Nearly half of online pharmacies selling weight loss drugs are operating illegally, study finds

Consumers who try to buy popular weight loss drugs online without a prescription risk being scammed or receiving unsafe products, a new study shows.

About 42% of online pharmacies that sell semaglutide, the active ingredient in Novo Nordisk’s anti-obesity drug Wegovy, are illegal, operating without a valid license and selling medications without prescriptions, according to a study published Friday in JAMA Network Open.

People who shop online for weight loss drugs “face serious consumer risks” of receiving “ineffective and dangerous products,” said Tim Mackey, an author of the report and professor of global health at the University of California, San Diego, as well as the director of the Global Health Policy and Data Institute. The study also included researchers from University of Pecs in Hungary.

Shortages of the popular weight loss medication, which belongs to a class of drugs called GLP-1s, have led to “a black market of illegal knockoffs,” said Dr. Christopher McGowan, the founder, medical director and research director of True You Weight Loss, a weight loss clinic in Cary, North Carolina.

“This is absolutely terrifying,” said McGowan, who wasn’t involved with the research. Illegal pharmacies are “exposing patients to risks related to unregulated, low-quality, potentially contaminated products. The average person cannot be expected to safely navigate this online medication minefield, which is why it’s best to stick to brand-name, FDA-authorized medications,” he said.

The popularity of semaglutide has surged in recent years, with more than 2.5 million prescriptions filled in the U.S. by December 2023, according to a separate study published Friday in JAMA Health Forum.

Manufacturers can’t keep up with the demand for drugs, which can cost up to $1,300 a month out of pocket, and many who can’t find the drugs in their local pharmacies turn to online vendors and telehealth.

Many shop online for semaglutide, which is also sold as Ozempic to treat Type 2 diabetes, because their insurance plans won’t pay for the injections or because their doctors won’t write them a prescription, Mackey said.

Medicare doesn’t cover the drugs when prescribed for weight loss, and many state Medicaid plans heavily restrict coverage. Most people who receive GLP-1 prescriptions have private insurance, according to the JAMA Health Forum study.

“It is no shock that people would turn to the internet for alternatives,” McGowan said. “Unfortunately, this is where unscrupulous purveyors are preying on the desperate.”

Illegal pharmacies pose safety risks

In Mackey’s study, he and his colleagues tested samples of semaglutide ordered from six online pharmacies for quality and safety.

Two of the online pharmacies had received warning letters from the Food and Drug Administration within the last year for unlawful sale of unapproved and misbranded semaglutide.

One vial of semaglutide had high levels of endotoxin, a toxin found in bacterial cells, although researchers didn’t find any live bacteria that could cause infection. Being injected with endotoxin, which may have come from environmental contamination during manufacturing, can make people feel sick.

The online purchases sampled in the study contained up to 39% more semaglutide than what is indicated on label, which could result in an overdose.

Overdosing on semaglutide can cause severe nausea and vomiting, as well as dangerous drops in blood sugar, which can lead to fainting, according to the FDA.

From January to November 2023, control poison centers across the U.S. reported nearly 3,000 calls involving semaglutide, a more than 15-fold increase since 2019. Most overdoses resulted from dosing errors made by consumers injecting themselves with the drug.

Wegovy and Ozempic, both made by Novo Nordisk, are sold in injection pens that are relatively easy to use. Off-brand versions of semaglutide — which can come from compounding pharmacies or the online pharmacies examined in the study — often come in vials of liquid that require consumers to fill a syringe with the correct dose.

On its website, Novo Nordisk says patients can spot counterfeit medications by looking for certain telltale signs, such as packages with spelling errors or which are unsealed, or prices that seem too good to be true.

In a statement, a company spokesperson said that patients should be aware that Novo Nordisk is the only drugmaker in the U.S. that makes FDA-approved medicines with semaglutide.

“Telehealth providers and compounding pharmacies that are claiming to offer or sell unapproved compounded products claiming to contain ‘semaglutide’ are sourcing their ingredients from entities other than Novo Nordisk," the spokesperson said.

Online scams

Some websites purporting to be online pharmacies take consumers’ money but never deliver the medications, according to the study.

Although Mackey and the co-authors of the study paid for six orders, they received only three. Three of the websites they ordered from were “non-delivery scams,” asking for additional payments of $650 to $1,200 to help their products “clear customs,” according to the report.

In the best-case scenario, consumers who purchase GLP-1 drugs from illegal online pharmacies “just lose their money,” said Shabbir Safdar, executive director of the Partnership for Safe Medicines, which researches the dangers of counterfeit medicines. “In the worst scenario, you end up with medications that are potentially harmful.”

Some people who can’t find semaglutide at their regular pharmacy have turned to compounding pharmacies, which mix or alter drug ingredients to create medications tailored to specific patient needs. Legitimate compounding pharmacies don’t dispense medications without a prescription, said Scott Brunner, chief executive officer of the Alliance for Pharmacy Compounding, an industry group.

Compounded drugs can be made and distributed with fewer restrictions when the drug appears on FDA’s drug shortages list, the agency says; currently, several dosages of Wegovy are in shortage. Still, the FDA cautions that “compounded drugs should only be used for patients whose medical needs cannot be met by an available FDA-approved drug.”

In a statement on its website, Novo Nordisk said it’s working to address shortages. “While we will do our best to support those who want to start taking Wegovy, it is important to recognize that overall demand will continue to exceed supply and some patients may still have difficulty filling Wegovy prescriptions,” the statement reads in part.

Safdar said that buying compounded semaglutide carries risks compared to the brand-name versions.

People who made dosing errors while administering semaglutide from compounding pharmacies have been harmed and even hospitalized after accidentally taking too much, according to an alert issued last week by the FDA.

Brunner said consumers should only buy medications from compounders that are licensed by their state board of pharmacy.

Under the best circumstances, deciding to take a GLP-1 drug is a complex medical decision and patients need regular monitoring, McGowan, from True You Weight Loss, said. Consumers won’t get that sort of care if they buy drugs online without seeing a health care provider.

Even when taken as directed, GLP-1 drugs can cause many side effects, including nausea, diarrhea, vomiting, constipation, stomach pain, headache and fatigue, and, as a result, many people stop taking them after two years. The FDA advises health care providers to monitor patients carefully for kidney disease, eye disease, depression or suicidal behaviors or thoughts.

Some doctors have also observed that GLP-1 drugs can trigger eating disorders in some patients, and the Collaborative of Eating Disorders Organizations, whose members provide treatment or support for people with disordered eating, recommend that doctors screen people for conditions such as anorexia before prescribing semaglutide.

“If a pharmacy doesn’t require a prescription, a medical consultation or any understanding of your health, it’s not legitimate,” McGowan said.

“Right now, there are no shortcuts,” he said. “Either you’re fortunate to have insurance coverage for GLP-1 meds, or you’re willing and able to pay hundreds, if not thousands, of dollars per month in cash. There is currently no proven, safe workaround.”