Obesity Drugs Just Got More Powerful

Data is everywhere. When orchestrated properly, it sings. At Morningstar, we analyze and enrich data, making it actionable and powerful for you. Morningstar, where data speaks. We're at the beginning of an era where maybe in 10 years' time we'll think about obesity management, chronic weight management just like we do hypertension today. If you have high blood pressure, we treat it. We don't accept non-treatment. It's malpractice not to treat it, actually. And yet today we walk into an office and if someone is overweight, we think of that as something else.

Hello and welcome to the Barron StreetWise Podcast. I'm Jack Howe. The voice you just heard is David Ricks. He's the CEO of Eli Lilly, which just announced a big new breakthrough in obesity treatment. We'll talk about that and hear from David, plus a top Wall Street analyst. And you might be shocked to hear what one nurse practitioner says that obesity drugs have done for her beauty and wellness clinic. Listening in is our audio producer, Meta. Hi, Meta.

Hey, Jack.

So my summer slim down is not really going according to plan so far.

Oh, no.

I'm very exercise adjacent because, you know, when I'm not working, the kids have a lot of sports, you know, camps and clinics where they have leagues and games. And so I'm always taking them around somewhere. I drive them somewhere, often somewhere far, and then I sit and I watch them play. I'm very close to physical fitness, but I'm not actually, you know, it doesn't work that way. You can't just be close to it. That's not working. I might be developing tournament belly as a matter of fact, because you eat some fast food when you're traveling like that. So there's that. And plus you and I have talked off the podcast about my recent wicked tuna habit.

Bottom line is these fish are worth money, big money.

That's why we're here.

That's why we play this game.

For people who don't know, that's a show. It's not a new show. There are many seasons of it, but it's new to me. I just discovered it. And you watch, how shall I describe, other people fish, right? You watch, you watch other people fish. There are these like, they're sort of grizzled New England, um, you know, fishermen. And they sit there sometimes with like lit cigarettes hanging out of their mouth, reeling in 500-pound tuna. And, um, You know, there's a lot of discussion about, I got to get this butterball on the deck. And I, and I watched these guys and it's very exciting for me, but then I sort of, you know, I'm not getting as much activity as I should. And then hear them talk about these fish and obsessing about how much the fish weigh. And then they take them into the port at Gloucester, Massachusetts, and then they do a tail cut and they look at the, the fat and they say, you know, like, is there, is there marbling almost like a, you would look at a steak. So I feel like that combination of not really getting activity and then watching fishermen discuss these big tuna and their fat content is—

is it making you think about your own marbling?

Yeah. I mean, on one hand, I said to myself, I could probably fetch $20 plus per pound at Gloucester. But on the other hand, I say, no way. I'm not nearly as good a condition as those big tuna. They're swimming all day. But amid all this tournament travel and excessive fishing spectatorship, I can't help but pay attention to the headlines in the background about these breakthrough obesity drugs. So many people taking them, so many people having remarkable success with them. And you, you hear about them all the time, including, uh, you see things on social media, TikTok, YouTube. This is a once weekly injection that helps with, um, your appetite, insulin resistance, and it's been prescribed for people with diabetes and now is being prescribed off-label for weight loss. The first step is to look at the expiration date on the pan to make sure it is not expired. I'm never hungry. I had to remind myself to eat.

I do, however, have a constant, like, tummy ache.

It feels more like I did 1,000 sit-ups, but I don't have that battle in my head, or I'm not thinking about my next meal.

I felt absolutely terrible.

I was dizzy all the time.

