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Weight Loss Treatment

Answers to all your weight-loss medication questions

Weight Loss Medications

Information on available weight loss drugs, including their efficacy, mechanism, side effects, and costs, is provided at the links below. A table that ranks weight loss treatments (medications and bariatric procedures) by effectiveness is available here - Obesity treatment effects table.



Zepbound and Mounjaro (tirzepatide) 21% weight loss

Efficacy
  • In a 72-week trial enrolling 2539 overweight adults, tirzepatide caused the following weight loss: 15% (5 mg dose), 19.5% (10 mg dose), and 21% (15 mg dose) [Study abstract]
  • See tirzepatide (Zepbound) for a comprehensive review

Mechanism
  • Tirzepatide is a once-weekly injection that mimics the actions of GLP-1 and GIP, endogenous hormones released in response to food intake that slow gastric emptying, suppress hunger, and stimulate insulin release

Side effects
  • Side effects of tirzepatide are primarily gastrointestinal. In weight-loss studies, the following was seen: nausea (31%), diarrhea (23%), constipation (12%), vomiting (12%), stomach upset (11%)

Cost
  • Cash pay: Eli Lilly has a savings card for people without insurance coverage that brings the price down to $650/month (see Zepbound coverage and cost). In August 2024, Lilly started offering Zepbound single-use vials in the 2.5 mg and 5 mg doses through their online pharmacy, LillyDirect. Unlike the pens, the vials require that the patient draw the medication into a syringe and inject it subcutaneously. Four vials, which last 28 days, cost $399 for the 2.5 mg dose and $549 for the 5 mg dose.
  • Insurance:
    • Zepbound: Zepbound is FDA-approved for weight loss, and some plans cover it, while others do not. If prior authorization is required, the form typically asks if the patient meets FDA-approved indications (BMI ≥ 30 or ≥ 27 with comorbidities like hypertension or high cholesterol), and most people are approved.
    • Mounjaro: Mounjaro is only approved to treat diabetes, so its use in weight loss is considered off-label. It is preferred on some insurance plans, which means it can be prescribed without prior authorization. If prior authorization is required, the form will ask if the patient has diabetes and what drugs they have tried. This prevents it from being prescribed for weight loss in nondiabetics.

Other conditions
  • Obstructive sleep apnea (OSA): In a 52-week trial enrolling overweight adults with OSA (N=469), Zepbound significantly reduced the apnea-hypopnea index, body weight, hypoxic burden, and systolic blood pressure. [Study abstract] In December 2024, Zepbound received FDA approval for moderate to severe OSA in adults with obesity. However, it is too soon to know if insurance companies will cover it for this indication and what the criteria will be.
  • Nonalcoholic steatohepatitis (NASH), also called fatty liver disease: In a 52-week study (N=190) enrolling adults with NASH, more patients treated with Zepbound had NASH resolution compared to placebo (62% [15 mg dose] vs 10%). [Study abstract] Zepbound has not been FDA-approved to treat NASH.
  • Prediabetes: In a 3-year study (N=1032), Zepbound was significantly better than placebo at preventing progression to diabetes in participants with prediabetes (1.3% vs 13.3%). [Study abstract] Zepbound has not been FDA-approved to prevent diabetes.
  • Heart failure with preserved ejection fraction (HFpEF): In a 104-week study (N=731) enrolling obese adults with HFpEF, Zepbound was superior to placebo for improving heart failure outcomes and symptoms. [Study abstract] Zepbound has not been FDA-approved to treat HFpEF.


Wegovy and Ozempic (semaglutide) 15 - 17% weight loss

Efficacy
  • Adults: In a 68-week trial enrolling 1961 overweight adults, Wegovy caused 15% weight loss. [Study abstract] In other similar studies, Wegovy caused 16 - 18% weight loss.
  • Adolescents: In a 68-week trial enrolling 201 obese adolescents aged 12 - 17 years, Wegovy caused 16% weight loss. [Study abstract]
  • See Wegovy for a comprehensive review

Mechanism
  • Semaglutide is a once-weekly injection that mimics the actions of GLP-1, an endogenous hormone released in response to food intake that slows gastric emptying, suppresses hunger, and stimulates insulin release

Side effects
  • Side effects of semaglutide are primarily gastrointestinal. In weight-loss studies, the following was seen: nausea (44%), diarrhea (30%), vomiting (24%), constipation (24%), abdominal pain (20%)

