Studies Highlight Rapid Growth of Semaglutide Use, Risks of Some Online Sources

Prescription fills for semaglutide—sold under trade names Ozempic, Wegovy, and Rybelsus (Novo Nordisk)—have skyrocketed in recent years in the United States, even in the face of ongoing shortages. Still, some are seeking out sketchy online sources to get the drug and that may be putting them at risk.

According to a research letter published in JAMA Health Forum, the number of prescriptions for the glucagon-like peptide-1 (GLP-1) receptor agonist jumped by 442% from 2021 to 2023. Most were for Ozempic (indicated for the treatment of type 2 diabetes), although the largest percentage increase occurred for Wegovy, which has become popular due to semaglutide’s weight-loss effects. Commercial insurance covered the majority of the prescriptions, with fewer covered by Medicare and Medicaid.

Another research letter, this one published in JAMA Network Open, highlights the risks associated with trying to obtain semaglutide without a prescription from online sellers. Only three of six orders were actually delivered and there were signs of safety concerns with the medications that did show up.

Together, the studies speak to the fact that semaglutide and similar medications—which currently carry high costs—are potentially inaccessible for many people, Christopher Scannell, MD, PhD (University of Southern California, Los Angeles), lead author of the first report, told TCTMD.

“In our paper, we're very much looking at patterns of people who are safely able to get the medication, with that pointing to disparities in access,” he said. “This other paper really shows what happens if people can't work within the confines of insurance and have to find some other way of getting access to this medication and how dangerous that might be.”

Fills Vary by Insurance Type

For their study, Scannell and his colleagues used IQVIA’s National Prescription Audit PayerTrak, which captures 92% of prescriptions filled and dispensed at retail pharmacies across the US.

Between 2021 and 2023, prescriptions for the various formulations of semaglutide increased from 471,876 to 2,555,308, with Ozempic accounting for more than 70% of fills. Over that span, Ozempic prescriptions increased by 392%, whereas from July 2021 (a month after Wegovy was approved for chronic weight management) to the end of 2023, Wegovy prescriptions spiked by 1,361%.

“We knew it was going to be large, but we didn't know it was going to be quite that large,” Scannell said about the increase.

A rising number of prescriptions was observed across insurance types, with commercial payers covering most of them—61.4% for Ozempic, 89.5% for Wegovy, and 58.1% for Rybelsus. In 2023, Medicare Part D covered 28.5% of prescriptions for Ozempic, 32.9% for Rybelsus, and 1.2% for Wegovy. Medicaid coverage accounted for less than 10% of fills.

“There's disproportionately high levels of obesity and diabetes in patients that have Medicare or Medicaid, and so you have a population that potentially needs those medications even more so and that just doesn't have the same access to it as those patients with private insurance,” Scannell said. He predicted, however, “that access will increase over time as the preponderance of evidence grows for the health benefits of semaglutide.”

Beware of Sites Selling No-Prescription Semaglutide

In the other study, researchers led by Amir Reza Ashraf, PharmD (University of Pécs, Hungary), explored what risks might be encountered by people who, for whatever reason, are seeking out online sources of semaglutide sold without a prescription. Regulators around the world, they note, have issued warnings about illicit versions of the drug that have cropped up in response to high demand and high prices, as well as shortages.

“Illegal online pharmacies, which operate without valid licenses and sell medicines like semaglutide without prescription, represent a consumer risk for ineffective and dangerous products,” Ashraf et al write.

The investigators performed a search online to find websites offering semaglutide without a prescription, initially finding 1,080 sites. Of those, 317 were online pharmacies, 42% of which were being illegally operated.

If it's too cheap to believe or it's too good to be true, it's usually not the product that you're looking for. Tim Mackey

The researchers then performed test buys of semaglutide from six of the illegal pharmacies that had been classified as “not recommended” or “rogue” by LegitScript and/or the National Association of Boards of Pharmacy, with prices for the smallest quantity and dose ranging from $113 to $360 (in US dollars). Only three orders showed up, with the other sites running nondelivery scams that involved asking for additional payments to purportedly help the shipments clear customs.

A visual inspection of the vials that were delivered revealed signs of possible counterfeiting or falsification, “with clear discrepancies in regulatory registration information, accurate labeling, and evidence products were likely unregistered or unlicensed,” the authors write.

Testing the contents of the vials showed that one sample had elevated endotoxin, indicative of “possible contamination, although no viable microorganisms were detected,” the researchers report.

All contained semaglutide but the purity levels were far below genuine Ozempic (7%-14% versus 99%). Moreover, the amount of semaglutide contained in each vial exceeded the labeled amount by 29% to 39%.

“Whenever you have a drug like a blockbuster drug like the GLP-1s that were coming out or any other type of drug that becomes popular, we just know that a counterfeit market's going to develop around it,” study co-author Tim Mackey, MAS, PhD (University of California San Diego, La Jolla), told TCTMD. “So what you're seeing here is just another market that is created because there's so much demand around these products. And these markets tend to be very adaptive. . . . They meet [consumers] with lower cost and more convenient options, but of course they're unsafe.”

He added, “If it's too cheap to believe or it's too good to be true, it's usually not the product that you're looking for.”

Speak to a Pharmacist or Physician

Commenting for TCTMD, Craig Beavers, PharmD (Baptist Health Paducah, KY), said he expects demand for semaglutide and other GLP-1 receptor agonists to continue to grow as more and more data showing improvements in cardiorenal metabolic risks come out.

In that context, “it’s going to be more and more prudent to figure out how to make sure we have equitable access to them and make sure that [their use is] appropriate and safe,” he said. There is a need, he added, to better understand “how we become stewards of these agents to create health equity.”

The study of obtaining no-prescription semaglutide from illegal online sellers, Beavers said, “underscores the importance of understanding where you’re getting your therapy and not just accepting it because it’s available. . . . There’s a reason that there are processes and regulations in place to try to mitigate or limit the risk.”

Patients who buy drugs from these sources are at risk for receiving a dose higher than what’s expected, which could lead to adverse events, but there’s also a risk of harmful interactions with other medications they might already be taking, Beavers said.

Drug shortages that may drive patients to look for online sources are frustrating, but it’s critical to “look at the safety and the sourcing and how you’re getting the therapy and not just take a chance on someone that potentially could be doing a money grab,” he said.

Beavers said the biggest take-home message is: “Don’t take a risk, include your healthcare providers, and ask questions.”

Mackey agreed that having a discussion with a clinician is important when using these agents. “It's really crucial that you talk to a clinician and your physician first to see even if this drug is appropriate for your use,” he said. “That's why physicians and pharmacists exist—they're there to protect us and make sure that we appropriately use medications.”