I was exhausted. Exhausted all the time. Ladies, to submit your order, you do need to inbox me your full name, mailing address, and also submit your payment. We did an episode of this podcast on obesity drugs last summer, and we talked at the time about how this category could become the first $100 billion a year seller for the drug industry. And to put that in context, last year Pfizer became the first company to do more than $100 billion in revenue in a single year. And that wasn't from obesity drugs, that was from COVID drugs, vaccines, and treatments. So the thinking is that obesity drugs could ultimately become much bigger than COVID drugs were during the pandemic, only on an ongoing basis. And there are two companies out in front on this. One is Novo Nordisk, and it has a, a history in diabetes treatment, including insulin. And its drug is called semaglutide. I hope I'm pronouncing that right. And it's given for both diabetes, where it's called Ozempic, and for obesity, where it's called Wegovy. The other drug is from Eli Lilly. It's called tirzepatide, and that is approved so far just for diabetes. It's sold under the name brand Mounjaro., but it is expected to be approved later this year for obesity. We don't have a name brand for that yet. So that's where things stand now. And we've talked before about just how effective these new drugs are for weight loss relative to other drugs that have been tried in the past. Um, but this past week there were study results that were presented on Monday at an American Diabetes Association conference. They were from Eli Lilly for a drug called retatrutide. I want to say Ratatouille, but it looks more like retatrutide. Retatrutide. And this is a phase 2 study. There are typically 3 phases to clinical drug trials, and then a company will file for an approval. So they're sort of in the middle of it. And I'm not really going to describe how this drug is different from the others because it's a struggle for me to both understand and pronounce, frankly. But suffice it to say that this new experimental drug, it works in 3 ways. That initial Novo drug, Wegovy, that targets a hormone called GLP-1, glucagon-like peptide 1. Okay, so that's one way it's effective. And then the, the Lilly drug that is on the market for diabetes now and is expected to be approved for obesity at the end of this year, that works in two different ways. It targets both that GLP-1 but also something different called GIP, glucose-dependent Insulinotropic polypeptide. Thank you very much. So the new Lilly drug retatrutide that works on both those things and something else called a glucagon receptor agonist. So it's a three-way treatment and it has shown to be significantly more effective than the treatments that are currently out there. Again, in, in clinical trials, in phase 2 trials.

So how much weight loss are we talking about?

You want to jump right to that? Because I was going to say, you know, some more about receptor agonists, but I could get to the numbers if that's what you're into. Okay, so just for a benchmark, there was a study that talked about 17% weight loss for that, that first obesity drug from Novo, which is Wegovy. And there was one that showed 22% weight loss for Mounjaro. That's the, the, the Lilly drug that is expected to soon be approved for obesity. This new experimental drug, the weight loss was 24%, but there's two little things that suggest that the actual weight loss could ultimately be higher than that. For one thing, it was only a 48-week study, and at the end of the study, the, the weight loss hadn't yet plateaued. People were still losing weight. So if they, if they do a later, a phase 3 study, and it lasts for longer, it suggests that people might lose more weight also. In earlier studies, females lost more in percentage terms than males, and those earlier studies were skewed female. They were about two-thirds female. This study was more evenly split between men and women. So in other words, if the study makeup, if the gender balance of the study was identical to previous studies, it suggests that the percentage weight loss would've been higher. I know people think about weight loss in terms of pounds, not percentages, so the headline number for this latest study is 58 pounds over 48 weeks for the average participant. And again, there's good reason to believe that that number might ultimately be higher in later studies. We'll see. There are things that have to be figured out, like how to optimize the dosage levels in the next trial in order to, you know, get the side effects as minimal as possible. But the early results from this drug are very promising. Here's what Colin Bristow, a drug analyst at UBS who covers Eli Lilly, told me about conversations he's had recently with experts in the field of obesity treatment.

They're working views right now are that towards the end of the decade, with regards to everything we're seeing now, Lilly is absolutely going to have dominant share. Their estimates are anywhere from, I think, two-thirds to 80% of the market. And so that would equate to just that huge peak sales numbers.

Now, Colin calls Eli Lilly his top large-cap biopharma pick. The stock at a glance, you wouldn't call it cheap. It's over 50 times this year's projected earnings. But because of this coming revenue surge from obesity drugs, those earnings are expected by Wall Street to, to double in the space of 2 to 3 years. So people are paying an elevated price for a company that is expected to have very rapid earnings growth. And it's difficult with a company like that to say exactly what to make of the stock. Um, Colin has a price target that last I checked implied about 8% upside from recent levels. But the thinking is that later in the decade, the growth could become really profound. The job for Eli Lilly now is to ramp up manufacturing capacity because there will be many people looking for its current obesity drug as soon as it's approved. Again, that's expected later this year. I had a chance recently to speak with David Ricks. He's the CEO of Eli Lilly, and our conversation took place just before, uh, these latest results were announced this past Monday. Let's bring you part of that conversation now. I'm sure that everyone starts conversations asking you about obesity treatments. These days, but it's, you know, people want to know. Everyone has the idea that you have this class of diabetes medicine that has proven effective for weight loss. What's the latest promise on that front?

