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The politics of skinny pens
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It’s perverse that Wegovy and Mounjaro are being positioned as a key solution to the obesity problem. I can’t see mass medicalisation with these drugs because the moral hazard is written across this policy trend, says Terry Maguire…
In early December, I took part in a BBC radio discussion about ‘skinny pens.’
NICE had just published its direction on tirzepatide (Mounjaro) and although the drug is licensed for the management of obesity (BMI 30), the NHS will only fund it for patients with a BMI over 35 plus one weight-related condition; diabetes, hypertension or sleep apnea.
I suggested that using these drugs for cosmetic purposes was impacting availability for patients with, for example, diabetes. An expert on the panel was having none of it. All obese patients would benefit from the drug, he insisted, and the NHS needed to make it more widely available.
I was then attacked for suggesting there was ‘cosmetic use’ of the drug, as all obese people needed all the help they could get to achieve a healthy weight. This would, in turn, reduce future treatment costs for diabetes, hypertension or sleep apnea.
Wanless predicted diabetes would likely destroy the NHS by 2025
There were, after all, too many people living with obesity and obesity is as much a disease as diabetes and hypertension. It is a seductive argument indeed. Skinny pens Wegovy and Mounjaro are being positioned by vested interests as the solution to our obesity problem.
It’s now over 20 years since retired banker Derek Wanless published his report for the then chancellor Gordan Brown. Wanless was asked to consider how the NHS might be funded in the future given its escalating year on year costs.
He was not the first to realise that unless individuals take more responsibility for their own health; lose weight, take exercise, stop smoking – a time would come when the NHS would be bankrupted by demand.
He predicted that by 2025, diabetes would most likely destroy the NHS. You could argue it does feel that way now that we have arrived at that moment.
Wanless promoted the ‘fully engaged’ citizen who actively adopted behaviours to keep healthy and, as a result, reduced NHS costs. It hasn’t really worked out like that mainly due to a lack of investment in primary prevention.
Terry Maguire believes the private supply of Mounjaro is rife in nail bars and hair salons.
The obesity epidemic remains, with some 66 per cent of the population either overweight or obese. The incidence of Type 2 diabetes increased by 10 per cent from three million in 2017 to 3.3 million in 2021.
Wegovy and Mounjaro are the most famous medicines we don’t have enough of.
For England, NICE has allowed NHS prescribing for patients in Tier 3 and Tier 4 weight management services, mostly specialist centres in hospitals and which covers about 35,000 patients – not very many given the 12 million who potentially need treatment.
NICE guidance generally applies to Northern Ireland but we don’t have Tier 3/4 weight management services so a ‘managed entry’ process will apply.
In June 2023, the UK government announced a pilot to add 40,000 patients to treatment by GPs and to determine Wegovy’s real world effect. The then Prime Minister Rishi Sunak was keen to see how the drug might perform. I’m not aware of any outcomes.
Pharmacies are main source of private legal supply of skinny pens
Here in Northern Ireland, the Strategic Planning and Performance Group (SPPG) has written to all healthcare professionals stating Wegovy would not be available on prescription and asked private medicine providers to comply with this health service restriction.
I assume the same will apply to Mounjaro. This was a really interesting request given that private supply is already rife in nail bars, hair salons and pharmacies and is likely to increase massively now that Mounjaro has arrived.
In May 2023, medicines inspectors raided a number of retail premises and confiscated scores of skinny pens.
Pharmacies, both online and bricks and mortar, are the main source of the private legal supply and I predict their commercial cosmetic business will turn a deaf ear to the SPPG request.
Where debate may continue on whether obesity is a disease, a syndrome or a natural response to an abnormal environment, there remains little disagreement on the causal link between obesity and illness.
I can’t see mass medicalisation with these drugs
Yet for obesity, the question of whether a drug or a lifestyle intervention is superior has been in favour of lifestyle intervention; better diet and increased activity, have proved effective in reducing morbidity and mortality.
Losing weight is difficult and perhaps too many people struggle to achieve meaningful targets. Individuals with insulin resistance, for instance, have been shown to lose weight only half as successfully as others by whichever means is attempted.
I might find myself on the wrong side of history in this political debate. I do feel it’s somewhat perverse that skinny pens are being positioned as a key solution to our obesity problem. I can’t see mass medicalisation with these drugs because the moral hazard is written in large across this policy trend.
With the use of these highly effective satiety hormone agonists, there is no need to apply any personal control to nutritional intake or to bother taking exercise.
This is a dystopian future and one that would have Wanless turning in his grave.
Terry Maguire is a leading community pharmacist based in Northern Ireland.