Public Interest in the Off-Label Use of Glucagon-like Peptide 1 Agonists (Ozempic) for Cosmetic Weight Loss: A Google Trends Analysis

Medical Weight Management Considerations in Plastic Surgery

SUMMARY

Obesity is one of the greatest public health concerns in the United States and has reached an epidemic scope over the past few decades. Plastic surgery in patients with obesity has been linked to higher complication rates both before and after weight loss. This article discusses the evolution and landscape of antiobesity medications as they apply to plastic surgery. Although bariatric surgery has been effective in long-term treatment, new pharmacologic advances in glucagon-like peptide-1 agonists, such as semaglutide, have demonstrated promising effectiveness. These medications pose several unique challenges, particularly with regard to perioperative management and risk of weight regain after discontinuation. An understanding of these new pharmacologic agents is crucial for plastic surgeons, who treat patients with obesity.

Quality Assessment of Medical Institutions' Websites Regarding Prescription Drug Misuse of Glucagon-Like Peptide-1 Receptor Agonists by Off-Label Use for Weight Loss: Website Evaluation Study

BACKGROUND

Misuse of glucagon-like peptide-1 receptor agonists (GLP-1RAs) has emerged globally as individuals increasingly use these drugs for weight loss because of unrealistic and attractive body images advertised and shared on the internet.

OBJECTIVE

This study assesses the quality of information and compliance with Japan's medical advertising guidelines on the websites of medical institutions that prescribe GLP-1RAs off-label for weight loss.

METHODS

Websites were identified by searching Google and Yahoo! by using keywords related to GLP-1RAs and weight loss in August 2024. The quality of information on these websites was assessed using the DISCERN instrument. To comply with Japan's medical advertising guidelines, we evaluated whether the 5 mandatory items for advertisements of self-paid medical treatments involving the off-label use of drugs were stated and whether there were any exaggerated claims. The content of the exaggerated advertisements was categorized into themes.

RESULTS

Of the 87 websites included, only 1 website stated all 5 mandatory items. Websites listing "ineligible for the relief system for sufferers from adverse drug reactions" had the lowest percentage at 9% (8/87), while 83% (72/87) of the websites listed exaggerated advertisements. Approximately 69% (60/87) of the websites suggested that no exercise or dietary therapy was required, 24% (21/87) suggested that using GLP-1RAs is a natural and healthy method, and 31% (27/87) of the websites provided the author's personal opinions on the risks of using GLP-1RAs. The mean total DISCERN score for all 87 websites was 32.6 (SD 5.5), indicating low quality. Only 1 website achieved a good rating, and 9 websites were rated as fair. The majority of the websites were rated as poor (72 websites) or very poor (5 websites).

CONCLUSIONS

We found that the quality of information provided by the websites of medical institutions prescribing GLP-1RAs off-label for weight loss was very low and that many websites violated Japan's medical advertising guidelines. The prevalence of exaggerated advertisements, which may lead consumers to believe that they can lose weight without dietary or exercise therapy, suggests the risk of GLP-1RA misuse among consumers. Public institutions and health care providers should monitor and regulate advertisements that violate guidelines and provide accurate information regarding GLP-1RAs, obesity, and weight loss.

GLP-1 receptor agonists significantly impair taste function

Over 10 % of the US population are prescribed glucagon-like peptide-1 receptor agonists (GLP-1 RAs) to combat obesity. Although they decrease cravings for foods, their influence on chemosensory function is unknown. We employed state-of-the-art quantitative taste and smell tests to address this issue. The 53-item Waterless Empirical Taste Test (WETT®) and the 40-item University of Pennsylvania Smell Identification Test (UPSIT®) were completed by 46 persons taking GLP-1 RAs and 46 controls matched on age, sex, smoking behavior, and COVID-19 infection histories. Data were analyzed using analyses of variance. The WETT® scores were significantly diminished in the GLP-1 RA group relative to controls [total means (95 % CIs) = 28.61 (25.66,31.56) and 40.63 (38.35,42.91), p < 0.001, η2 = 0.37]. Eighty five percent of the GLP-1 subjects scored worse than their individually matched controls. All 5 WETT® subtest scores were similarly affected (ps < 0.001). Smell function, although slightly decreased on average, was not significantly impacted (p = 0.076). Women outperformed men on all tests. Remarkably, UPSIT® and WETT® scores were higher, i.e., better, in those reporting nausea, diarrhoea, and other GLP-1-related side effects. This study demonstrates, for the first time, that GLP-1 RAs alter the function of a major sensory system, significantly depressing the perception of all five basic taste qualities. The physiologic basis of this effect is unknown but may involve GLP-1 receptors in the brainstem and afferent taste pathways, as well as vagus nerve-related processes.

An analysis of national news coverage of semaglutide for weight loss

BACKGROUND

Glucagon-like peptide 1 (GLP-1) agonists like semaglutide have risen significantly in use in recent years as a therapeutic option for the management of obesity. Popular media serves as an information source for many patients, and depending on the content, may influence how a patient views a particular therapy.

OBJECTIVE

To describe the content of online/print news articles published about semaglutide for weight loss.

