020: Findings from the cross-sectional surveys. Health Promot. J. Aust. 2024, 35, 701–712. [Google Scholar] [CrossRef]
  11. Wilding, J.; Batterham, R.; Calanna, S.; Davies, M.; Van Gaal, L.F.; Lingvay, I.; McGowan, B.M.; Rosenstock, J.; Tran, M.T.; Wadden, T.A.; et al. Once-weekly semaglutide in adults with overweight or obesity. N. Eng. J. Med. 2021, 384, 989–1002. [Google Scholar] [CrossRef]
  12. Wadden, T.; Bailey, T.; Billings, L. Effect of subcutaneous seamglutide vs placebo as an adjunct to intensive behavioural therapy on body weight on adults with overweight or obesity: The STEP 3 randomized clinical trial. JAMA 2021, 325, 1403–1413. [Google Scholar] [CrossRef]
  13. Jastreboff, A.M.; Aronne, L.J.; Ahmad, N.N.; Wharton, S.; Connery, L.; Alves, B.; Kiyosue, A.; Zhang, S.; Liu, B.; Bunck, M.C.; et al. Tirzepatide once weekly for the treatment of obesity. N. Eng. J. Med. 2022, 387, 205–216. [Google Scholar] [CrossRef] [PubMed]
  14. Knudsen, L.; Lau, J. The discovery and development of Liraglutide and Semaglutide. Frontiers 2019, 10, 155. [Google Scholar] [CrossRef]
  15. Clemente-Suárez, V.J.; Beltrán-Velasco, A.I.; Redondo-Flórez, L.; Martín-Rodríguez, A.; Yáñez-Sepúlveda, R.; Tornero-Aguilera, J.F. Neuro-vulnerability in energy metabolism regulation: A comprehensive narrative review. Nutrients 2023, 15, 3106. [Google Scholar] [CrossRef] [PubMed]
  16. Sarma, S.; Palcu, P. Weight loss between glucagon-like peptide-1 receptor agonists and bariatric surgery in adults with obesity: A systematic review and meta-analysis. Obesity 2022, 11, 2111–2121. [Google Scholar] [CrossRef]
  17. Murtha, J.A.; Alagoz, E.; Breuer, C.R.; Finn, A.; Raffa, S.D.; Voils, C.I.; Funk, L.M. Individual-level barriers to bariatric surgery from patient and provider perspectives: A qualitative study. Am. J. Surg. 2022, 224, 429–436. [Google Scholar] [CrossRef] [PubMed]
  18. Talay, L.; Vickers, M.; Loftus, S. Why people with overweight and obesity are seeking care through digital obesity services: A qualitative analysis of patients from Australia’s largest digital obesity provider. Telemed. Rep. 2024, 5, 187–194. [Google Scholar] [CrossRef]
  19. Kaplan, L.M.; Golden, A.; Jinnett, K.; Kolotkin, R.L.; Kyle, T.K.; Look, M.; Nadglowski, J.; O’Neil, P.M.; Parry, T.; Tomaszewski, K.J.; et al. Perceptions of barriers to effective obesity care: Results from the national ACTION study. Obesity 2017, 26, 61–69. [Google Scholar] [CrossRef] [PubMed]
  20. Golovaty, I. Direct-to-consumer platforms for new antiobesity medications—Concerns and potential opportunities. N. Eng. J. Med. 2024, 390, 677–680. [Google Scholar] [CrossRef]
  21. Foo, D.; Spanos, S.; Dammery, G.; A Ellis, L.; Willcock, S.M.; Braithwaite, J. The rise of direct-to-consumer telemedicine services in Australia: Implications for primary care and future research. Med. J. Aust. 2023, 219, 344–347. [Google Scholar] [CrossRef]
  22. Talay, L.; Alvi, O. Evidence over ego: How Australian private digital weight-loss services need to respond to continual skepticism from prominent medical bodies. Ser. Endocrinol. Diabetes Metab. 2024, 6, 1–6. [Google Scholar] [CrossRef]
  23. Wisbey, M. GP Concern over New Ozempic Copycat. NewsGP, 18 December 2023. Available online: https://www1.racgp.org.au/newsgp/clinical/gps-concerned-over-new-ozempic-copycat (accessed on 1 June 2024).
  24. Roberts, W. Facts and ideas from anywhere. Proceedings 2000, 13, 303–311. [Google Scholar]
  25. Sacks, F.M.; Bray, G.A.; Carey, V.J.; Smith, S.R.; Ryan, D.H.; Anton, S.D.; McManus, K.; Champagne, C.M.; Bishop, L.M.; Laranjo, N.; et al. Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates. N. Eng. J. Med. 2009, 360, 859–973. [Google Scholar] [CrossRef] [PubMed]
  26. Wu, T.; Gao, X.; Chen, M.; Van Dam, R.M. Long-term effectiveness of diet-plus-exercise interventions vs. diet-only interventions for weight loss: A meta-analysis. Obes. Rev. 2009, 10, 313–323. [Google Scholar] [CrossRef]
