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Is the new oral Wegovy pill a breakthrough or a risk most patients never hear about? Shiv K. Goel, an internal medicine and functional medicine physician, joins the show to unpack his KevinMD article, “Oral Wegovy: the miracle and the mess of the new GLP-1 pill,” and why treating this drug casually could hurt you. He breaks down emerging data linking high-dose semaglutide to ischemic optic neuropathy, with reporting odds nearly five times higher for Wegovy than Ozempic, and explains why the obesity population faces unique hemodynamic risks. You will learn why he never prescribes a GLP-1 without prescribing a plan, including slow titration, protein and resistance training to protect lean mass, hormone optimization, and red flag education. Goel also addresses the rebound weight gain most patients face after stopping, the dangers of buying compounded GLP-1 medications from medical spas, and why losing just 10 pounds may not warrant these drugs at all. If you are considering oral Wegovy or already on a GLP-1, this episode could change how you approach weight loss medication.
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Transcript
Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast today. Welcome back, Shiv K. Goel, internal medicine and functional medicine physician. Today’s KevinMD article is “Oral Wegovy: the miracle and the mess of the new GLP-1 pill.” Shiv, welcome back to the show.
Shiv K. Goel: Thank you for having me, Kevin.
Kevin Pho: All right, so tell us what your latest article is about.
Shiv K. Goel: My latest article is about how oral Wegovy is both a miracle and a mess. The article is really about two main things: the miracle and the mess of the new oral Wegovy era. The miracle is what I see in a clinic when a patient who has battled weight and diabetes for decades finally feels their food noise go quiet. They eat less, not because of shame or willpower, but because their biology finally cooperates. Along with the weight loss, we see better blood sugar, blood pressure, inflammation, mobility, and a real return of agency. The mess is everything the Instagram reels don’t show: the relentless nausea, constipation bad enough for urgent care, reflux that ruins sleep, and the disappointment when the weight loss is not just linear or when the rebound happens after stopping the medication. My core message in this article is that oral Wegovy can be life-changing, but if we treat it like a casual pill instead of a serious metabolic drug, we hurt people through unrealistic expectations, poor monitoring, and the lack of a long-term plan.
Kevin Pho: So tell us about the data between oral Wegovy and the injectable forms for people who just aren’t familiar with that form. I know that it has recently been introduced. So what is the data behind oral Wegovy?
Shiv K. Goel: Recently we came across a lot of new data which has been emerging, especially the risk associated with what we call nonarteritic anterior ischemic optic neuropathy, and why it matters. We now have several complementary data sources. A large pharmacovigilance analysis using the FAERS reports found that semaglutide products as a class had a significant signal for ischemic optic neuropathy. Within that class, Wegovy, the high-dose obesity formulation, carried the strongest relative reporting odds for ischemic optic neuropathy. The odds for it were reported to be nearly five times higher with Wegovy than with Ozempic, and more than three times higher in men than in women.
Separately, a nationwide EHR-based cohort study in JAMA recently published showed that Wegovy or tirzepatide, which is Mounjaro, compared with other anti-diabetic medications, were associated with an increased risk of optic neuropathy and other optic nerve disorders over a two-year follow-up. But all of those studies and the data come from retrospective analysis. Semaglutide and tirzepatide belong to one group, but there are some differentiating factors. The head-to-head comparison suggested that semaglutide and tirzepatide, as newer, more potent agents, carried a higher optic nerve-related risk than other older GLP-1 RAs.
Regulators have responded. European and UK agencies now list ischemic optic neuropathy as a very rare but recognized side effect of semaglutide. But why is Wegovy standing out more than Ozempic or tirzepatide? The working hypothesis isn’t that Wegovy is a fundamentally different molecule, but that its dose indications and hemodynamic effects are different. Wegovy uses higher weekly doses of semaglutide for aggressive weight loss, which can drive rapid weight reductions, intravascular volume contractions, and larger blood pressure changes, particularly nocturnal dips. All of this may reduce optic nerve perfusion in susceptible patients, especially people who have sleep apnea, obesity-induced hypoventilation, or higher metabolic disorders. Wegovy is also predominantly used in obesity populations most of the time, and that often has all those issues. This crowds a disk at risk anatomy, precisely the nonarteritic anterior ischemic optic neuropathy profile.
