Key Questions About Pharmacological Obesity Therapy

When Are Weight Loss Medications Prescribed?

Prescription of medications for obesity therapy in adults is recommended in two cases: if body mass index (BMI) exceeds 30 kg/m² or exceeds 27 kg/m² with risk factors and comorbidities present. These include arterial hypertension, dyslipidemia, type 2 diabetes mellitus, and non-alcoholic fatty liver disease.

Pharmacological therapy is used in combination with lifestyle modification and does not replace but rather complements dietary habit correction and physical activity. According to clinical guidelines of the Russian Ministry of Health for treating obesity in adults, therapy is effective and may be continued only if body weight decreases by at least 5% from baseline during the first 3 months.

Are Original Modern Medications Available in Russia?

Only analogs of all three modern obesity medications are available in Russia. These include, first, analogs of glucagon-like peptide-1 (GLP-1, produced in the small intestine and a natural appetite regulator), such as semaglutide and liraglutide. Second, dual-action medications, GLP-1 and glucose-dependent insulinotropic polypeptide receptor agonists. Only one representative of this group is currently used in Russia, tirzepatide. Let's explain why original modern obesity medications cannot be purchased in Russia.

Injectable semaglutide (Ozempic), developed by Danish company Novo Nordisk, was registered in Russia in 2019, but was intended for type 2 diabetes therapy, not weight loss. Nevertheless, in various countries worldwide where semaglutide was registered at that time, it was used off-label (unofficially) for obesity due to a "fortunate" side effect consisting of satiety sensation and prolonged food digestion.

In 2021, Novo Nordisk registered a second injectable semaglutide product in the U.S. and EU specifically intended for obesity treatment, Wegovy. But it never came to Russia, and in 2022 the company decided to cease Ozempic supplies to the country as well. However, supplies of tablet-form antidiabetic semaglutide, the drug Rybelsus, continue.

Because semaglutide is included in the list of vital and essential medications, in late 2023 the Russian government decided to grant two domestic companies compulsory licenses to manufacture and market Ozempic analogs. Others soon joined, and Russian pharmaceutical manufacturers began offering consumers Wegovy analogs, medications aimed not at treating diabetes but at obesity therapy.

What Are the Side Effects and Complications?

Weight loss medications can cause side effects, including serious ones. For example, orlistat in some cases causes liver damage, so individuals with liver disease need to use it cautiously and under strict medical supervision, or not use it at all. Sibutramine use is characterized by unjustified risk for consumers with cardiovascular disease, which led the U.S. and Europe to ban its sale in 2010.

One risk of semaglutide use is exacerbation of diabetic retinopathy in patients with type 2 diabetes. Additionally, the original semaglutide instructions contain warnings about pancreatitis, acute gallbladder pathology, and acute kidney injury. Also in 2024-2025, data appeared regarding a possible causal relationship between semaglutide and suicidal thoughts, but there is no evidence for this, and U.S. and European Union regulatory agencies deemed these claims unfounded.

But there's another problem related to GLP-1 agonist popularity and uncontrolled use, that is, without physician prescription. When purchasing medication without prescription, there's risk of receiving poor-quality, spoiled, or counterfeit medication with unpredictable effects.

What Additional Effects Beyond Weight Loss Does Pharmacological Therapy Provide?

All benefits are in some way connected to weight reduction. First, this is cardiovascular risk reduction, noted in semaglutide and liraglutide studies. In people with prediabetes, long-term therapy reduced risk of progression to type 2 diabetes and improved metabolic parameters. Additionally, GLP-1 medication trials are currently underway regarding psoriatic arthritis treatment.

Tirzepatide, in turn, can reduce the apnea index in adults with obesity. Cases are also known where injectable obesity medications helped patients become pregnant, but this is probably primarily a consequence of excess weight loss rather than medication use per se.

Who Is Suited for Which Medication?

It depends on the patient's baseline health parameters and degree of obesity. The physician evaluates body mass index (BMI), cardiovascular risk, presence of diabetes (or prediabetes), mental state, and reproductive plans.

Can Foreign Patients Obtain Russian Medications?

The patient schedules an appointment with an endocrinologist at a private or public clinic. The physician evaluates BMI, blood pressure, obtains medical history, and orders standard testing including blood work, glucose, HbA1c, lipid profile, TSH, liver enzymes, ECG, and in women also pregnancy test. If medication prescription criteria are met, the physician selects medication and writes a prescription for purchase. Follow-up examination at 3 months: if weight has not decreased ≥5%, the course is changed or discontinued.

