ASOI and ICPO response to : Medical Council Communication: “Important medicine shortage information – Ozempic (semaglutide)”

ASOI and ICPO response to : Medical Council Communication: “Important medicine shortage information – Ozempic (semaglutide)”, dated 22nd May 2023

The Association for the Study of Obesity on the island of Ireland, ASOI, and the Irish Coalition for People Living with Obesity, ICPO, have expressed our concern regarding the recent Medical Council communication sent to doctors in Ireland about semaglutide. It stated that semaglutide as “Ozempic” is licensed for the treatment of T2DM. It should have advised that semaglutide is also licensed for the treatment of obesity (used together with diet and physical activity) as per HPRA/EMA in Jan 2022.  Generic prescriptions for semaglutide to treat obesity are within license and it is misleading and inaccurate to imply that prescribing semaglutide is not appropriate for weight management.

The communication raises the issue of reimbursement, which is a separate and important issue, but does not pertain to the conversation about appropriate prescribing. Given that pharmacotherapy for obesity is only reimbursed under strict criteria and a managed access protocol, the cost of medication can pose an insurmountable barrier to people with obesity accessing evidence-based treatment. We are aware that an alternative medication for the treatment of obesity is available in Ireland and produced by the same company as semaglutide but at a significantly higher cost to the patient.

The ASOI requested clarification with regard to the statement that “medical practitioners are expected to use resources appropriately and responsibly”, suggesting that prescribing semaglutide for obesity (without diabetes) is inappropriate and irresponsible.  Additional advice that practitioners should be mindful of the “risk to patient safety arising from medicine supply issues” evokes an alarmist tone and implies a disregard to patients with diabetes if doctors prescribe semaglutide appropriately to those with obesity.

The Medical Council communication poses a risk to the reputation and standing of experts who prescribe semaglutide to patients with obesity in accordance with evidence base and international guidelines. Advising that practitioners “must consider the needs of all patients and balance these duties where resources are limited” further implies that people with obesity are less deserving of treatment than those living with diabetes and that their clinical need is less significant. Section 8.2 of the Guide to Professional Conduct and Ethics for Registered Medical Practitioners (Amended) (8th edition): “Patients have the right to be offered all treatment options that are likely to be of benefit to them.”

People living with obesity face many barriers to care. The ASOI endeavors to increase the awareness and understanding of obesity as a complex progressive neuroendocrine chronic disease. This communication reinforces the weight bias, stigma and discrimination that pervades society and healthcare. 

The ASOI works closely with The Irish Coalition of People living with Obesity (ICPO) and it has been clearly communicated to us that people with obesity are facing increasingly negative experiences when attending for medical care and to collect medication (see Appendix for some examples of feedback to ICPO via their support groups in recent weeks) which they have been prescribed in good faith following detailed discussion with their treating clinician. The guidance offered to pharmacists in the Medical Council communication poses a significant risk of increasing the bias and discrimination people living with obesity experience in the community.

The ASOI draws on the expertise of its members, who have a wide variety of multidisciplinary backgrounds including academics/researchers, clinicians, allied health professionals and patient representatives. We believe the recent communication from the Medical Council must be addressed, clarified and revised immediately so as not to adversely affect the treatment of those living with obesity and to mitigate the impact it will have on their treatment in the future.

A key focus of ASOI activities is the education of health care professionals and policy makers about the science of obesity, with a view to elimination of obesity stigma in healthcare settings, and we would welcome the opportunity to address the misunderstanding underlying the implicit bias in this Medical Council communication, and aid with any remedial actions deemed necessary.

ASOI Committee 2023

Appendix – Quotes from ICPO patient advocates

My uncontrollable hunger brought my BMI to over 47, and as a 29 year old girl my life had completely changed with Ozempic… My depression and anxiety is starting to ease and my sleep pattern has been amazing but this will all go now as my Dr cannot prescribe the medicine that has truly helped me cope better in life.

I felt normal with my hunger and portion sizes on Ozempic and I have lost 2 stone since January which with PCOS and my crazy hunger has been almost impossible before.