METHODS

Online websites and databases were used to access 8 major U.S. online/print news outlets, including the New York Times, Wall Street Journal, Washington Post, USA Today, Fox News, CNN, ABC News, and CBS News. Sources were searched for articles focusing on semaglutide and weight loss published in 2023. Articles were excluded if they focused on: (1) type 2 diabetes, (2) company press releases, or were (3) videos or transcripts of oral broadcasts/podcasts. A random sample of articles was chosen with equitable distribution across sources. Articles were assessed for the presence of data across 9 domains and 30 different content codes, stratified by news source.

RESULTS

A total of 127 articles were analyzed, split almost equally between print (n = 63) and online (n = 64) sources. The vast majority of articles were news articles/analyses (122; 96.1%). The most popular primary focus of articles were social/popular aspects of GLP-1 agonists (22; 17.3%), followed by basic medication information (20; 15.8%), harms of the medication (20; 15.8%), and benefits of the medication (17; 13.4%). Print sources were more likely to report on the cash price (55.6% Vs. 28.1%, P = 0.002), lack of insurance (61.9% Vs. 21.9%, P < 0.001), and cost-effectiveness (11.1% Vs. 1.6%, P = 0.027) of the medication compared to online sources.

CONCLUSION

Online/print news articles regarding semaglutide for weight loss provide a variety of information about the medication, commonly focusing on social aspects of treatment.

Impact of glucagon-Like peptide-1 agonists in optimizing abdominal wall Reconstruction patients

PURPOSE

Pre-optimization of obese patients prior to abdominal wall reconstruction (AWR) is essential in mitigating their increased preoperative risks. Traditionally diet, exercising, bariatric surgery are the tools typically prescribed for weight loss. The advent of glucagon-like peptide-1 agonists (GLP-1A) which stimulate insulin secretion and inhibit gastric emptying have improved the weight loss armamentarium. However, there is a limited amount of literature on GLP-1A effectiveness and postoperative outcomes in AWR patients. This study compares the efficacy of GLP-1A to Bariatric Surgery (BAS) in perioperative AWR patient.

METHODS

A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2021 and March 2024. We included patients who required GLP-1A or BAS for weight optimization prior to AWR. We excluded patients on GLP1-A or history BAS not performed for AWR preoptimization. Basic demographics such as age, sex, race, weight and BMI at initial clinic visit and at surgery were compared. Primary endpoints included time to surgery, time to bowel recovery and length of stay (LOS). Time to surgery was defined as the number of months between the initial clinic visit and AWR. Time to bowel recovery was defined as the number of days it took for the first postoperative bowel function. Secondary endpoints included standard 30-days postoperative variables. Nominal variables were analyzed using a Fisher exact test and continuous variables were analyzed with Student's T test.

RESULTS

35 patients were included in this study (GLP-1A: 17, BAS: 18). The GLP-1A cohort had a lesser BMI at the initial clinic visit (40.8 vs 43.4, p = 0.188). GLP-1A cohort made it to the operating room faster (9.1 months vs 13.5 months, p = 0.06) from the first clinic visit; and (7.9 months vs 9.7 months, p = 0.4) from initiation of weight loss intervention. Albeit losing less weight (14.9 kg vs 27.1 kg, p = 0.008) with a lesser reduction in the BMI (4.69 vs 9.23, p = 0.004). The GLP-1A cohort showed a non-significant elevated LOS (5.2 days vs 3.6 days, p = 0.25) and an increased ileus rate (17.6% vs 0%, p = 0.1). However, there were no differences noted in time to bowel recovery (2.9 days vs 3.1 days, p = 0.76).

CONCLUSION

GLP-1A is effective in optimizing patients needing weight loss before AWR. They shorten the timeline to AWR intervention and have comparable peri-operative outcomes to BAS patients.

Multifactor Quality and Safety Analysis of Semaglutide Products Sold by Online Sellers Without a Prescription: Market Surveillance, Content Analysis, and Product Purchase Evaluation Study

BACKGROUND

Over the past 4 decades, obesity has escalated into a global epidemic, with its worldwide prevalence nearly tripling. Pharmacological treatments have evolved with the recent development of glucagon-like peptide 1 agonists, such as semaglutide. However, off-label use of drugs such as Ozempic for cosmetic weight loss has surged in popularity, raising concerns about potential misuse and the emergence of substandard and falsified products in the unregulated supply chain.

OBJECTIVE

This study aims to conduct a multifactor investigation of product quality and patient safety risks associated with the unregulated online sale of semaglutide by examining product availability and vendor characteristics and assessing product quality through test purchases.

METHODS

We used a complex risk and quality assessment methodology combining online market surveillance, search engine results page analysis, website content assessment, domain traffic analytics, conducting targeted product test purchases, visual quality inspection of product packaging, microbiological sterility and endotoxin contamination evaluation, and quantitative sample analysis using liquid chromatography coupled with mass spectrometry.

