Eli Lilly’s Cheaper Weight Loss Med Comes With a Catch

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Eil Lilly has recently announced that they are going to sell their weight loss drug, Zepbound, directly to consumers who can’t get insurance coverage and don’t qualify for other cost-lowering programs. They are going to do that through their private pharmacy Lilly Direct.

The subject of whether drug companies should have their own pharmacies is the topic for another day.

I’ve previously done deep dives into the research and claims made about these weight loss medications. I do not think they are going to live up to the hype and I think people aren’t getting appropriate informed consent around these drugs.

Still, I believe in bodily autonomy and I think that people who choose to take these medications deserve a safe experience.

What I want to talk about today is the catch of Lilly’s direct drug discount. That catch is the delivery system.

Zepbound is delivered by weekly injection. Those with insurance coverage will get a single-dose autoinjector pen that looks like this (picture and instructions sourced from zepbound.lilly.com/how-to-use - content warning for weight stigma)

Patients don’t have to see the needle or pull up the medication, they simply pull off the gray base, put the larger end against their skin and push the purple button until they hear two clicks.

Those who get the medication through Lilly’s private pharmacy will need a doctor’s prescription and will then have their medication mailed to them in a vial.

In order to use the medication safely they will need to have a syringe, needle, alcohol wipe, and a sharps container.

They (or someone who is helping them) needs to remember to wipe off the top of the vial with an alcohol swab, assemble the needle and syringe, pull the proper dosage of medication into the syringe (while these are single-dose vials, this step still exists in the video instructions that Lilly provides,) insert the needle into their skin and push the plunger to dose the medication.

Besides being more work and requiring more comfort around needles, there are safety issues here.

Customers need to buy their own syringes and needles (it sounds like Lilly’s pharmacy will sell those to them as well,) as well as alcohol swabs and sharps containers. They are instructed to use a different needle each time and to never share needles in order to reduce the chances of infection.

These are customers who are seeking lower-priced medication. For those who are struggling just to afford the medication, especially those with more than one person using the medication in the household, I’m wondering how likely it is that they use needles more than once, share needles, or both?

Also, if they fail to dispose of the needles in a proper sharps container, they can put others at risk of needle sticks and infections.

Then there is the dosage:

Per an ABC article called “Eli Lilly to sell Zepbound directly to consumers without insurance coverage”:

“With insurance coverage, Zepbound can cost as low as $25 per month, but without coverage, the medication can cost more than $1,000 per month.” (Note: That’s in the US, people in other countries can pay substantially less.)

Selling through their private pharmacy, a one-month supply of the 2.5mg dose will be $299, 5mg will be $549.

Let’s pause here for some quick Zepbound facts:

Zepbound was originally a type 2 diabetes medication with a side effect of weight loss that has been repurposed as a weight loss drug (Tirzepatide is the drug name, Mounjaro is the brand name for T2D, Zepbound is the brand name for weight loss.) When dosed for T2D the goal is to give the minimum dose to get the desired glycemic management and minimize side effects. In the weight loss application, the goal is to maximize the weight loss side effect and so patients are often encouraged to take the highest dose possible. While the “recommended maintenance doses are 5mg, 10mg, or 15mg,” in the latest studies, those would couldn’t tolerate at least a 10mg dose were kicked out of the studies.

The autoinjector pen comes in doses of 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg. The recommended maintenance dosages are 5 mg, 10 mg, or 15 mg injected subcutaneously once weekly.

Here’s where I start to have some questions.

This medication needs to be titrated (started at a lower dose and gradually increased over time.) All patients start at 2.5mg, this is considered a non-therapeutic dose that helps the body get used to the medication to hopefully reduce side effects as it increases. Then the medication is increased to 5mg and can be increased by 2.4 mg each subsequent four weeks until the patient can’t tolerate the dose or they are on the maximum dose.

The single dose vials come in 2.5mg and 5mg. While the 2.5mg dose is $299 the Zepbound prescribing instructions (content note, link contains weight stigma) are clear that “The 2.5 mg dosage is for treatment initiation and is not intended for chronic weight management.” Per those instructions, patients will spend 1 month at the $299 dose and then move up to the $549 dose which, at best, will need to be taken for the rest of their life to maintain weight loss (though there is no research that shows that will actually work, just research that shows that going off the med is followed by rapid weight regain.)

Again, while 5mg is one of the “recommended doses,” in the most recent studies they only allowed patients to continue if they could tolerate 10mg or more. The research shows that, at least short term and for at least some patients, higher doses mean more weight loss (though, again, there is no research proving that weight loss is sustained long-term and their own research shows that those who go off the drug rapidly regain weight.)

So, are patients who are getting their discounted vials from Lilly’s private pharmacy only going to be on the 5mg dose, or will they be titrating up using multiple vials? If so that will obviously be more expensive and increase the risks of infection and dosing errors.

Or is this a situation where they discount the product to get people started on it and then pressure them to pay more and/or pressure insurance companies to cover the drug?

Just to be clear - these are solid type 2 diabetes drugs that work well, including for people who are contraindicated for other drugs and/or aren’t able to achieve their desired glycemic management on these drugs. That said, having spent considerable time studying the research that exists on these drugs for their weight loss, I have serious concerns about them for weight loss, including short and long-term side effects, the fact that people regain the weight when they go off the drug and that they may well gain it back even if they stay on the drug. Regardless, I believe that those who choose to take the drug should have an equitable, safe experience and I’m not at all certain that this new discount plan qualifies.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.