Ozempic users, by contrast, are mainly a diabetic cohort because it was a drug originally introduced for diabetic patients, not for weight loss. So their dosing schedule is also very different. Tirzepatide does show an association with optic nerve disorder in some cohort data, but in pharmacovigilance analysis, it hasn’t shown the same strong or specific optic neuropathy signal that high-dose Wegovy has. I think that is something which as physicians we have to take into consideration when we are prescribing all those GLP-1 medications.
Kevin Pho: Now, are patients asking you specifically for the oral form of Wegovy because they found that the injectable form was too much of a barrier for them?
Shiv K. Goel: Yes, they do. Because obviously we have to inject everyone every week. A lot of people don’t like injecting, and so they ask for oral Wegovy because it is easier for them. But I always tell them it is not just a prescription. In my practice, I don’t prescribe a GLP-1 without prescribing a plan. That plan includes slow titration with explicit permission to pause if side effects are impairing functions. It includes strategies for hydration and bowel management, upfront protein, and resistance training to protect their lean mass, along with very clear red flag education about when to call urgent care. So while the food noise is quieter, when they see the changes, we work on their circadian rhythm, movement, stress, nutrition, and sleep habits. We need to optimize their hormones and their lifestyle. Everything goes in together. If we just give the prescription and keep titrating the dose, we are going to end up with more side effects plus rebound weight.
Kevin Pho: So it sounds like a pretty involved process whenever you start a GLP-1. What do you think about Super Bowl commercials that sell compounded GLP-1s? Now that we have oral forms, it is probably going to be easier to get them outside of a physician’s office. Tell us about some of the ramifications of that.
Shiv K. Goel: I think this is something that people need to get educated about because they are pitching these medications. I see people getting them from medical spas on every corner. There are health care professionals who are prescribing it, and pharmacies as well. First of all, we don’t even have a lot of data on those medications. I think the weight loss aspect was launched too early, before we had very long-term 10- or 20-year data to see what the real side effects are, how they behave, and even what the effect is on the central nervous system. So it is very important not to just get these medications from anyone. Don’t just go and buy the medications because you want to lose weight. First of all, those medications are not cheap. If you do that, there is not just a higher risk of developing blindness or other related side effects. You can have pancreatitis, you can have severe hypertension, you can end up with a stroke, and so many other things.
Given the amount of money you spend doing that, you can have a much higher rebound of weight gain as well. So when you want to do things, do it the right way. Always seek a health care professional and get their opinion because it is not about the drug, it is about your lifestyle and how to be safe at the end of the day. You want to lose weight, but you want to keep maintaining that lost weight and you want to look healthy, not sick.
Kevin Pho: Now I understand those who stop GLP-1s, the majority of those patients regain their weight. So talk to us about how you counsel patients because not every patient can continue GLP-1s long term due to cost issues and whatnot. Tell us how that conversation goes.
Shiv K. Goel: First of all, it is very important that my first time when I have consultations, I go into detail because we have to understand why they gained the weight to begin with. Everyone has different reasons. A lot of times they may have underlying psychological behaviors, or sometimes it just runs in their family that everybody is overweight. Food is such an integral part of our culture that when we are happy we eat, and when we feel sad we eat. It is about how to disconnect yourself from that belief that food has something to do with your emotions. It feels like a lot of times my patients’ food has become a crutch because it releases endorphins so they feel a little better, so they keep eating whenever they feel stressed. That is one thing.
The second thing is to understand whether their body is optimized and ready. Do they have any endocrine issues? Do they have any thyroid issues? Are their hormones in place or not? For someone who is in menopause, they are already not there. That is why women start gaining weight during menopause, not just post-pregnancy, but because their hormones are everywhere. They do not have enough testosterone, estrogen, or progesterone, they can’t sleep, and they have a lot of issues happening. Hormones affect your neurotransmitters. The neurotransmitter is like that; that is when we start feeling more anxious, more depressed. We have more stress, and we can’t sleep at night. All of this combined together causes weight gain.