RESULTS

We collected and evaluated 1080 links from search engine results pages and identified 317 (29.35%) links belonging to online pharmacies, of which 183 (57.7%) led to legal pharmacies and 134 (42.3%) directed users to 59 unique illegal online pharmacy websites. Web traffic data for the period between July and September 2023 revealed that the top 30 domains directly or indirectly affiliated with illegal online pharmacies accumulated over 4.7 million visits. Test purchases were completed from 6 illegal online pharmacies with the highest number of links offering semaglutide products for sale without prescription at the lowest price range. Three injection vial purchases were delivered; none of the 3 Ozempic prefilled injection pens were received due to nondelivery e-commerce scams. All purchased vials were considered probable substandard and falsified products, as visual inspection indicated noncompliance in more than half (59%-63%) of the evaluated criteria. The semaglutide content of samples substantially exceeded labeled amounts by 28.56%-38.69%, although no peptide-like impurities were identified. The lyophilized peptide samples were devoid of viable microorganisms at the time of testing; however, endotoxin was detected in all samples with levels ranging between 2.1645 EU/mg and 8.9511 EU/mg. Furthermore, the measured semaglutide purity was significantly low, ranging between 7.7% and 14.37% and deviating from the 99% claimed on product labels by manufacturers.

CONCLUSIONS

Glucagon-like peptide 1 agonist drugs promoted for weight loss, similar to erectile dysfunction medications more than 2 decades ago, are becoming the new blockbuster lifestyle medications for the illegal online pharmacy market. Protecting the pharmaceutical supply chain from substandard and falsified weight loss products and raising awareness regarding online medication safety must be a public health priority for regulators and technology platforms alike.

Utilization patterns of glucagon like Peptide-1 receptor agonists prior to bariatric and metabolic surgery: a multicenter study

BACKGROUND

Glucagon-like-peptide-1 receptor agonists (G1RA) have gained popularity as a treatment for weight loss in patients who are overweight or obese, but their utilization patterns and impact on candidates for metabolic and bariatric surgery (MBS) remain understudied.

OBJECTIVE

We aimed to investigate the prevalence, characteristics, and outcomes of patients with a history of G1RA utilization among MBS candidates.

SETTING

Five high-volume MBS centers in Israel.

METHODS

Data were collected retrospectively from February 1st, 2023, to September 30th, 2023. Demographic, clinical, and treatment data were analyzed to assess a history of G1RA use, associated factors, adverse events, and treatment outcomes.

RESULTS

Four hundred thirty-four MBS candidates were included in the study. A history of G1RA utilization was obtained in 275 (63%) MBS candidates, with Liraglutide and Semaglutide being the most commonly used agents. Younger age, type 2 diabetes mellitus, dyslipidemia, and no previous MBS history were associated with a higher rate of G1RA utilization. With these medications, median maximal weight loss was 5.38 kg, and mean duration of use was 19 weeks. Patients using G1RA for ≥6 weeks experienced significantly greater weight loss compared to those using it for shorter periods (6.3 ± 6.43 vs 1.65 ± 1.69; P < .001). GI-related adverse events were reported in 57.8% of patients. Over 95% of patients discontinued G1RA due to insufficient weight loss and/or adverse effects. Patients reaching the maximal recommended dose exhibited significantly greater weight loss versus patients who did not reach it for both Liraglutide (5.9 ± 4.98 kg vs. 3.9 ± 5.53 kg; P = .03) and Semaglutide (6.5 ± 7.8 kg vs. 2.5 ± 3.8 kg; P = .016).

CONCLUSION

Pre-MBS G1RA utilization and failure are prevalent among MBS candidates. Our study underscores the need for further research to understand the role of G1RA therapy in obesity management and the development of guidelines for its appropriate use in MBS candidates.

Impact of Manufacturing Process and Compounding on Properties and Quality of Follow-On GLP-1 Polypeptide Drugs

PURPOSE

The prevalence of follow-on and compounded products of glucagon-like peptide-1 analogs is increasing. We assessed glucagon-like peptide-1 analogs semaglutide and liraglutide for purity, potential immunogenicity, and expected stability, by comparing a representative selection of commercially available follow-on drug substances (DSs) and drug products (DPs) with their corresponding originators.

METHODS

Tests included several chromatography methods coupled with ultraviolet and mass spectrometry detectors, inductively coupled plasma optical emission spectroscopy, inductively coupled plasma mass spectrometry, nuclear magnetic resonance, dissolution analyses, in silico peptide/major histocompatibility complex II-binding prediction, and fibrillation assays.

RESULTS

Overall, 16 injectable semaglutide, 8 oral semaglutide, and 2 injectable liraglutide follow-on products were analyzed alongside originator products. Compared with originator, follow-on injectable semaglutide DSs and DPs had new impurities and impurity patterns, including high molecular weight proteins, trace metals, anions, counterions, and residual solvents. Analyses showed that several commercialized follow-on oral semaglutide DPs had a markedly lower quantity of semaglutide than the label claim, while dissolution tests indicated different semaglutide and sodium N-(8-[2-hydroxybenzoyl] amino)caprylate (SNAC) release profiles, which may reduce bioavailability. Neoepitopes were identified in DS and DP semaglutide follow-ons, indicating potential immunogenicity. Fibrillation assays showed increased fibrillation tendency and reduced physical stability in liraglutide follow-on DP samples compared with originator.