Yeah, of course, it's a common condition, and I walk through my neighborhood and I get questions like that from people, but also, you know, policymakers, because obesity and overweight is such a common condition. 40% of adults in the U.S. suffer from that, and it's also well thought to cause many other serious health consequences. So I want to mention that because this conversation often deviates into, you know, more of a cosmetic discussion, but it's a serious health issue and maybe the most important one in America. So we're excited by the data we've produced with our drug, which is called tirzepatide, is the chemical name. It's a dual-acting incretin agonists. These drugs were developed originally, this category, for diabetes. We had the first one actually almost 20 years ago, using one hormone that your stomach, your gut secretes when you eat, and it has the effect of suppressing appetite, telling your body it's eaten and you're full. Turns out there's many of these, and we've combined a second one with that to create this, you know, best weight loss ever seen drug. Terzepatide. It's under review at the FDA. Our submission's complete. We expect approval probably around the end of this year, and in the meantime, as you mentioned, we're trying to figure out how to make a lot of it, because there's already shortages with these drugs from us and our competitor, and of course there'll be many more people interested in this once we have full FDA approval.

What comes next? Let's say you get the approval at the end of the year, you scale up manufacturing, people are, are buying this for obesity, What is your thinking about how to expand the potential patient population for this down the road, or new ways to administer it or package it, or what have you?

Yeah, two major vectors here. One, with tirzepatide, we have proven already in two studies that have been published a pretty significant weight loss, 22.5% of your body weight. Just to put that in pounds, people came into the study at 232 pounds, and and exited at 179 pounds. So that you can imagine, visualize someone changing their size that much. It's a profound effect. So the first thing we have to do is not just show weight loss, but the health benefits of weight loss. So we've launched a series of studies that do that in our business. You know, we take it on to prove the health consequence, and we want to do that both to drive demand for the product, but also to drive reimbursement. I think most people would think their insurance company would pay for this treatment because it's a healthcare product. But in truth, more than half of Americans who have employer insurance don't pay, and all of people who have government insurance don't have coverage either. So how do we change that? Well, I think demands will change it. If you call your HR department and tell them you'd like to use this and it's not covered, enough people will eventually, you know, put pressure on them But really, I think for the government employers and other commercial payers, having proof that we can reduce heart attacks or reduce other conditions— one of our first studies we'll read out is a reduction in sleep apnea. This is a sleep disturbance that's significantly driven by overweight, and there's 7 million people who use machines, CPAP machines at night to sleep comfortably through the night. We're trying to demonstrate that these drugs could reduce or eliminate the need for that kind of care, which is a direct cost savings and of course a huge convenience for people. So we have right now as a company 30 of these health consequence studies going, and that I think will help in the long term. The second thing we're doing is inventing newer and better drugs. That's what we do. We actually this weekend at the American Diabetes Association will present on two of them. One is a triple-acting one. We took the original idea, which is what something like semaglutide is based on, that's Ozempic, or artrulicity, and we added another hormone to make tirzepatide. Now we're adding a third, and as you might guess, it's even more powerful. People losing, we would project, into the high 20% of their body mass, so really a profound effect. And then also we have data coming on an oral therapy, like a pill. These are injectables you give once a week so far, but to make this available in a pill form I think would be really satisfying for a lot of people.

You have these drugs that have tremendous promise for weight loss. We have heard about, you know, people who have used ones on the market. They're very expensive. You've talked about coverage. There are a lot of people out there who are overweight and who are poor. The drugs might be a great deal for people who have that money sitting in the bank, but they don't have that money sitting in the bank. So how does it— how does your company go about balancing? On one hand, you want to and you deserve to get paid for for your innovation, but on the other hand, this is such a profound health crisis for so much of the country and the world. How do you get that to as many people as need it who might not have the means?

Yeah, you know, I think the first way is what I described before, which is create the information that allows decision makers who decide what's covered and what isn't, what's optional and what should be, you know, really an important health product, to have the best tools to do that. We're at the beginning of an era where maybe in 10 years' time, we'll think about obesity management, chronic weight management, just like we do hypertension today, right? The first thing that happens when you go sit in the room, even waiting for your doctor, is one of his assistants takes your blood pressure. And if you have high blood pressure, we treat it.