Cost
  • Cash pay: Novo Nordisk has a savings card for people without insurance coverage that brings the price down to $650/month (see Wegovy website)
  • Insurance:
    • Wegovy: Wegovy is FDA-approved for weight loss, and some plans cover it, while others do not. If prior authorization is required, the form typically asks if the patient meets FDA-approved indications (BMI ≥ 30 or ≥ 27 with comorbidities like hypertension or high cholesterol), and most people are approved. The Wegovy manufacturer has set up a webpage to help determine insurance coverage - Wegovy coverage checker.
    • Ozempic: Ozempic is only approved to treat diabetes, so its use in weight loss is considered off-label. It is preferred on some insurance plans, which means it can be prescribed without prior authorization. If prior authorization is required, the form will ask if the patient has diabetes and what drugs they have tried. This prevents it from being prescribed for weight loss in nondiabetics.

Other conditions
  • Secondary prevention of cardiovascular disease (CVD): In a 40-month study (N=17,604) enrolling overweight adults with a history of CVD, Wegovy was superior to placebo for reducing CVD events. [Study abstract] Based on this study, Wegovy received FDA approval for the prevention of CVD events in patients with a history of CVD (e.g., heart attack, stroke). Some insurance plans will cover Wegovy for this indication.
  • Heart failure with preserved ejection fraction (HFpEF): In a 52-week study (N=529) enrolling obese adults with HFpEF, Wegovy was superior to placebo for improving heart failure symptoms. [Study abstract] Wegovy has not been FDA-approved to treat HFpEF.
  • Knee osteoarthritis (OA): In a 68-week study (N=407) enrolling obese adults with moderate knee OA, Wegovy was superior to placebo for improving knee pain. [Study abstract] Wegovy has not been FDA-approved to treat knee OA.


Phentermine (appetite suppressants) 10% weight loss

Efficacy
  • In studies lasting 3 to 6 months, phentermine and similar appetite suppressants caused 10% weight loss.
  • See appetite suppressants for a comprehensive review

Treatment duration
  • The prescribing information for phentermine recommends that it be taken for 3 months. In practice, many patients take it off and on or continuously for longer. Phentermine is also a part of the diet drug Qsymia (phentermine + topiramate), which has been taken for two years in studies. Furthermore, there is an ongoing study comparing two years of continuous phentermine to placebo. [Study abstract]

Mechanism
  • Appetite suppressants are stimulants that work by blocking hunger pathways in the hypothalamus. Phentermine has been available since the 1950s and is one of the most widely prescribed drugs ever.

Side effects
  • Side effects of phentermine are related to its stimulant properties and include insomnia, dry mouth, palpitations, anxiety, agitation, and increased heart rate. See phentermine patient information (pdf) for more.
  • In the 1990s, phentermine was combined with a drug called fenfluramine in the popular "Phen-fen" diet pill. Fenfluramine was later pulled from the market because it increased the risk of heart valve disease. In studies, phentermine has not been linked to any type of heart or lung problems.

Cost
  • Cash pay: around $15/month
  • Insurance: Insurance coverage is not typically relevant since cash pricing is affordable


Qsymia (phentermine + topiramate) 10% weight loss

Efficacy
  • Adults: In a 56-week study enrolling 2487 overweight adults, Qsymia (15/92 mg) caused 9.8% weight loss [Study abstract]
  • Adolescents: In a 56-week study enrolling 233 obese adolescents aged 12 to 17, Qsymia caused the following weight loss: 5.2% (7.5/46 mg dose) and 8.6% (15/92 mg dose) [Study abstract]
  • See Qsymia for a comprehensive review

Mechanism
  • Qsymia is a daily capsule containing both immediate-release phentermine and extended-release topiramate. Phentermine is an appetite suppressant, and topiramate is a seizure medication that suppresses hunger through an unknown mechanism. At its highest dose, Qsymia contains 15 mg/day of phentermine, which is less than half the standard daily dose of 37.5 mg.

Side effects
  • Side effects of Qsymia include dry mouth (21%), tingling sensation in the fingers (21%), taste perversion (10%), insomnia (10%), and dizziness (10%). The Qsymia prescribing information recommends that electrolytes be measured before and during therapy to check for metabolic acidosis, a potential side effect of topiramate.