CONCLUSION

This study highlights that differences in the manufacturing processes of follow-on semaglutide and liraglutide (vs those used for originators) can result in several changes to the DSs and DPs. The impact of these changes on efficacy and safety outcomes remains unknown and should be investigated by clinical studies.

Population-Level Interest in Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss Using Google Trends Statistics in a 12-Month Retrospective Analysis: An Infodemiology and Infoveillance Study

Obesity is an exacerbated public health challenge, increasing the risk of several diseases and mortality while deteriorating the quality of life. There is significant dedication to exploring obesity therapies using glucagon-like peptide-1 (GLP-1) agonists, which have shown efficacy in reducing the number of deaths and complications associated with type 2 diabetes. This research aimed to examine the recent search popularity of GLP-1 agonists using Google Trends at both national (in Iraq) and global levels. To quantify relative search volume (RSV), the total search query activity has been transformed to a percentage scale ranging from 0% to 100%. The word "Ozempic" was chosen because of its extensive coverage in social media and web/print publications pertaining to this subject matter. A comparative search was performed targeting the phrases "Wegovy," "Saxenda," and "Mounjaro" to identify a novel combination GLP-1 agonist from August 2023 to August 2024. The present study demonstrated a statistically significant difference in the RSV among the four drugs (P < 0.0001) nationally and globally. In Iraq, the highest RSV for Ozempic was documented in Duhok, followed by Sulaymaniyah and Erbil. A comparable RSV profile has been noted for Saxenda, while substantial interest in Wegovy is seen in Ninawa. Meanwhile, globally, the highest RSV for Ozempic was recorded in Canada, the United States of America, and Australia. A distinct RSV profile has been observed for Saxenda, with heightened search interest recorded in Latin America, Poland, Sweden, and Australia. By contrast, Mounjaro received search interest primarily in Greenland and the United States, while Mounjaro search interest was noted in Canada, the United States, and Australia. This study demonstrates a significant and growing public interest in GLP-1 agonists, namely, Ozempic, Saxenda, Wegovy, and Mounjaro. As the use of GLP-1 agonists for weight loss becomes more common, more knowledge, understanding, and continuous scientific research will make it more convenient to obtain the best patient outcomes.

Sweetening the deal: an infodemiological study of worldwide interest in semaglutide using Google Trends extended for health application programming interface

BACKGROUND

Off-label use of semaglutide for non-diabetic weight loss (which regulators have linked to social media promotion) created worldwide supply shortages. We evaluated worldwide semaglutide interest measured by online search behavior to gauge social media and conventional print media reporting's effect on search interest.

METHODS

Using Google Trends Extended for Health (GTEH) multiple sampling, we retrieved regional online interest (ROI) for all countries and extracted timelines and top search queries for January 2021-August 2023 for countries with median ROI ≥ 20 using the "semaglutide" topic. We obtained semaglutide media reporting from the ProQuest database. We estimated the effect of media and within-country semaglutide interest on between-country interest with Granger causality analysis. We determined changepoints for trends within each country with joinpoint regression. We determined prominent themes in search queries for each country with natural language processing thematic analysis.

RESULTS

Twenty-seven countries were included. Most countries showed an increase in semaglutide interest over time, with Canada and the USA showing the largest sustained interest. Most of the search interest arose from 2022 onwards. Granger's analysis showed that media coverage could only partially explain interest, and interest in some countries partially preceded interest in others, with the UK and Germany showing strong relationships between news reports and lagged search interest. Joinpoint analysis identified up to four significant within-country changepoints. Most countries showed significant positive weekly trends in 2021-2022, although uptrends in search interest varied considerably between countries. One episode of the Dr. Oz show (TV media event) coincided with strong peaks in numerous countries. Natural language processing of top search queries showed some agreement between countries and country-specific themes. Weight loss was a major theme in most countries, while a diabetes theme was generally absent or weak. Some countries (Australia, Chile, South Africa, UK) had themes for buying Ozempic from (named) local retailers, and Germany had a theme related to buying Ozempic without a script.

CONCLUSIONS

GTEH data provided insights into global search interest in semaglutide and regional variation. Studies focusing on specific countries which include social media data can elucidate specific drivers behind the surge in off-label use of semaglutide.

Comparison of societal guidance on perioperative management of glucagon-like peptide-1 receptor agonists: implications for clinical practice and future investigations

PURPOSE

The use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) by patients undergoing surgery and procedures requiring anesthesia has become a topic of significant concern for perioperative providers because of the potential increased risk of aspiration resulting from the medication's effect of delaying gastric emptying. There is currently a lack of high-quality data regarding the safety of GLP-1 RAs in patients undergoing surgery, which has led to variations in practice.

SOURCE

We performed an internet search of society-endorsed statements and guidelines related to perioperative management of GLP-1 RAs, focusing on the top 20 countries with the largest anesthesiology societies determined by membership data from the World Federation of Societies of Anesthesiologists. We excluded articles and websites that were not in English.