Why?

Because we know that that signal, that biologic signal, turns into chronic health disease that's very expensive, and very personally debilitating. We don't accept non-treatment. It's malpractice not to treat it, actually. And yet today, we walk into an office, and if someone is overweight, we think of that as something else. So, we have to prove clinically it's not something else. It is the same as hypertension. It is the same as other lab values we get where we say, "That's a problem. We're going to address it." Second thing we need to do is destigmatize treatment because A lot of people maybe think they can't afford it. They also think something else, which is if they go complain to their doctor and ask for medicine, they'll get blamed. And even when we interview doctors, they tell us more than half the time they don't think of obesity as a health condition that can be managed medically. They think it is a personal failing or people aren't trying hard enough. But there's plenty of evidence that— our own study, for instance— that diet and exercise that's strictly regimented, which we did for people who got placebo in our studies, so they're getting a saline water injection and following a calorie-reduced diet, exercising regularly, doesn't work. On average, people lost 5 pounds after 72 weeks versus 52 pounds on drug. That's the difference of the drug. This is not in their heads, they're not lazy, Their bodies are wired differently. They need help. And we live in an environment where everything wants us to feed more. It's easy to feed more. That was a survival benefit when we had famines and had trouble finding food. So we need to destigmatize. That's the second step. And then finally, I think we need to think about different models. You know, we think about drugs as something your insurance company will pay for or not, but maybe there's models in between. Total nonpayment like a cash market and full reimbursement, maybe depending on your risk profile, your goals, we could perhaps think about that. We've done some of this with insulin where there's been a lot of controversy about payment. We launched a so-called generic of our own product, same drug, same packaging, even slightly different name, much lower price on list. Now, why would we do that? It's because a lot of people were in an insurance program that wasn't paying much at all for their insulin, and it was actually cheaper to buy the drug outside the insurance program. We could do something like that in obesity, too, that might open up the aperture for people. And finally, we need to work with policymakers, because they're usually the slowest, to make Medicaid, which are, you know, some of the people you spoke about, truly poor. And actually, obesity has a higher incidence in the poor than the wealthy, which seems strange, at first glance, but is true in America. We need Medicaid to pay for these drugs. And that may require more of a population health idea that we go to states and say, how about we have you buy enough for your whole population and let's negotiate sort of a population price versus thinking about this as a one-by-one patient price. So we're open to all those ideas. And I think it's incumbent on us to not just innovate new great medicines, but new ways of getting them to patients.

Thank you, David. I asked David what Eli Lilly plans to do with all the cash that will soon be coming its way from sales of obesity drugs, and he mentioned reinvesting in the company's obesity portfolio but also in other treatments. And he highlighted treatments for Alzheimer's. Eli Lilly has recently announced progress on Alzheimer's treatments. I asked David, how close is the industry to making a profound improvement for those patients. And he said it's upon us if profound means potentially cutting the rate of progression by a third. Okay, that's a good place for a break. We're going to come back with more on obesity treatment back in a moment.

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Welcome back. Meta, I wonder if these obesity drugs are going to have some sort of big, you know, profound effect on society. You know, they're, they're effective for weight loss, but a relatively small number of people are taking them now. The people who take them lose a lot of weight. Presumably, if there is insurance coverage down the road, many more people will be taking them. That's certainly the hope of Eli Lilly and others. But what happens if so many people are taking these drugs? You read these stories and what people will say who have taken the drugs, they say, well, before I started taking it, I heard a lot of food noise. I was always thinking I would be driving and thinking, you know, I want to stop for tacos. And after I started taking the drugs, The food noise just stopped and then I would just sort of eat sensibly and I didn't need to make that stop for tacos on the way home. So what does that mean for companies that are in the taco business? What does it mean for companies that, um, that treat diseases that are related to obesity, high blood pressure or diabetes, or like even a company that makes artificial knees, right? Somebody who needs knee replacement in their older age. Well, are they as likely to need that knee replacement if they had treated an overweight condition earlier in their life and then had less stress on those joints? Do you think I'm overthinking this or underthinking this?

I think it makes a lot of sense. If 40% of the population is struggling with this and then one day they might not be, I mean, that might really change things.