  27. Tobias, D.K.; Chen, M.; E Manson, J.; Ludwig, D.S.; Willett, W.; Hu, F.B. Effect of Low-Fat vs. Other Diet Interventions on Long-Term Weight Change in Adults: A Systematic Review and Meta-Analysis. Lancet Diabetes Endocrinol. 2015, 3, 968–979. [Google Scholar] [CrossRef]
  28. Barte, J.C.M.; Veldwijk, J.; Teixeira, P.J.; Sacks, F.M.; Bemelmans, W.J.E. Differences in Weight Loss across Different BMI Classes: A Meta-analysis of the Effects of Interventions with Diet and Exercise. Int. J. Behav. Med. 2014, 21, 784–793. [Google Scholar] [CrossRef] [PubMed]
  29. Greaves, C.J.; Sheppard, K.E.; Abraham, C.; Hardeman, W.; Roden, M.; Evans, P.H.; Schwarz, P.; The IMAGE Study Group. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health 2011, 11, 119. [Google Scholar] [CrossRef]
  30. Horn, D.; Almandoz, J.; Look, M. What is clinically relevant weight loss for your patients and how can it be achieved? A narrative review. Postgrad. Med. 2022, 4, 359–375. [Google Scholar] [CrossRef]
  31. Kim, M. The neural basis of weight control and obesity. Exp. Mol. Med. 2022, 54, 347–348. [Google Scholar] [CrossRef]
  32. Karatsoreos, I.N.; Thaler, J.P.; Borgland, S.L.; Champagne, F.A.; Hurd, Y.L.; Hill, M.N. Food for Thought: Hormonal, Experiential, and Neural Influences on Feeding and Obesity. J. Neurosci. 2013, 33, 17610–17616. [Google Scholar] [CrossRef]
  33. Ard, J.; Fitch, A.; Fruh, S.; Herman, L. Weight loss and maintenance related to the mechanism of action of Glucagon-like peptide-1 receptor agonists. Adv. Ther. 2021, 38, 2821–2839. [Google Scholar] [CrossRef]
  34. World Health Organisation. Health Service Delivery Framework for Prevention and Management of Obesity; WHO: Geneva, Switzerland, 2023. [Google Scholar]
  35. National Institute for Health and Care Excellence. Semaglutide for Managing Overweight and Obesity; National Institute for Health and Care Excellence: London, UK, 2023. [Google Scholar]
  36. Australian Government Department of Health: Therapeutic Goods Administration. Australian public assessment report for Liraglutide. April 2019.
  37. Sargeant, J.A.; Henson, J.; King, J.A.; Yates, T.; Khunti, K.; Davies, M.J. A Review of the Effects of Glucagon-Like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors on Lean Body Mass in Humans. Endocrinol. Metab. 2019, 34, 247–262. [Google Scholar] [CrossRef] [PubMed]
  38. Wilding, J.P.; Batterham, R.L.; Davies, M.; Van Gaal, L.F.; Kandler, K.; Konakli, K.; Lingvay, I.; McGowan, B.M.; Oral, T.K.; Rosenstock, J.; et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes Obes. Metab. 2022, 8, 1553–1564. [Google Scholar] [CrossRef] [PubMed]
  39. Talay, L.; Alvi, O. Digital healthcare solutions to better achieve the weight loss outcomes expected by payors and patients. Diabetes Obes. Metab. 2024, 26, 2521–2523. [Google Scholar] [CrossRef] [PubMed]
  40. Talay, L.; Vickers, M. Patient adherence to a real-world digital, asynchronous weight-loss program in Australia That Combines Behavioural and GLP-1 RA Therapy: A Mixed Methods Study. Behav. Sci. 2024, 14, 480. [Google Scholar] [CrossRef] [PubMed]
  41. Department of Health Care and Ageing. Protecting Australians from Unsafe Compounding of Replica Weight Loss Products. 22 May 2024. Available online: https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/protecting-australians-from-unsafe-compounding-of-replica-weight-loss-products?language=en (accessed on 1 June 2024).
  42. Watson, C.J.; Whitledge, J.D.; Siani, A.M.; Burns, M.M. Pharmaceutical compounding: A history, regulatory overview, and systematic review of compounding errors. J. Med. Toxicol. 2021, 17, 197–217. [Google Scholar] [CrossRef]
  43. Kochanowska-Karamyan, A. Pharmaceutical compounding: The oldest, most symbolic, and still vital part of pharmacy. Int. J. Pharm. Compd. 2016, 20, 367–374. [Google Scholar]
  44. Australia Government: Therapeutic Goods Administration. What You Need to Know about Compounded Weight Loss Medicines. 3 June 2024. Available online: https://www.tga.gov.au/news/blog/what-you-need-know-about-compounded-weight-loss-medicines (accessed on 1 June 2024).
  45. Lambson, J.; Flegal, S.; Johnson, A. Administration errors of compounded Semagltuide reported to a poison control center—Case series. J. Am. Pharm. Assoc. 2023, 63, 1643–1645. [Google Scholar] [CrossRef]