PRINCIPAL FINDINGS

Our search revealed endorsed statements from fourteen major anesthesiology, endocrinology, and gastroenterology societies. There was considerable variation between societies in the recommendations and guidance for withholding these medications before surgery, the duration of withholding, assessment of the need for avoiding deep sedation or general anesthesia, use of rapid sequence intubation, need for prolonged fasting periods and clear fluid before a nil per os period, recognition of signs and symptoms for aspiration risk, the management of glucose in the perioperative period, and the use of point-of-care ultrasound for risk assessment.

CONCLUSION

Society-endorsed statements and guidelines provide varying recommendations on the perioperative management of GLP-1 RAs. The insights gained from this comparative analysis may help guide clinical practice, develop institutional practice guidelines, and direct future research efforts.

GLP-1 receptor agonists for weight reduction in people living with obesity but without diabetes: a living benefit-harm modelling study

Background

The benefit of Glucagon-like Peptide-1 (GLP-1) receptor agonists (RAs) in weight reduction against potential harms remains unclear. This study aimed at evaluating the benefit-harm balance of initiating GLP-1 RAs versus placebo for weight loss in people living with overweight and obesity but without diabetes.

Methods

We performed benefit-harm balance modelling, which will be updated as new evidence emerges. We searched for randomised controlled trials (RCTs) in PubMed, controlled trials registry, drug approval and regulatory documents, and outcome preference weights as of April 10, 2024. We synthesize data using pairwise meta-analysis to estimate the effect of GLP-1 RAs to inform the benefit-harm balance modelling. We predicted the absolute effects of the positive and negative outcomes over 1 and 2 years of treatment using exponential models. We applied preference weights to the outcomes, ranging from 0 for least concerning to 1.0 for most concerning. We then calculated whether the benefit of achieving 5% and 10% weight loss outweighed the harms on a common scale. The analyses accounted for the statistical uncertainties of treatment effects, preference weights, and outcome risks.

Findings

We included 8 RCTs involving 8847 participants. The pooled average age was 46.7 years, with the majority being women (74%) and people living with obesity (96%). Of 1000 persons treated with GLP-1 RAs for 2 years, 375 (95% confidence interval 352 to 399) achieved a 10% weight loss, and 318 (296 to 339) achieved a 5% weight loss compared to those treated with placebo. Several harm outcomes were more frequent in the GLP-1 RA group, including 41 abdominal pain events per 1000 persons over 2 years (19 to 69), cholelithiasis (8, 1 to 21), constipation (118, 78 to 164), diarrhoea (100, 42 to 173), alopecia (57, 10 to 176), hypoglycaemia (17, 1 to 68), injection site reactions (4, -3 to 19), and vomiting (110, 80 to 145) among others. Achieving a 10% weight loss with GLP-1 RA therapy outweighed the cumulative harms, with a net benefit probability of 0.97 at year 1 and 0.91 at year 2. The absolute net benefit was equivalent to 104 (100 to 112) per 1000 persons achieving a 10% weight loss over 2 years without experiencing any worrisome harm. A 5% weight loss did not show a net benefit, with probabilities of 0.13 and 0.01 at year 1 and year 2, respectively. However, these benefits were sensitive to preference weights, suggesting that even a 5% weight loss could be net beneficial for individuals with less concern about harm outcomes. The net benefit for a 10% weight loss was highest for semaglutide, followed by liraglutide and tirzepatide, with 2-year probabilities of 0.96, 0.72, and 0.60, respectively.

Interpretation

The benefit of GLP-1 RAs exceeded the harms for weight loss in the first 2 years of treatment, yet the net benefit was dependent on individual' treatment goals (10% or 5% weight loss) and willingness to accept harms in pursuit of weight loss. This implies that treatment decisions have to be personalized to individuals to optimize benefits and reduce harms and overuse of treatments. Due to varying evidence, especially regarding harm outcomes across studies, it is necessary to continuously update and monitor the benefit-harm balance of GLP-1 RAs.

Funding

SNSF and LOOP Zurich.

Optimizing Surgical Outcomes and the Role of Preventive Surgery: A Scoping Review

BACKGROUND

 Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount.

METHODS

 Herein, we aim to understand efforts supporting the nascent field of Preventive Surgery, including (1) enhanced risk stratification, (2) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized.

RESULTS

 (1) medical optimization and prehabilitation, (2) surgical mitigation techniques.

CONCLUSION

 Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.

The use of proteins and peptides-based therapy in managing and preventing pathogenic viruses

Therapeutic proteins have been employed for centuries and reached approximately 50 % of all drugs investigated. By 2023, they represented one of the top 10 largest-selling pharma products ($387.03 billion) and are anticipated to reach around $653.35 billion by 2030. Growth hormones, insulin, and interferon (IFN α, γ, and β) are among the leading applied therapeutic proteins with a higher market share. Protein-based therapies have opened new opportunities to control various diseases, including metabolic disorders, tumors, and viral outbreaks. Advanced recombinant DNA biotechnology has offered the production of therapeutic proteins and peptides for vaccination, drugs, and diagnostic tools. Prokaryotic and eukaryotic expression host systems, including bacterial, fungal, animal, mammalian, and plant cells usually applied for recombinant therapeutic proteins large-scale production. However, several limitations face therapeutic protein production and applications at the commercial level, including immunogenicity, integrity concerns, protein stability, and protein degradation under different circumstances. In this regard, protein-engineering strategies such as PEGylation, glycol-engineering, Fc-fusion, albumin conjugation, and fusion, assist in increasing targeting, product purity, production yield, functionality, and the half-life of therapeutic protein circulation. Therefore, a comprehensive insight into therapeutic protein research and findings pave the way for their successful implementation, which will be discussed in the current review.