Cost
  • Cash pay: the Qsymia® manufacturer has set up a website that allows cash-pay patients to get Qsymia for $98/month (Qsymia Home Delivery Pharmacy). However, it's usually cheaper to prescribe the individual components (phentermine and topiramate) separately since they both have cheap generics.
  • Insurance: insurance coverage varies


Saxenda (liraglutide) 8% weight loss

Efficacy
  • Adults: In a 56-week study enrolling 3731 overweight adults, Saxenda caused 8% weight loss [Study abstract]
  • Adolescents: In a 56-week study enrolling 251 obese adolescents aged 12 - 17, Saxenda caused 2.3% weight loss compared to a weight gain of 2.3% in the placebo group [Study abstract]
  • See Saxenda for a comprehensive review

Mechanism
  • Saxenda is a daily injection that mimics the actions of GLP-1, an endogenous hormone released in response to food intake that slows gastric emptying, suppresses hunger, and stimulates insulin release
  • Saxenda is in the same drug class as Wegovy and Ozempic. It was approved for weight loss in 2014, but its effects are not as pronounced as the newer GLP-1 therapies, so it was not as highly touted.

Side effects
  • Saxenda side effects are primarily gastrointestinal. In weight-loss trials, the following was seen: nausea (40%), diarrhea (21%), constipation (20%), vomiting (16%), and upset stomach (10%).

Cost
  • Cash pay: around $1400/month
  • Insurance: Few insurance plans cover Saxenda. The manufacturer has a webpage to help determine insurance coverage (Saxenda coverage checker).


Xenical and Alli (orlistat) 7.6% weight loss

Efficacy
  • Adults: In a two-year study enrolling 729 overweight adults, orlistat caused the following weight loss: 6.8% (60 mg dose) and 7.6% (120 mg dose) [Study abstract]
  • Adolescents: In a 54-week study enrolling 539 obese adolescents aged 12 to 16, orlistat 120 mg three times a day caused 3.3% weight loss [Study abstract]
  • See orlistat for a comprehensive review

Mechanism
  • Xenical and Alli, capsules taken three times daily with meals, contain orlistat, a lipase inhibitor. Lipase is an enzyme secreted into the intestinal lumen by the pancreas and stomach. Lipase breaks down dietary fat so that it can be absorbed systemically. Orlistat inhibits lipase, thus reducing intestinal fat absorption by as much as 30% (120 mg dose).

Side effects
  • Reduced fat absorption can cause a variety of gastrointestinal symptoms, including oily rectal spotting (27%), flatus with discharge (24%), fecal urgency (22%), oily evacuation (20%), and fatty/oily stools (17%). These side effects usually improve over time, with all dropping to less than 5% after a year. The absorption of fat-soluble vitamins (A,D,E,K) may also be reduced, so it's recommended that patients take a daily multivitamin at least two hours before orlistat.

Cost
  • Cash pay: Alli (60 mg) is available over-the-counter, and Xenical (120 mg) is by prescription only. Xenical has no generic and costs around $800/month. Alli costs about $50/month.
  • Insurance: Some insurance plans cover Xenical


Contrave (bupropion + naltrexone) 6 - 8% weight loss

Efficacy
  • In a 56-week study enrolling 1742 overweight adults, Contrave caused 6.1% weight loss. [Study abstract] In a second similar study, Contrave caused 7.8% weight loss. [Study abstract]
  • See Contrave for a comprehensive review

Mechanism
  • Contrave is a tablet containing bupropion, an antidepressant, and naltrexone, an opioid antagonist. It's unclear how either drug suppresses hunger, but nonclinical studies suggest that naltrexone and bupropion affect two separate areas of the brain involved in regulating food intake: the hypothalamus (appetite regulatory center) and the mesolimbic dopamine circuit (reward system).

Side effects
  • Common side effects of Contrave include nausea (33%), constipation (19%), headache (18%), vomiting (11%), dizziness (10%), and insomnia (9%)
  • Patients should also be aware that naltrexone blocks the analgesic effect of opioid medications (e.g. morphine, hydrocodone). In emergency situations, the blockage can be overridden with higher opioid doses, or other analgesic classes can be used.