Pharmacotherapy in Russia can also be undertaken as preparation for bariatric surgery. Extended diagnostics are performed beforehand, ultrasound, upper endoscopy, spirometry, consultations with cardiologist, psychiatrist, anesthesiologist. Medications at this stage (more often semaglutide or tirzepatide) help reduce surgical risk. After surgery, remote monitoring by a Russian physician is welcomed.

What Is the Future of Pharmacological Obesity Therapy?

It lies in treating comorbidities, cardiovascular risk, heart failure, kidney disease, fatty liver disease, and others. New drug classes are currently being developed, dual and triple hormonal receptor agonists, oral analogs of injectable medications, combinations with amylin. The advantage of such medications is that they target multiple pathways simultaneously, reducing appetite, accelerating energy expenditure and fat burning, controlling blood sugar and lipids. Due to this synergy, they typically produce greater and more sustained weight loss.

Additionally, research is currently underway on weight reduction agents for people without formal obesity (below 30 kg/m²) but with high cardiovascular risk. Among new approaches are hydrogel-based tablets that create satiety sensation without hormonal effects, as well as medications that restore metabolic health rather than simply reducing weight. This expands therapy potential for patients whose need for weight loss relates more to risks than to classic obesity.

Another development direction is medication form. One significant barrier to prescribing injectable forms is the need for injections, so there's competition among development companies for the tablet formulation market. This is important for extending obesity therapy coverage to patients who fear injections. Such a solution will make obesity therapy more accessible and convenient, expand treatment coverage, and increase adherence, ultimately improving outcomes and quality of life for people suffering from excess weight and related diseases.

EXPERT COMMENTARY

Yuri Poteshkin, MD, PhD
Neuroendocrinologist, Healthcare Organizer, Preventive Medicine Specialist at Atlas Clinic Network

Pharmacological therapy for excess weight and obesity is an effective approach in most cases. However, there's a patient category that can immediately be advised another treatment type, surgical. These are people with BMI 35 and above. Most likely in their case, treatment with injections and tablets will be minimally effective or completely ineffective, and in this case it's better to immediately resort to bariatric operations.

This is a faster-acting method, but it's associated with greater risks, because part of the organ is removed, future vitamin and nutrient absorption may worsen. Additionally, rehabilitation is required after surgery, regular physician monitoring is necessary, including from the standpoint of correcting possible deficiencies. Compared to bariatrics, pharmacological therapy is tolerated more easily, more calmly, but physicians usually prescribe it for first-degree obesity, and for second and third degrees advise surgery. But all of this is decided individually, of course.

Vladislav Davydov, MD, PhD
Deputy Chief Medical Officer for Surgery, Director of Bariatric Surgery Center at SM-Clinic

Pharmacological therapy is indispensable in two key situations: first, for patients with early-stage obesity when health status requires weight loss but indications for surgery don't yet exist. Second, for correcting weight regain or recurrence of comorbidities after bariatric interventions. About 25-30% of patients encounter this problem after sleeve gastrectomy and 10-15% after bypass operations in the long term (5 years and beyond). In their case, medication use is absolutely justified and effective. There are also limitations of pharmacological therapy: first, the necessity of continuous use.

After discontinuation, weight returns in most cases. Second, high discontinuation rates. About 70-80% of patients discontinue therapy within two years due to side effects. Third, cost. Long-term medication treatment proves more expensive. Fourth, efficacy. Even the most modern dual agonists demonstrate 20-22% weight loss from baseline, while bariatric surgery allows achieving 25-35% loss of initial body weight. And let's not forget that incretin receptor agonists have been on the market for about 10 years and even long-term results of their clinical use are still insufficient.

Thus, surgery today remains the more effective method. Medications are not yet a full replacement for surgery. But the global trend is such: patients now often come to us having already had unsuccessful experience with pharmacological therapy. And I consider it correct that the medical community is beginning to raise alarm regarding uncontrolled use of these agents. Bariatric surgery is a serious step, and its risks must be justified. The indication for it is obesity itself, not the desire to lose weight at normal weight. The health threat from excess weight must objectively exceed the risks of the surgical intervention itself.