Wegovy, weight loss, and Scotland's fight against obesity

Obesity is one of the biggest public health crises facing the NHS and, at a population level, has seemed impossible to reverse. Two thirds of adults in Scotland are overweight or obese.

This week, Scotland's medicines regulator, the SMC, took an important step in changing how we might deal with the country's weight problem in future by signalling that doctors will be allowed to prescribe the drug semaglutide - marketed under the brand name Wegovy - to help overweight and obese patients slim down.

What's happened?

On Tuesday, the SMC accepted Wegovy for "restricted use" on the NHS in Scotland.

This means the drug can be prescribed to patients who have a body mass index (BMI) of 30 or more - the official threshold for obesity - as long as they also have at least one weight-related co-morbidity, such as diabetes.

In some cases, patients will be considered for their drug at a lower BMI if they belong to an ethnic minority group where the risks associated with obesity are known to begin at a lower level.

Additionally, patients prescribed Wegovy should also be receiving help with diet and exercise through specialist NHS weight management clinics.

This follows a similar decision by NICE for the NHS in England at the end of March.

Semaglutide is already approved for use on the NHS under the brand name, Ozempic, as a treatment for Type 2 diabetes, but this is the first time that it is being recommended for prescription in Scotland specifically to aid weight loss.

Clinical trials have shown that patients typically shed 12% of their bodyweight on the drug, which mimics the effects of a gut hormone to slow to passage of food and make users feel full. Patients have to self-administer the medication by injection once a week.

SMC documents indicate that an estimated 4,843 patients a year in Scotland would be eligible for Wegovy initially, although how many actually get it will be complicated by very limited stocks (the Danish manufacturer, Novo Nordisk, is building new factories in bid to keep up with huge global demand) and by a postcode lottery of access NHS weight loss services, some of which already have lengthy waiting lists.

Risks and benefits

One problem hanging over the drug is that current guidance for the NHS indicates that it should only be prescribed for a maximum of two years, despite evidence showing that discontinuation is associated with rapid weight gain back to pre-treatment levels.

This has led to calls from some scientists and clinicians that obesity should be treated as a lifelong condition in the same way that statins are used in patients with high blood pressure.

This is backed by growing evidence for the wider health benefits of using semaglutide to treat obesity.

Read more: 

• Analysis: Obesity, deprivation, women - and the surprising cost of being 'too fat'
• Analysis: Weight-loss drugs and the future of obesity treatment
• Exclusive: Top Scottish surgeon warns patients have 'died waiting' for weight-loss surgery

In August, the results of a major clinical trial, presented at the European Society of Cardiology conference, found that weekly 2.4mg injections of semaglutide (the same dose used in Wegovy) was associated with significant improvements in heart failure symptoms and physical fitness.

It also appears to slash the risk of heart attacks and other cardiovascular events.

This has prompted the UK Government to commission a two-year, £40 million pilot to test whether Wegovy can be used to cut NHS waiting lists in England and increase employment levels if it is made available through the NHS on a less restricted basis with support from apps and pharmacists rather than only via weight-loss clinics.

Around 10,000 are being recruited for the study, which could ultimate influence approaches taken north of the border.

Sign up for our health correspondent Helen McArdle's exclusive look inside the NHS

However, it also comes as a US study of 16 million people from 2006 to 2020 found that those given weekly doses of 2.4mg of semaglutide were at increased risk of gastrointestinal problems including pancreatitis, intestinal blockage, and stomach paralysis.

It found that nearly five in every 1000 patients developed pancreatitis and nine in every 1,000 developed stomach paralysis. Intestinal blockages are already listed as a potential side effect of Wegovy.

Obesity brings its own complications and risks, however, so as ever the potential for wider use must boil down to the question of whether the benefits outweigh the harms.