Cost
  • Cash pay: the Contrave manufacturer has set up a website that allows cash-pay patients to get Contrave for $99/month through a mail-order pharmacy (Contrave CurxAccess program). However, it's usually cheaper to prescribe the individual components (bupropion and naltrexone) separately since they both have cheap generics.
  • Insurance: few insurance plans cover Contrave


Other drugs touted as weight loss treatments

  • Metformin: Metformin is a widely-prescribed diabetes medication that increases insulin sensitivity. Even though some providers tout it as a weight-loss drug, it has never been shown in a clinical trial to cause meaningful weight loss.

  • Vitamin B12: Vitamin B12 is recommended by some to promote weight loss. It has never been proven to cause weight loss or increase energy in a clinical trial.

  • Rybelsus (semaglutide): Rybelsus is an oral form of semaglutide approved to treat diabetes. In a 26-week diabetes study, it caused 4.2% (14 mg dose) weight loss. Insurance companies will not cover Rybelsus for weight loss.

  • Human chorionic gonadotropin (HCG): HCG is a hormone released during pregnancy that has been promoted for decades as a weight-loss treatment. In small studies, weight loss with HCG was no better than placebo.


Future therapies

  • Retatrutide: Eli Lilly is developing a triple-hormone-receptor agonist (GLP, GIP, and Glucagon) called retatrutide that is given as a once-weekly injection. In a 48-week study enrolling 338 overweight adults, the highest dose of retatrutide caused 24.2% weight loss. [Study abstract]

  • Oral semaglutide: Novo Nordisk is developing a 50-mg oral version of semaglutide. In a 68-week trial enrolling 667 overweight adults, oral semaglutide caused 15.1% weight loss. [Study abstract]

  • Semaglutide + cagrilintide (CagriSema): Novo Nordisk is developing CagriSema, a once-weekly injection that contains semaglutide (the active ingredient in Wegovy) and cagrilintide, an amylin analog. In a 68-week study enrolling 3417 overweight adults, patients receiving CagriSema achieved an average weight loss of 22.7% compared to 11.8% with cagrilintide, 16.1% with semaglutide, and 2.3% with placebo. [NovoNordisk press release]

  • Orforglipron: Eli Lilly is developing a once-daily oral GLP agonist called orforglipron. In a 36-week study enrolling 272 overweight adults, the highest dose of orforglipron caused 14.7% weight loss. [Study abstract]

  • Danuglipron: Pfizer is studying an oral GLP-1 agonist called danuglipron, which it hopes to get approved for diabetes and obesity. Weight-loss studies have not been published yet, but development of a twice-daily version was recently abandoned because of excessive side effects. [Medscape article]


  • BPD/DS - Biliopancreatic diversion with duodenal switch
  • References [PMID: 32202076, 33625476, 28017964, 19564877, 21481449, 26132939, 10678259, 20673995, 30421844, 35658024]
Typical weight loss seen with obesity treatments
Treatment % weight loss from baseline
(length of follow-up)
BPD/DS 35 - 40%
(> 10 years)
Gastric bypass 30 - 35%
(> 10 years)
Gastric sleeve 25 - 30%
(> 10 years)
Gastric banding 20 - 25%
(> 10 years)
Zepbound and Mounjaro (tirzepatide) 21%
(72 weeks)
Wegovy (semaglutide) 16%
(68 weeks)
Endoscopic sleeve gastroplasty 11.4%
(104 weeks)
Intragastric balloon 10%
(6 months)
Appetite suppressants (e.g. phentermine) 10%
(6 months)
Qsymia (topiramate + phentermine) 10%
(56 weeks)
Saxenda (Liraglutide) 8%
(56 weeks)
Xenical (orlistat) 7.6%
(2 years)
Contrave (naltrexone + bupropion) 6 - 8%
(56 weeks)

Options after achieving weight-loss goal on GLP Drugs

A question I'm often asked is how semaglutide (Wegovy) and tirzepatide (Zepbound) are managed after someone reaches their weight-loss goal. There is no one-size-fits-all answer, as it mostly depends on the individual and their ability to maintain good eating habits. The three main options are discussed below.

  • Stay on the medication at the same or a reduced dose: There is no limit on the duration of GLP therapy. The first GLP analog, Byetta, was approved in 2005, and since then, many diabetics have used these medications for life. Some patients may choose to lower their dose to see if they can maintain their weight at a reduced strength.