Yeah. And I feel like so much of basic life is built around that number. Everything from the things people do for recreation, the way companies make their money, the different kinds of companies out there that make money from trying to treat these conditions now. And a lot of that could be— I think the word disrupted is often overused, but I think a lot of the way that money is made and life is lived in America and maybe around the world could be disrupted by this class of obesity drugs. I guess we'll have to see. We spoke with one business owner who is already seeing a profound change in her work because of this class of drugs. And her name is Annmarie Pham-Boo. And you might have seen her on TikTok.

The top 3 ways of addressing Ozempic butt or Ozempic face. So it's not that Ozempic is causing people to have Ozempic face.

I have a lot of follow-up questions about Ozempic butt, but there's no time now. I want to make sure I get Annemarie's credentials right. She goes by Dr. Phamboo on her website and on TikTok, but she clarified to me she's a nurse practitioner, which is someone who can prescribe medicine, and she has a doctorate degree in nursing, so it's not an MD. So let's get to her practice and what it looked like initially and what it looks like now. What were patients in the beginning when you start— when did you start? Like, how long ago? And what were the patients seeing you for initially?

In practice in general is, you know, looking more confident, beautiful in their skin. And it was Botox, fillers, and other aesthetic procedures that's going to help them enhance their face. So that's the initial things.

What percentage of your initial, you know, body of patients would you say were doing, we're looking for Botox or related treatments? 90%.

Okay. And now it's 90% weight loss.

Wow. That's a big change. And when did that happen?

COVID times, I think, about 2 years ago is when all of this all started. When, you know, things are opening back up, and people have a little bit more disposable income. And they're wanting to travel, spend more money, or to gain weight during COVID And yeah, then it all boomed from there.

COVID and the pandemic and staying at home might have gotten a lot of people thinking about their weight, but there was also this news in the background about new obesity treatments on the rise. I asked Annmarie, where are her patients hearing about these treatments?

TikTok. They're coming in and saying, oh, I heard— I saw Ozempic commercial. Oh, I heard something about the celebrity newest weight loss drug. Or they may not even know the name of it. And they're coming in with those requests, not specifically knowing a lot about it, but thinking that given that they've read about it and some people are on it, celebrities are on it, anyone should be on it. I think that's the misconception about the medications.

Annemarie says her typical patient is upper middle class or middle class and a woman and above 30. She says she sees some that are in their 20s that are curious,, but they're not financially able to start a program like hers, as she puts it. Annemarie says that she sees an overwhelming percentage of her patients in person for consultations. The drugs that we're talking about are injections. Annemarie says patients typically get their first injection in her clinic, and then they self-administer the rest at home. Annemarie doesn't accept insurance. She says that patients sometimes file for it by telling their providers about comorbidities, other health problems that they have that are related to their obesity. But to her knowledge, insurance coverage has been difficult to obtain.

If there is coverage, sometimes it's only 10% or 20% depending on your copay, and it's been costing them around $1,000 to $1,500 per month. And they end up coming back to us because it's a little bit cheaper than paying $1,500 a month.

Oh, I see. And how is it— how is it cheaper? Are you using the sort of branded off-the-shelf product? Are you using that product that has the chemical name and doing your own formulation? What do you do for these patients?

So we work with an FDA-approved compounding pharmacy. So the semaglutide or the tezepatide chemical form of it. So in that capacity, it allows us to be able to see patients We're not taking the drug away from type 2 diabetes patients, but it allows us to address obesity as a disease and something that could lead to other issues later on for the patient at a price that is not, you know, $1,500 a month.

Well, what would the price be? How much would it be for the version that you provide for people?

So we provide value. It's not just a medication because quite often we get people that will say, oh, I just want the meds. I went online, I got it for $299. I just want the meds. Yes, we're not just giving people the medication. We're giving them support, accountability, management of all their side effects because they're going on TikTok and YouTube trying to figure out how to manage side effects, which is irresponsible to be, you know, giving out those medications and not helping the patient understand those things. And we also emphasize a lot of lifestyle changes and, you know, diet changes and stuff like that because lifestyle changes is so important to ensure that these results are maintained and sustainable.