Pharmacological treatment of obesity in adults in Norway 2004-2022

AIMS

To describe trends in the use of anti-obesity drugs in Norway during the period 2004-2022.

MATERIALS AND METHODS

We assessed the annual utilization of any available drug indicated for obesity recorded in the nationwide Norwegian Prescribed Drug Register for adults (age 18-79 years) from 1 January 2004 to 31 December 2022. Prevalence was stratified by sex and age group (18-29 years and 10-year age groups thereafter). Additional analyses were performed in individuals initiating treatment with an anti-obesity drug and on the cost of the anti-obesity drugs since 2017.

RESULTS

The prevalence of anti-obesity drug use decreased from 2009, when sibutramine and rimonabant were withdrawn from the market, and increased again after the approval of bupropion-naltrexone in 2017 and liraglutide in 2018. The use of the peripheral-acting anti-obesity drug orlistat decreased from 2004. In 2022, 1.04% of the adult Norwegian population (72.8% women) filled at least one prescription of bupropion-naltrexone, 0.91% used liraglutide (Saxenda; 74.2% women), and semaglutide without reimbursement was used by 0.68% (76.7% women). The prevalence increased with age, peaking in the age group 50 to 59 years, and decreased in older age groups. From 2017 to 2022, 2.8% of the adult residents initiated treatment with an anti-obesity drug. The total sale of those drugs increased from 1.1 million euros in 2017 to 91.8 million euros in 2022.

CONCLUSIONS

The use of anti-obesity drugs in Norway has increased substantially in recent years, especially among women aged 40 to 59 years. Changes in availability and reimbursement have influenced the use of these drugs in recent years.

An Assessment of Semaglutide Safety Based on Real World Data: From Popularity to Spontaneous Reporting in EudraVigilance Database

Some glucagon-like peptide-1 receptor agonists (GLP-1 RAs), first used in the treatment of type 2 diabetes mellitus (T2DM), have been approved for the treatment of obesity in patients with or without T2DM (liraglutide-LIR, semaglutide-SEM, and tirzepatide-TIR). Social media had an important influence on the off-label use of GLP-1 RAs for obesity, especially for SEM. We analyzed the Google queries related to SEM to assess people's interest in this drug. We also investigated the occurrence of adverse drug reactions (ADRs) by searching the EudraVigilance database (EV) for Individual Case Safety Reports (ICSRs) that reported SEM as the suspected drug and performed a descriptive and a disproportionality analysis. The data obtained for SEM were compared to other GLP-1 RAs. SEM had the highest proportions of searches on Google associated with the term "weight loss" and presented the lowest number of severe ADRs, but it also had the highest number of ICSRs reported in EV. Even though no unexpected safety issues have been reported for it until now, SEM has a hi3gh tendency for overdose reports. The most frequent off-label use was reported for SEM and TIR. In order to lower the risks of ADRs, the off-label use should be reduced and carefully monitored.

Probiotics, prebiotics, synbiotics and other microbiome-based innovative therapeutics to mitigate obesity and enhance longevity via the gut-brain axis

The global prevalence of obesity currently exceeds 1 billion people and is accompanied by an increase in the aging population. Obesity and aging share many hallmarks and are leading risk factors for cardiometabolic disease and premature death. Current anti-obesity and pro-longevity pharmacotherapies are limited by side effects, warranting the development of novel therapies. The gut microbiota plays a major role in human health and disease, with a dysbiotic composition evident in obese and aged individuals. The bidirectional communication system between the gut and the central nervous system, known as the gut-brain axis, may link obesity to unhealthy aging. Modulating the gut with microbiome-targeted therapies, such as biotics, is a novel strategy to treat and/or manage obesity and promote longevity. Biotics represent material derived from living or once-living organisms, many of which have therapeutic effects. Pre-, pro-, syn- and post-biotics may beneficially modulate gut microbial composition and function to improve obesity and the aging process. However, the investigation of biotics as next-generation therapeutics has only just begun. Further research is needed to identify therapeutic biotics and understand their mechanisms of action. Investigating the function of the gut-brain axis in obesity and aging may lead to novel therapeutic strategies for obese, aged and comorbid (e.g., sarcopenic obese) patient populations. This review discusses the interrelationship between obesity and aging, with a particular emphasis on the gut microbiome, and presents biotics as novel therapeutic agents for obesity, aging and related disease states.

