Sept. 16, 2024 – Tiny bottles of the weight loss drug Zepbound have started arriving in mailboxes across the country. People who order the medicine directly from drugmaker Eli Lilly can pay much less for the newly available vials, compared to prefilled pens they get at a local pharmacy.
But the move to self-administration with a syringe and needle, just like how insulin is often taken for diabetes, means a whole new set of people will be learning the sometimes intimidating skill. Doctors experienced in teaching patients how to do this say there are some key considerations that can help make the first time successful and less stressful.
Alongside the growing popularity of weight loss drugs, safety concerns have regularly come up, including federal warnings about accidental overdoses and hospitalizations, and a steep increase in calls to poison centers after people took doses of a similar drug too closely together or took more than recommended.
“Unfamiliarity with withdrawing medication from a vial into a syringe and coupled with confusion between different units of measurement (e.g., milliliters, milligrams and ‘units’) may have contributed to dosing errors,” the FDA warned in July, referring particularly to reports from people taking substitute, compounded versions of weight loss drugs. The FDA urged health care providers to help patients select the correct syringe size and teach them how to measure a dose.
So far, Eli Lilly has only released the two lowest doses of Zepbound in vials, but at a significant savings for people without good insurance coverage. The medicine will still be expensive, costing around $7,000 for a year’s supply, but the price could amount to thousands of dollars in savings for many people. And the vials are direct-pay only, meaning people can’t use insurance to pay, and they must fill their prescriptions through the drugmaker’s own LillyDirect Cash Pay program.
In Canada, where the diabetes version of Zepbound, called Mounjaro, is available in vials, there haven’t been any marked safety concerns, said Lawrence A. Leiter, MD, a professor of medicine and nutritional sciences at the University of Toronto. Both Zepbound and Mounjaro have the same active ingredient called tirzepatide.
“This has not been an issue at all. I have not had a single patient who declined a Mounjaro prescription because of the need for vial and syringe administration and have not seen (or heard of) any dosing errors related to this mode of administration,” he said in an email.
Whether you're being prescribed Zepbound during an in-person or telehealth visit, experts have a few suggestions on how to safely make the switch or learn to use the medicine in vials.
Tips for First-Time Vial Users
For people considering using Zepbound in vials who don’t have syringe-and-needle experience, watching a video or reading a pamphlet may be enough to guide them confidently toward a safe and successful first injection. Eli Lilly includes instructions in the package containing the vials and has posted instructional videos online.
But for many people, having a personalized demonstration or in-the-moment assistance with the first injection is helpful.
“I have younger, tech-savvy patients who might feel comfortable with a video link I might send them and the instructions that I give them, and then I have other people who may need an office appointment with a nurse or someone in the pharmacy to provide some teaching,” said Wudeneh Mulugeta, MD, MPH, an obesity medicine specialist at Cambridge Health Alliance in Massachusetts, and also a Harvard Medical School instructor.
Some patients feel confident with being instructed during a virtual visit, he said, noting that telehealth platforms are also well-positioned to support patients learning to do injections.
At 9amHealth, an independent telehealth service that is also partnered with Lilly Direct, patients are offered a variety of support.
“Drawing something up from a bottle, for some reason, can feel very, very intimidating for most people if they have not done it before,” said Avantika Waring, MD, chief medical officer for 9amHealth, which specializes in cardiometabolic and obesity care. Waring also maintains a small endocrinology practice in Seattle.
“Because it’s a once-a-week injection and you have control over when you do it, our team will offer to hop on a quick Zoom call, and you can actually walk someone through it while they’re doing their first shot,” she said. “It’s like there’s somebody there. We have patients who just want to be on the phone with you while they do it.”
The early days of the COVID-19 pandemic, which moved many aspects of health care to a virtual setting, really helped make virtual support and instruction more effective, particularly when teaching people to take insulin for the first time, Waring said.
“You can’t physically put your hand on the patient on Zoom, but there’s so much you can do. You can demo on yourself on camera,” she said, acknowledging that holding a one-week supply of medicine in your hand worth hundreds of dollars plus a sharp needle can feel intense.
“We tell people, ‘You can do this,’” she said.
It’s best to plan ahead to set that teaching or support session up in advance, but there are also resources for anyone who is holding that vial for the first time and suddenly realizes they’d like some help. Eli Lilly provides a toll-free number in the package insert, and that line is answered by agents trained by the Lilly medical team who can help talk a patient through the process.
In deciding to offer Zepbound in vials, the company leveraged its experience with its insulin products, many of which come in vials, said Rhonda Pacheco, PharmD, who is a group vice president for Eli Lilly’s U.S. Cardiometabolic Health division, based in Indianapolis.
“They are single-dose vials, and so I think when people think of big vials of insulin, they are probably thinking of the big ones that have multiple doses,” she said. “These are smaller vials. It’s a single dose, so there’s less confusion.”
The mailed vials arrive at people’s homes with detailed instructions, and for $5 more, Eli Lilly will include a month’s worth of needles and syringes.
While the single-dose vials are intended to reduce measurement errors, having the right-size syringe and needle is important, Waring said. Prescribers also write prescriptions for syringes and needles.
“When you give someone a really big syringe, and they’re pulling up a tiny amount, it’s hard and it looks weird, and it feels wasteful because you have this huge thing of plastic,” Waring said. “When you’re pulling up Zepbound from vials, I think it’s 0.5 milliliters, so you want to give a small syringe so you can visually see it coming out.”