My pharmacy has been so helpful as they recognize it as a disease and don’t agree they should refuse treatment to someone who wishes to get better.
Sarah-Louise, Ardee

Last week I went into my local pharmacy where I have been dispensed Ozempic on numerous occasions. I asked one of the two pharmacists behind the counter if they had 1mg in stock.
I was then grilled quite loudly as to what I was taking it for. I got very embarrassed and stated insulin resistance, I was then sniggered at and the response was ‘so weight loss yeah?’ I said in conjunction with other concerns discussed with my Endocrinologist. I was then advised that she had plenty in stock and that she wouldn’t be giving me it and that I was taking life-saving medication out of the hands of a diabetic patient and that those patients are the pharmacies main concern. I felt scolded and humiliated and by this stage a queue had formed behind me full of local people some I knew. I was mortified. I was advised in a very condescending tone to phone my consultant and demand a script for Saxenda as that is the medication for obese people.
I asked how much this medication cost and the other pharmacist shouted over the desk twice the price and you need to pay extra for needles so over €300. I left the pharmacy in tears and honestly I have been very low since.
I feel I finally found a consultant that heard and understood me and now every month it’s like a battle to fill my prescription for a medication that has greatly improved my quality of life.
Rachel, Meath

My own pharmacist is a lovely man & he had a genuinely kind conversation with me on Saturday where he said that the letter from the HPRA/medical council/PSI meant that ethically he believed he could only justify giving the prescription to LTI patients given the problems he was facing with the quota. Again, to be fair to him, he has been able to provide me with Ozempic for the last few months despite the shortage as I’m a long-standing customer of the pharmacy – a colleague of his also previously told me that they haven’t accepted any new non-diabetic prescriptions for Ozempic for several months now.
In ringing other pharmacies to see if I can get the prescription filled elsewhere, there was a certain dismissive attitude/question around not being an LTI patient. No particularly horrible comments, thankfully, but definitely sniffy attitude from some.
I do think it’s an unfair position to put pharmacists in, where they are acting as judge and jury.
I asked my GP for a second time for a prescription for Ozempic about a month ago, and she was incredibly dismissive and said that she expected that ‘to be cracked down on’ and that they would be instructed not to prescribe for non-diabetic patients.
Mary, Dublin

I live in Dublin City centre and have been on Ozempic for about 3 months now. I would like to comment on the impact on mental health benefits. I am not diabetic, only insulin resistant. But the main reason I looked into this new drug is mainly because, not only have I heavily struggled with weight my whole life along with mental health, but that I’ve been on psychiatric medications for several years and they have saved my life. Downside of one the medications is weight gain and an insane amount of increased appetite, to the point that it’s almost torture, but the benefits of the other medications outweigh it. I gained almost 15 kg within the first year with health issues attached to it… With ozempic is the first time I felt “normal” in years.

So, in my case I might  not be diabetic for example, but the scope of how this medication helps people in different walks of life has to be acknowledged as it has made me improve not only my physical health but also mentally, it’s a real struggle to feel hungry all the time in part because of another medication you can’t stop taking. 

I’ve been denied ozempic many many times as I’m not a diabetic, but how or to whom do I explain the underlying reasons why this medication is helpful to me?

Veronica, Dublin

I have been using a pharmacy in Donnybrook for months now and paying over the odds €160 per pen, when I queried the price a few months ago I was told the supplier charges extra to “guarantee” supply , however for the past 2 months they will not fill my prescription as I’m using it for weight loss . They advised me to go to my GP and ask him to prescribe Saxenda. I told them I am not in a position to pay out any more money monthly for medication as I already pay the dps too, they said there’s nothing they can do, they have to keep it for their diabetic customers.
Elizabeth, Dublin

I have been turned away from all pharmacies in Kilkenny recently and í travelled to Dublin where it was not a problem. I was told they were keeping it for their customers who are diabetics but it was the attitude that annoyed me  The chemist in Dublin asked no questions and put my name on it until I got there.
Sylvia, Kilkenny

Today I went to get my monthly medications which include blood pressure and thyroid medication and to collect my “weight loss” ozempic script for 1mg pen.
Initially the pharmacy denied I had a script for it but when they looked closer into the records they found it. They asked if it was for weight loss or diabetes in front of the full shop. I replied off license.

A second one came over and said that he could give me my script back but that the weight loss crowd like me have caused shortages and he couldn’t dispense to me even if he had it in stock. I said I understood that diabetic patients were prioritised, but it had been dispensed to me before and would there be other places to get it. Again, he referred to weight loss people are taking the medication for diabetic patients and besides I had last been dispensed on 12th April so why was I looking for it again- I pointed out that a 0.5mg pen lasts 4 weeks and I have one left (actually none of his business given that my script allowed for it and it’s been a month since the dispensing). He gave me my script and I took it.

I will be changing pharmacy which is a pity because I’ve attended them for 20 years and some of the staff have been phenomenal. My BMI is 43 today, so it’s apparent that I’m not a Hollywood starlet using the meds for a laugh- it has helped control my appetite, helped with my breathlessness and reducing my heart rate (I’m already on blood pressure medication and am pre-diabetic)- my health risks are equally as important as any other customer and whilst I understand the need to prioritise life threatening conditions- being labelled as the weight loss people is not helpful as my weight is leading to life threatening conditions for me and if untreated will lead me into the prioritised category.
Anonymous, Dublin