That is a lot to take in, so let me try to sum it up. And the subject seems a little fraught to me. Let's see if I can tiptoe through it. A compounding pharmacy— what is that? Well, the FDA on its website describes compounding as the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient. And it specifies compounded drugs are not FDA approved. There are reports on social media of patients getting obesity drugs from compounding pharmacies and paying $300 a month for drugs that they believe are as effective as those big name brand drugs that sell for $1,000 to $1,500 a month. I'm certainly in no position to evaluate what they're getting or how effective it is, Colin Bristow, that UBS analyst we heard from earlier, he says he doesn't factor in any impact from sales of compounded drugs into his earnings estimates for drug companies. As he puts it, there's FDA-approved drugs and then there's non-FDA-approved drugs. And so your willingness to subject your body to a sort of non-approved therapy for what is potentially sort of a lifelong treatment, I think it warrants some consideration. I think that's fair to say. Ann Marie says that she sells her suite of weight loss services for $850 a month. And if these compounded obesity drugs are out there for $300 a month, well, you can do the math yourself on the potential margins. Drug companies, as you might imagine, are not taking this lightly. Novo Nordisk, the maker of Wegovy and Ozempic, recently announced legal actions, quote, against certain medical spas, weight loss or wellness clinics, and compounding pharmacies to cease and desist from false advertising, trademark infringement, and/or unlawful sales of non-FDA-approved compounded products claiming to contain semaglutide. I reached out to Annmarie after our call to ask her about the action that Novo Nordisk is taking. In an email, she said that's in quote, reference to med spas advertising that they are doing Ozempic, but they aren't. She said of her medicine that it's a quote, compounded medication that has the same active. She also said it's proprietary to the pharmacy making it. During our original call, Annmarie had told me that she sometimes has the compounding pharmacy combine a weight loss drug with B12, a common vitamin. She says that's helpful for alleviating some of the side effects of the drugs. Again, that's not an FDA-approved therapy, and I have no idea how effective it is. Whatever you might think about this treatment model, Annemarie says it's been good for growth. Has, has there been a big increase in the number of patients?

Yeah, it's been a big increase as media talks more about it, or they're on Instagram or social media, they're seeing more of these discussions. And a lot of patients are coming in saying, oh, my friend said she was on it, so I want to find out how to get on it. So I would say about 700% growth in our practice in terms of inquiries and leads.

Over what time period, a 700% increase?

Over a year and a half.

Oh my goodness. That's— it must be hard to keep up with that increase.

Yes. Given how involved our program is, you know, it's a lot of hands-on.

Have you had to expand at all? Have you had to get some additional help?

Yeah, we've had to get a few nurses to help out with, you know, supporting our patients, especially on our online platform.

Oh, how many people work for you altogether now?

4.

4. Wow. Meta Annemarie told us about a patient who had lost a staggering amount of weight. How many pounds was it?

I think 160 pounds in 18 months. The emotional transformation is what's most impactful to us because they have been working on this for probably 20 years to try to lose some weight. It's just a mindset shift. There's that thing that it creates for the patient where they see more opportunities in life. Like, I I can wear this type of outfit, I feel like I can travel more. There's that motivation to do more things because they feel more confident in themselves.

I mean, think of that. This is the part of the podcast where I tell people don't go this route, and I am telling people that. I mean, I'm, I'm a cautious person when it comes to this stuff. Um, I don't understand, frankly, the— not just the medical science here, the, the legality and so forth. Um, so I would say get a branded drug, go the traditional route, get— go for something with that FDA approval, of course. But at the same time, Ann Marie said this woman had tried for 20 years to lose weight. And think of what it is to carry 160 pounds for 20 years. And there are people out there who are going to need these drugs and who can't afford them. Where does that leave us? I'm not saying to go some alternate route. I'm just saying it is going to be profoundly important for these drug companies to figure out a way to make these things affordable for the people who need them who don't have the means. For some people, that, that extra $1,000 a month, that's rent. And that's going to matter a lot if there's not going to be some kind of ongoing gray market for these medicines, I would imagine. Thank you, Anne-Marie. And And thank you, David and Colin, and thank all of you for listening. If you have a question that you'd like answered on the podcast, just tape it on the voice memo app on your phone, send it to jack.hough@barons.com. Meta Lutzoff is our producer. You can subscribe to the podcast on Apple Podcasts, Spotify, or wherever you listen. And if you listen on Apple, please write us a review. See you next week.

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