  • Stop or taper off the medication: GLP analogs may be stopped abruptly without adverse withdrawal symptoms. Alternatively, they may be tapered off over a period of time. Once the medication is discontinued, its effects on appetite dissipate over several weeks. Weight regain after stopping depends on the individual's ability to maintain their eating habits. Several studies have evaluated weight regain after stopping GLP drugs. In one, patients who lost 10.6% of their weight after 20 weeks of Wegovy were randomized to continue it or switch to placebo. Over the next 48 weeks, patients who received placebo regained 7% of their weight, while those who continued Wegovy lost an additional 8%. [PubMed abstract] In another, patients who lost 21% of their weight after 36 weeks of Zepbound were randomized to continue it or switch to placebo. Over the next year, the placebo group regained 14% of their weight, while the Zepbound group lost an additional 5.5%. [PubMed abstract]

  • Increase the interval between doses: Another option is to increase the interval between doses to greater than one week. No studies have evaluated this practice, so I cannot speak to its effects in a controlled setting. Anecdotally, I can say this has worked for some of my patients.

Insurance Coverage for GLP drugs

  • Zepbound and Wegovy: Zepbound (tirzepatide) and Wegovy (semaglutide) are approved for weight loss and covered by some insurance plans. Insurance companies typically require prior authorization to confirm that the patient meets FDA-approved indications (BMI ≥ 30 or ≥ 27 with comorbidities like hypertension or high cholesterol). Recently, some plans started requiring a BMI of 40 or greater for coverage. The Wegovy manufacturer has set up a webpage that provides coverage information - Wegovy coverage checker. (NOTE: The provider information is Todd Crump, Austin, TX)

  • Ozempic and Mounjaro: Ozempic (semaglutide) and Mounjaro (tirzepatide) are only approved for diabetes and typically require prior authorization (sometimes called "stepped therapy") for coverage. If the patient does not have diabetes, coverage is denied. A few plans offer these medications without prior authorization, in which case, they are covered when prescribed for weight loss. Please note that insurance companies will not approve these medications for pre-diabetes, insulin resistance, high cholesterol, family history of diabetes, PCOS, etc.

  • Coverage for other indications:
    • Wegovy: In March 2023, the FDA approved Wegovy for the secondary prevention of cardiovascular disease in overweight patients. Some insurers will cover it for this indication. In order to qualify, patients must have a documented history of cardiovascular disease (e.g., heart attack, stroke) and a BMI of at least 27.
    • Zepbound: In December 2024, the FDA approved Zepbound for the treatment of obstructive sleep apnea in obese adults. It is too early to know if insurers will cover it for this indication and what the criteria will be.

  • Coverage across insurance plans: Coverage is not the same across an individual insurance company, as each employer negotiates different benefits for their plan. For example, a person with Aetna who works for company A may be covered, while another person with Aetna who works for company B may not. The best way to find out if your insurance will cover these medications is to call them and/or look at an online formulary


Weight loss therapies from Texas Telemedicine Doctor

We prescribe the following weight loss therapies:
  • Zepbound® and Mounjaro® (tirzepatide)✝
  • Wegovy® and Ozempic® (semaglutide)✝
  • Phentermine
  • Qsymia® (phentermine + topiramate)
  • Saxenda® (liraglutide)
  • Contrave® (bupropion + naltrexone)
  • Xenical® (orlistat)
✝We do not prescribe the compounded versions

How it works:
  • Appointments:
    • Initial visit, then every 3 months
  • Cost: All visits are $60 if we only see you for weight loss. If you want us to address additional problems (e.g., hypertension, low thyroid, eczema), it's $10 per issue (see pricing for more). HSA and FSA cards may be used to pay for appointments.
  • Labs: For Zepbound, Wegovy, Ozempic, Mounjaro, and Saxenda, we recommend some basic labs (CMP, CBC, TSH, FLP). If you have done labs within the last year, we can accept those. You can use your insurance or pay with cash, including HSA/FSA cards (total cost is $52 for all labs)

Texas Telemedicine Doctor Advantage

The table below shows how we compare to other weight-loss options

Texas Telemedicine Doctor Calibrate Weight Watchers Local doctor
Cost per year $240 $1656 $1237 Copays and deductibles
Manage other issues YES NO NO YES
Telemedicine appointments YES YES YES Varies