Some healthcare providers are becoming more comfortable prescribing compounded alternatives to popular weight loss medications like Wegovy and Zepbound, despite ongoing concerns from others about the ingredients used in these formulations.
Obtaining these weight loss drugs has proven difficult, even with a prescription, due to their high cost—exceeding $1,000 for a month’s supply—and frequent shortages.
Compounded versions of semaglutide (the active ingredient in Wegovy) and tirzepatide (found in Zepbound) are often more affordable and readily available.
“Physicians are not only increasingly willing to prescribe compounded GLP-1 medications, but they are also advocating for their use,” said Dr. Shauna Levy, an obesity medicine specialist and medical director of the Tulane Bariatric Center in New Orleans, referring to the drug class that includes Wegovy and Zepbound.
At Duke Health’s Hillsborough Primary Care Center in North Carolina, providers have been prescribing compounded versions of these drugs during brand-name shortages.
Leanne Owens, a physician assistant at the clinic, began prescribing compounded versions of these weight loss medications to 10 of her patients after the state ceased covering the brand-name drugs for state employees in April.
Initially hesitant about prescribing compounded medications due to her lack of experience, Owens felt reassured after consulting with a compounding pharmacist at Duke.
“Is this truly the same medication? Is the formula identical to that used by commercial drug manufacturers?” Owens recalled questioning. “Whenever we consider a new treatment for patients, we want to ensure we’ve done our due diligence.”
Owens isn’t the only one; other members of the medical practice have also turned to compounded weight loss medications.
Understanding Compounding
Compounded drugs are used for various reasons. A compounding pharmacy can alter a drug that only comes in tablet form into a liquid for patients who can’t swallow pills, or remove a specific dye if a patient is allergic to it.
Compounding is also useful during drug shortages: The Food and Drug Administration permits compounded versions that are “essentially a copy” of commercially available drugs under certain conditions.
Semaglutide for weight loss has been in short supply since 2022, according to the FDA’s drug shortage database. Tirzepatide, approved for weight loss in the U.S. only in November, went into shortage in April and remains in shortage.
Both drugs are under patent, and their manufacturers, Novo Nordisk and Lilly, do not supply the ingredients to external parties, raising concerns about the authenticity of what is being sold to consumers.
Compounding pharmacists typically source their ingredients from FDA-registered facilities, which cannot purchase the active ingredients directly from the drug manufacturers.
These facilities can replicate or produce the necessary active ingredients, according to the FDA. However, unlike generic drugs, the FDA does not test or verify these ingredients; that responsibility falls on the pharmacists. Experts recommend that doctors prescribe compounded drugs only from trusted compounding pharmacists, and patients should obtain prescriptions from their doctors and fill them at state-licensed pharmacies, avoiding online purchases or med spas.
It is also crucial for providers to instruct patients on accurate dosing. Last month, the FDA reported instances of patients overdosing on compounded semaglutide, leading to hospitalizations. The overdoses were attributed to patients incorrectly measuring and administering doses, as well as providers miscalculating dosages.
Matthew Brown, the pharmacy manager at the Duke Compounding Facility, stated that the center uses only state-licensed pharmacies vetted by Duke to compound medications it doesn’t produce itself, including semaglutide. The center provides compounding services for Duke’s entire health system, including the Hillsborough Primary Care Center.
Brown noted that Duke prescribes compounded weight loss medications only during shortages, switching back to brand-name drugs once availability resumes.
Owens, the physician assistant, expressed confidence that the compounded versions are the same as the brand-name medications, citing patient weight loss without an increase in side effects.
Elizabeth Kenly, 58, of Graham, North Carolina, was prescribed a compounded version of tirzepatide by a doctor at the Hillsborough practice in March after struggling to find Wegovy due to shortages. Since starting the compounded medication, she has lost 25 pounds and aims to lose another 25.
“I was initially apprehensive, wondering, ‘What is a compounded medication?’” Kenly said. “But after discussing it with my doctor, I felt much more comfortable.”
Concerns Persist for Some
Despite the growing acceptance among doctors, Novo Nordisk and Eli Lilly remain firmly opposed to the use of compounded weight loss medications.
Both companies have filed multiple lawsuits against compounding pharmacies, weight loss clinics, and medical spas. In statements to NBC News, the drugmakers emphasized that compounded drugs lack the oversight of FDA-approved medications, posing risks to patients.
A spokesperson for Novo Nordisk criticized the compounding system as “not functioning as intended.”
“Novo Nordisk will continue to pursue legal action against compounding pharmacies and other entities engaged in the unlawful marketing and sale of unapproved compounded ‘semaglutide’ drugs,” the spokesperson stated.
Lilly spokesperson Antoinette Forbes said, “Poison control centers, regulators, and patient advocacy groups nationwide are issuing warnings about the use of compounded anti-obesity products.”
Many doctors remain cautious as well.
“In theory, if everything is done correctly, it could be a viable product. But the challenge is that many things could go wrong,” said Dr. Scott Isaacs, president-elect of the American Association of Clinical Endocrinology. “While more doctors may be prescribing it, from an organizational and professional standpoint, there are increasing warnings.”
“Not everyone is likely following the same rigorous standards as Duke,” Isaacs added.
Dr. Christopher McGowan, a gastroenterologist who operates a weight loss clinic in Cary, North Carolina, said he frequently encounters patients who have used compounded weight loss drugs. However, he remains “very hesitant” to prescribe them himself.
“In my opinion, there are still too many uncertainties surrounding compounded versions of semaglutide and tirzepatide,” McGowan said. “Regardless of whether a pharmacy is accredited, the compound itself is not monitored, regulated, or tested by the FDA. Patients cannot be certain of what they’re receiving or if it’s equivalent to a brand-name drug.”
Dr. Daniela Hurtado Andrade, an endocrinologist at the Mayo Clinic in Jacksonville, Florida, noted that she’s increasingly seeing patients who have already started on compounded versions of these drugs. However, she often recommends alternative weight loss treatments—such as combination therapies like phentermine and topiramate (marketed as Qsymia) or naltrexone and bupropion (marketed as Contrave)—when brand-name drugs are unavailable.
“People are fixated on the idea that the only effective treatments for overweight and obesity are these new injectable medications. This is far from true,” Andrade said. “There are other anti-obesity medications that are also effective and more affordable.”