Using Social Media as a Source of Real-World Data for Pharmaceutical Drug Development and Regulatory Decision Making

INTRODUCTION

While pharmaceutical companies aim to leverage real-world data (RWD) to bridge the gap between clinical drug development and real-world patient outcomes, extant research has mainly focused on the use of social media in a post-approval safety-surveillance setting. Recent regulatory and technological developments indicate that social media may serve as a rich source to expand the evidence base to pre-approval and drug development activities. However, use cases related to drug development have been largely omitted, thereby missing some of the benefits of RWD. In addition, an applied end-to-end understanding of RWD rooted in both industry and regulations is lacking.

OBJECTIVE

We aimed to investigate how social media can be used as a source of RWD to support regulatory decision making and drug development in the pharmaceutical industry. We aimed to specifically explore the data pipeline and examine how social-media derived RWD can align with regulatory guidance from the US Food and Drug Administration and industry needs.

METHODS

A machine learning pipeline was developed to extract patient insights related to anticoagulants from X (Twitter) data. These findings were then analysed from an industry perspective, and complemented by interviews with professionals from a pharmaceutical company.

RESULTS

The analysis reveals several use cases where RWD derived from social media can be beneficial, particularly in generating hypotheses around patient and therapeutic area needs. We also note certain limitations of social media data, particularly around inferring causality.

CONCLUSIONS

Social media display considerable potential as a source of RWD for guiding efforts in pharmaceutical drug development and pre-approval settings. Although further regulatory guidance on the use of social media for RWD is needed to encourage its use, regulatory and technological developments are suggested to warrant at least exploratory uses for drug development.

Glucagon-like peptide-1 analogs: Miracle drugs are blooming?

Glucagon-like peptide-1 (GLP-1), secreted by L cells in the small intestine, assumes a central role in managing type 2 diabetes mellitus (T2DM) and obesity. Its influence on insulin secretion and gastric emptying positions it as a therapeutic linchpin. However, the limited applicability of native GLP-1 stems from its short half-life, primarily due to glomerular filtration and the inactivating effect of dipeptidyl peptidase-IV (DPP-IV). To address this, various structural modification strategies have been developed to extend GLP-1's half-life. Despite the commendable efficacy displayed by current GLP-1 receptor agonists, inherent limitations persist. A paradigm shift emerges with the advent of unimolecular multi-agonists, such as the recently introduced tirzepatide, wherein GLP-1 is ingeniously combined with other gastrointestinal hormones. This novel approach has captured the spotlight within the diabetes and obesity research community. This review summarizes the physiological functions of GLP-1, systematically explores diverse structural modifications, delves into the realm of unimolecular multi-agonists, and provides a nuanced portrayal of the developmental prospects that lie ahead for GLP-1 analogs.

Glucagon-Like Peptide-1 Agonists and General Anesthesia: Perioperative Considerations and the Utility of Gastric Ultrasound

Glucagon-like peptide-1 (GLP-1) agonists are very popular and useful medications for the treatment of type 2 diabetes mellitus and obesity. Potent gastric emptying delay is common with these medications, serving as a major contributor to the postprandial glycemic control and weight loss benefits of these medications. Recently, multiple case reports and studies indicating safety risks for these medications and their use in patients planning to undergo general anesthesia have been published, as retained gastric contents can lead to intraoperative aspiration. New guidelines for these medications have been released to guide clinical practice for anesthesiologists. Some degree of preoperative cessation of these medications is required. At this time, the ideal window for cessation of these medications to optimize clinical efficacy while reducing aspiration risks has not yet been well elaborated on. Aspiration of gastric contents can still occur despite appropriate preoperative fasting in patients taking GLP-1 agonists. Gastric ultrasound appears to be an effective and objective way of preoperatively assessing a patient's stomach contents to make decisions regarding anesthetic management for patients prescribed these medications. This practice is limited by a general lack of training and implementation in current anesthesiology practice.

Practice Patterns and Perspectives of the Off-Label Use of GLP-1 Agonists for Cosmetic Weight Loss

BACKGROUND

The off-label use of glucagon-like peptide 1 (GLP-1) agonists for cosmetic weight loss has captured the interest of the public. However, there is a paucity of published data on their utilization, implications, and management, particularly in the plastic surgery community.

OBJECTIVES

This study aims to explore the current practice patterns of aesthetic plastic surgeons regarding the off-label implementation of GLP-1 agonists.

METHODS

A 35-question survey was sent to the 2600 members of The Aesthetic Society in July 2023. The survey collected physician demographics, practice settings, patient population demographics, and the use and management of GLP-1 agonists in their practice. No identifying variables were collected; all responses were anonymous.

RESULTS

A total of 368 respondents were included. A quarter of respondents (25.3%) prescribed or utilized GLP-1 agonists in their practice. Nearly a third (29.9%) reported personal use of the medication, of which 71 (70.3%) indicated it was for cosmetic weight loss. Many aspects of the current treatment, counseling, and follow-up practices were similar among prescribing plastic surgeons. However, there were discrepancies in screening, nutrition counseling, and perioperative management. The majority believed that GLP-1 agonists were effective for weight loss (68.9%), profitable for business (57.8%), and would recommend its implementation to other plastic surgeons (68.5%).