  46. Novo Nordisk. Novo Nordisk Takes Additional Legal Actions to Help Protect US Patients from Potentially Unsafe and Ineffective Compounded Drugs Claiming to Contain Semaglutide That Are Not FDA Approved [Internet]; Novo Nordisk: Plainsboro, NJ, USA, 2023; Available online: https://www.novonordisk-us.com/media/news-archive/news-details.html?id=166352 (accessed on 1 June 2024).
  47. Spitery, A.; Elder, M.; Farhat, N. Legal, safety, and practical considerations of compounded injectable Semagltuide. J. Am. Coll. Clin. Phar. 2024, 1–6. [Google Scholar]
  48. Kommu, S.; Whitfield, P. Semagltuide; StatPearls Publishing: Treasure Island, FL, USA, 2024. [Google Scholar]
  49. Novo Medlink. Once-Weekly Ozempic (Semagltuide) Injection Mechanism of Action. January 2023. Available online: https://www.novomedlink.com/diabetes/products/treatments/ozempic/about/mechanism-of-action.html (accessed on 1 June 2024).
  50. Kapitza, C.; Dahl, K.; Jacobsen, J.; Axelsen, M.B.; Flint, A. Effects of Semagltuide on beta cell function and glycemic control in participants with type 2 diabetes: A randomized, double-blind, placebo-controlled trial. Diabetologia 2017, 60, 1390–1399. [Google Scholar] [CrossRef]
  51. Pharmacy Board of Australia. Guidelines on Compounding of Medicines (Internet). 2020. Available online: https://www.pharmacyboard.gov.au/Codes-Guidelines.aspx (accessed on 1 June 2024).
Obesities 04 00032 g001
Figure 1. Patient flowchart.
Figure 1. Patient flowchart.
Obesities 04 00032 g001
Table 1. Baseline characteristics.
Table 1. Baseline characteristics.
Pure SemaglutideCompounded Semaglutide
BMI–n (sd)33.66 (±5.18) kg/m233.46 (±5.87) kg/m2
Age–n (sd)40.46 (±10.11) years43.58 (±10.20) years
Ethnicity
Caucasian–n (%)1565 (84.2)783 (84.8)
Asian–n (%)111 (6.0)55 (6.0)
Not listed74 (4.0)38 (4.1)
Aboriginal or Torres Strait Islander51 (2.7)29 (3.1)
Pacific Islander or Maori40 (2.2)17 (1.8)
Middle Eastern35 (1.9)16 (1.7)
African18 (0.9)7 (0.8)
Latino16 (0.8)12 (1.3)
Table 2. Chi-square analyses of side effects.
Table 2. Chi-square analyses of side effects.
Pure Semaglutide Compounded Semaglutide
N%N%X2p-Value
Any side effects reported 32.32<0.001 ***
Yes373077.40205171.61
No1089 813
Any mild side effects reported 59.16<0.001 ***
Yes349472.50183764.14
No1325 1027
Any moderate side effects reported 0.0960.76
Yes128026.5777026.89
No3539 2094
Any severe side effects reported 0.0080.93
Yes 2855.911685.87
No4534 2696
Note. *** p < 0.001.
Table 3. Chi-square analyses of weight-loss milestones.
Table 3. Chi-square analyses of weight-loss milestones.
Pure Semaglutide Compounded Semaglutide
N%N% X2p-Value
≥5% weight lost 0.120.72
Yes151881.7074981.15
No34018.3017418.85
≥10% weight lost 10.340.001 **
Yes93950.5441244.64
No91949.4651155.36
≥15% weight lost 30.43<0.001 ***
Yes39821.4211812.78
No146078.5880587.22
Note. ** p < 0.01, *** p < 0.001.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Talay, L.; Vickers, M. Effectiveness and Side Effect Incidence in a Real-World Digital Weight-Loss Service Using Compounded Semaglutide: A Retrospective Comparative Study. Obesities 2024, 4, 399-411. https://doi.org/10.3390/obesities4040032

AMA Style

Talay L, Vickers M. Effectiveness and Side Effect Incidence in a Real-World Digital Weight-Loss Service Using Compounded Semaglutide: A Retrospective Comparative Study. Obesities. 2024; 4(4):399-411. https://doi.org/10.3390/obesities4040032

Chicago/Turabian Style

Talay, Louis, and Matt Vickers. 2024. "Effectiveness and Side Effect Incidence in a Real-World Digital Weight-Loss Service Using Compounded Semaglutide: A Retrospective Comparative Study" Obesities 4, no. 4: 399-411. https://doi.org/10.3390/obesities4040032

APA Style

Talay, L., & Vickers, M. (2024). Effectiveness and Side Effect Incidence in a Real-World Digital Weight-Loss Service Using Compounded Semaglutide: A Retrospective Comparative Study. Obesities, 4(4), 399-411. https://doi.org/10.3390/obesities4040032

Article Metrics

Back to TopTop