Needles are not necessarily one-size-fits-all.
“With the needle gauges, there’s the thinnest needle gauge that you can barely even feel, and that’s generally what we start with,” Waring said. “Some people actually like to have a slightly larger needle, especially people in bigger bodies. They actually feel like with the small, very thin needle, they can’t see it, they can’t feel it, and they want to feel something because they feel more confident knowing that it got in.”
“Those are things as a clinician, you learn with experience,” she said. “You shouldn’t be on your own as a patient trying to navigate that.”
Are Other Doses on the Horizon?
Pacheco said the rollout of vials is going well.
“I can’t share exact numbers, but every day, there are more and more, so we are getting the operational piece down and the product is out,” she said, stopping short of saying when or whether the additional, higher doses will be made available in vials.
“We had to start somewhere, so we started with 2.5 and the 5 milligram,” Pacheco said. “We will consistently assess for the future higher doses, et cetera, but right now, there is no exact date that I can provide.”
So far, Eli Lilly has started selling a month’s supply of the 2.5-milligram starter dose for $399, and a month’s supply of 5-milligram vials for $549. The medicine comes in several higher doses (up to 15 milligrams), but those remain available only in prefilled pens, which can cost up to $1,060 out-of-pocket monthly.
Zepbound only fully came off the official FDA drug shortage list less than 2 months ago. Taking any of the new weight loss drugs – like Zepbound, or a similar one called Wegovy – has required navigating many hurdles, from patchy insurance coverage to supply issues to out-of-pocket costs that are well beyond many people’s budgets.
Mulugeta, of Cambridge Health Alliance, said the new Zepbound discount may not be enough for many of the people who are most at risk of obesity.
“It is a good step in expanding access to effective obesity treatment options to more patients, but more such actions and steps are needed, as this will not be enough to meet the needs of, particularly, economically disadvantaged or low-income patients, who are at higher risk of obesity and obesity-related metabolic conditions,” he said.
People typically increase their dose of Zepbound very gradually, which can help lessen side effects. Some people don’t reach their long-term or maintenance level until 9 months after starting the treatment. The shortages earlier this year sometimes only affected specific doses, and rather than skipping a weekly shot, some people found other workarounds, such as buying substitute compounds, which are sometimes cheaper but the FDA has warned may be dangerous. Another practice has been to break open larger-dose pens and transfer the medication to vials.
Aja Beckett, a 42-year-old app developer in Oregon, resorted to buying higher-dose pens of Zepbound than what she needed in order to ensure supply shortages wouldn’t impact her treatment. She was first prescribed Wegovy in January but couldn’t fill the prescription due to shortages. She switched to Zepbound, and since then has lost 60 pounds. She takes 10 milligrams per week but buys the 15-milligram pens and transfers the contents to vials.
“My initial doctor at PlushCare [a telemedicine platform] approved it,” Beckett said. “She was concerned, but we had a good conversation about it. After we talked through the details, she said she felt comfortable trusting me to do it myself. She did quiz me on the math to make sure that I could do it safely.”
The telehealth platform has since stopped taking her insurance, and now she gets her monthly prescription from a brick-and-mortar, quick-service retail clinic near where she lives.
“I never would have considered myself somebody who would do a self-injection in the first place,” said Beckett, who has launched a side project app called Shotsy that helps people track their side effects from GLP-1 medicines, and also estimates varying drug concentration levels over time.
“I never thought I would do anything like DIY-ing the dosage myself. This is a bit out of character for me. I’m very pro-science, pro-medicine, and I like following instructions.”
Beckett said she would be interested in buying vials, if her dose became available.
“It’s two things. It’s the cost savings, and it’s just being able to control your titration schedule without having to jump through the prescription hoops every month,” she said. “A lot of people end up wanting to stay at a certain level or go up to a higher level, but then they have to wait several weeks because it doesn’t necessarily coincide with that they have in their fridge.”
When you’re splitting pens or when you have a vial, she said, you can choose how much you draw. “If you feel like you need to stay on a lower dose longer, you don’t have to go through several appointments or a trip to the pharmacy to make that decision,” Beckett said.
It also helps ease some of the stress about potential shortages, because if you have a box of 15-milligram pens in your fridge and you’re only taking 5 milligrams a week, you’ve got some time before you need to find another box, she said.
Waring, of 9amHealth, said her own patients have asked about such practices, and she understands their desire to try to find workarounds for access issues like high cost and shortages.
“The stability of supply is really, really important, not only psychologically but also metabolically. You don’t want to be going on and off the medication, it’s not great for your body,” she said, adding that people stockpiling the medicine can also contribute to shortages and that being honest with your health care provider is a matter of safety.
“This isn’t really a new phenomenon,” Waring said.
Patients taking insulin who have high deductibles will often ask to use vials until they run through their deductible. And then, when their insurance coverage kicks in, to start help covering costs, they are willing to use the more expensive pens.
“This is just the start,” said Waring, cautioning that she has no insider information and is just as curious as everyone else about the potential availability of higher doses of Zepbound in vials.
“It would be nice if we could have consistency, so if someone is on a vial, that they could continue using the single-use vials through all their doses, but we’re just not there yet,” she said.
You can reach your local poison center by calling Poison Help at 800-222-1222. To save the number in your mobile phone, text POISON to 301-597-7137.