CONCLUSIONS

As leaders in the aesthetic field, it behooves plastic surgeons to take charge of shaping public opinion surrounding the growing off-label use of GLP-1 agonists for cosmetic weight loss. Plastic surgeons' leadership is imperative in establishing safe and ethical guidelines and protocols for proper screening, management, and patient care.

LEVEL OF EVIDENCE: 4

Use of glucagon-like peptide-1 receptor agonists in eating disorder populations

Glucagon-like peptide-1 receptor agonists (GLP-1As) are being used as approved or off-label treatments for weight loss. As such, there has been increasing concern about the potential for GLP-1As to impact eating disorder (ED) symptomatology. This article seeks to (1) review the current state of knowledge regarding GLP-1As and ED symptomatology; (2) provide recommendations for future research; and (3) guide ED clinicians in how to discuss GLP-1As in clinical practice. Although evidence is limited, it is possible that GLP-1As could exacerbate, or contribute to the development of, ED pathology and negatively impact ED treatment. Preliminary research on the use of GLP-1As to treat binge eating has been conducted; however, studies have design limitations and additional research is needed. Therefore, at the current time there is not sufficient evidence to support the use of GLP-1s to treat ED symptoms. In summary, more research is required before negative or positive conclusions can be drawn about the impact of GLP-1As on EDs psychopathology. Herein, we provide specific recommendations for future research and a guide to help clinicians navigate discussions with their clients about GLP-1As. A client handout is also provided. PUBLIC SIGNIFICANCE: Despite glucagon-like peptide-1 receptor agonists (GLP-1As; e.g., semaglutide) increasingly being the topic of clinical and public discourse, little is known about their potential impact on ED symptoms. It is possible that GLP-1As could maintain, worsen, or improve ED symptoms. This article reviews the limited literature on GLP-1As and ED symptoms, recommends future research, and provides clinicians with a guide for discussing GLP-1As with ED clients.

Current Weight Loss Medications: What Plastic Surgeons Should Know

The World Health Organization (WHO) estimates that over 650 million adults are obese worldwide. Recently, antidiabetic medications have rapidly become popular as weight loss medications. With the rising prevalence of obesity and the increasing demand for aesthetic procedures, it is anticipated that a growing number of patients presenting for consultation will be prescribed these medications. Therefore, it is critical for practicing plastic surgeons to understand their potential synergistic effects and safety considerations. This manuscript explores the potential benefits and considerations of antidiabetic medications in plastic surgery patients for weight loss therapy. The authors discuss the mechanisms of action, clinical efficacy, potential side effects, and relevant considerations for incorporating these medications into plastic surgery practices and medical spas.

GLP-1 Receptor Agonists and Related Mental Health Issues; Insights from a Range of Social Media Platforms Using a Mixed-Methods Approach

The emergence of glucagon-like peptide-1 receptor agonists (GLP-1 RAs; semaglutide and others) now promises effective, non-invasive treatment of obesity for individuals with and without diabetes. Social media platforms' users started promoting semaglutide/Ozempic as a weight-loss treatment, and the associated increase in demand has contributed to an ongoing worldwide shortage of the drug associated with levels of non-prescribed semaglutide intake. Furthermore, recent reports emphasized some GLP-1 RA-associated risks of triggering depression and suicidal thoughts. Consistent with the above, we aimed to assess the possible impact of GLP-1 RAs on mental health as being perceived and discussed in popular open platforms with the help of a mixed-methods approach. Reddit posts yielded 12,136 comments, YouTube videos 14,515, and TikTok videos 17,059, respectively. Out of these posts/entries, most represented matches related to sleep-related issues, including insomnia (n = 620 matches); anxiety (n = 353); depression (n = 204); and mental health issues in general (n = 165). After the initiation of GLP-1 RAs, losing weight was associated with either a marked improvement or, in some cases, a deterioration, in mood; increase/decrease in anxiety/insomnia; and better control of a range of addictive behaviors. The challenges of accessing these medications were a hot topic as well. To the best of our knowledge, this is the first study documenting if and how GLP-1 RAs are perceived as affecting mood, mental health, and behaviors. Establishing a clear cause-and-effect link between metabolic diseases, depression and medications is difficult because of their possible reciprocal relationship, shared underlying mechanisms and individual differences. Further research is needed to better understand the safety profile of these molecules and their putative impact on behavioral and non-behavioral addictions.

Glucagon-Like Peptide-1 Receptor Agonists for Chronic Weight Management

Rates of obesity have risen over the past few decades. Subsequently, the popularity of the pharmaceutical weight-loss drug market has grown over the past few years to meet growing demand. Among the most commonly prescribed drugs for weight management, many are glucagon-like peptide-1 receptor agonists (GLP-1 agonists) which are also utilized for the management of type 2 diabetes. There is a substantial and growing body of research comparing the efficacy of different clinical trials and examining long-term safety. This literature review examines the rise of off-label prescribing practices in the management of weight, with a focus on GLP-1 agonists. Physicians and patients should be aware of the unique aspects of existing treatment options, the impacts of off-label prescribing, and the effects of these medications. This review emphasizes the importance of informed decision-making, as well as the need for further research to guide future clinical practice.