Another factor is a deficiency of lots of minerals and vitamins. I have seen about 95 percent of my patients are deficient in vitamin D. Women are also deficient in iron. When we don’t optimize their body, when we don’t know why they are gaining the weight to begin with, and when we don’t know their root causes, that weight loss is never going to be sustained. It is not a medication or a miracle drug. While they are on that medication and losing weight, I always do a slow titration. My goal is never for them to lose more than five to seven pounds a month. That timeframe, whether it is three, six, or nine months, is the time they have to make those changes in their body. There are studies that have shown that for any human to change one habit, it takes 90 days for consistent implementation. That is when that habit becomes a part of your normal routine.
If you go to the gym on Monday, it is going to hurt in the next couple of days. So if people stop just because it hurts after a couple of tries, they are never going to get there. It takes a consistent 90 days. That is why most programs are built around 12 weeks. Three months is the minimum time you are going to see the effect and be consistent about it. So it is basically a bridge between the old you and the new you. Medication is only a bridge, it is not a cure, and it is not a treatment.
Kevin Pho: So for patients who see these commercials for GLP-1s, and now they are all over the internet and TV, tell us the type of questions they need to be asking themselves before they go to a physician’s office and ask about obtaining them.
Shiv K. Goel: I think the most important question they should be asking is: “Is it the right drug for me?” Suppose I have a lot of patients who come in and they just want to lose 10 or 15 pounds. They are already in good shape and they don’t need to be on a GLP-1. They are going to end up losing more muscle mass and a lot of other things. They need to know that these medications are only going to work during the time they are on them. Plus, they should ask: “Is it safe for me to take these medications given whatever medical conditions I have?” For example, if they have sleep apnea, any underlying heart conditions, or if their BMI is over 30 or 40. Being overweight or obese is not just having extra fat; it changes your physiology.
The physiology of a person who is not overweight and the physiology of a person who is overweight or obese, especially morbidly obese, are completely different. Their endocrine system is completely different. Their cardiovascular physiology is completely different. When people see commercials on television, they see someone who took the medication and everybody feels good. Television shows that everybody’s life is great when they take that product. That is a marketing strategy. So, in the end, not every marketing strategy you see out there is going to work for you as well.
You need to go to a physician who is specialized in weight loss and knows what it is. You need to ask them questions instead of just saying: “Can you do GLP-1? Can I have it? Can you write a prescription for me?” I get so many calls from people asking: “How much do you charge for tirzepatide?” We don’t sell medications. They have to understand that a physician is there to make sure whether the drug is right for them or not, and to help with what they are going to do while on the medication. Ask the right questions. Be honest with your physicians about your medical issues. Be honest about what the main reasons are for your weight gain and how to optimize everything, because there is no shortcut. You are going to lose weight at the expense of everything else, and then you are going to regain the weight. So all the effort is going to go to waste if you are not asking the right questions. If you are not honest with yourself, then you are not going to honestly lose the weight for good.
Kevin Pho: We are talking to Shiv K. Goel, internal medicine and functional medicine physician. Today’s KevinMD article is “Oral Wegovy: the miracle and the mess of the new GLP-1 pill.” Shiv, as always, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Shiv K. Goel: My message to my fellow physicians is that the molecule is not the whole story. The way we practice around it determines whether this era is remembered as a breakthrough or a cautionary tale. These drugs can transform lives when we match them to the right patients at the right doses with the right education and monitoring, including for rare events like ischemic optic neuropathy. But they can also cause harm if we chase speed, supply, and social media expectations instead of long-term relationship-based care.
To patients and the public, my message is that Wegovy and its cousins are neither a pure miracle nor a pure mess. They are powerful tools. Used thoughtfully, with honest counseling and a holistic plan, they can quiet the food noise, improve metabolic health, and give you your life back. Used casually, without respect for their risks or for the work that still needs to be done on sleep, stress, movement, and relationship with food, they can disappoint and sometimes cause harm. I would say that my job is not just to write the prescription. It is to walk with you through both the miracle and the mess.
Kevin Pho: Shiv, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Shiv K. Goel: Thank you for having me again, Kevin. Thank you.
