[A_D_E_P_T]

> A study by researchers at Yale estimated that drugs like Wegovy can be profitably manufactured for less than $5 per month.

Serious question: Why not just bootleg the stuff?

It's a very small protein, easy to make, and "research chemical" companies that sell structurally similar bodybuilding drugs and nootropics are a dime a dozen. Search online for "BPC-157" (a protein drug of only slightly inferior complexity) and you'll find a million places that sell it at $25 for a month's supply. Those vendors are legitimate far more often than not.

If Novo Nordisk won't sell to humans at a humane price -- instead preferring to gouge insurance companies and the gatekeeping medical bureaucracy -- I'd argue that there's a moral imperative to bootleg the drug and distribute it to those who would benefit from it at a fair price.

And, unlike many of the bodybuilding drugs (which are a big business,) these new weight-loss drugs aren't scheduled, so you won't get in much trouble even in the unlikely event you are caught.

[adbge]

These same companies that manufacture and distribute BPC-157 and bodybuilding drugs already also offer various GLP1 drugs, semaglutide, tirzepatide, retatrutide. Google around and you can find them available for much cheaper via grey market vendors.

[A_D_E_P_T]

Well, there you go, I guess.

So high semaglutide pricing won't end up "bankrupting" the US medical system. It'll push an ever larger number of patients -- and more than a few well-meaning doctors, who already recommend things like BPC-157 -- into the gray market. That this would further delegitimize the medical establishment and FDA would be a well-deserved outcome.

[namlem]

Where does one go to find these vendors? Are they the sorts of places that other sites prohibit links to?

[ano-ther]

They have patent protection and the US government goes to great lengths to defend intellectual property rights.

Technically, compulsory licensing is allowed under TRIPS (https://www.wto.org/english/tratop_e/trips_e/public_health_f...). But the US and others opted out of this (https://www.wto.org/english/docs_e/legal_e/31bis_trips_annex...).

[hi-v-rocknroll]

I'm down for it or something similar. Not even joking.

A. The issue becomes creating a manufacturing and cold chain distribution system involving the fewest people with compartmentalized knowledge. I'm not sure how you'd launder it or keep enough of it a secret to not get eventually busted because someone would open their mouth. It'd probably be busted with RICO if any sort of profits were involved. Must pay taxes, for sure.

B. DIY chems home pharma kit is another approach.

C. Traffic from other countries like France at near cost prices.

D. Send patients to low-cost countries to buy up medications for their own personal use, and post or FedEx it back to themselves in bulk.

E. Hold politicians accountable and make the FDA and FTC set hard limits on price gouging so that Medicare, health insurance co's, and American patients aren't overcharged. You'd think health insurance co's would be right out in front complaining about the high cost of medications and lobbying for change.

[ASalazarMX]

> get eventually busted because someone would open their mouth

Aren't this what "corporations are people" prevent? Plenty of people doing shady, or outright evil stuff, get their way because they're behind a corporation.

[hi-v-rocknroll]

It's more like conspiracies fall apart whenever there is more than 1 person. When there are 800, then it's over immediately.

Evil or shady acts must first be illegal to be potentially prosecutable crimes or be injurious to have standing as tort claims. And limited liability isn't unbounded.

[ajross]

> Serious question: Why not just bootleg the stuff?

Historically, the black market for medication has been vanishingly small. People don't as a rule trust drugs they get off of alibaba or wherever; even the viagra gray market is a small fraction of the prescription revenue.

And this doesn't treat something critical, it's a weight loss drug. To be blunt most people would probably choose to remain fat vs. buying an illegal generic.

[operatingthetan]

>To be blunt most people would probably choose to remain fat vs. buying an illegal generic.

Wow, I think the exact opposite. Weight loss is a huge industry and people are desperate.

[paulryanrogers]

Fentanyl seems to be tainting a lot of black market drugs lately. I'd want to test anything if it came from unofficial sources.

[operatingthetan]

Totally different markets. They are adding fentanyl to cut intoxicant drugs as a way to make more money. Nobody gets high on a GLP-1. Never heard of supplement/nootropic drugs being tainted and doesn't make sense that anyone would on purpose because they are sold by companies with web stores and credit card processors.

[ClassyJacket]

I don't think this is true. Look at the number of people buying Modafinil off Indian websites.

[TheLoafOfBread]

Well technically because India is not a black market, more like a grey market. They didn't pay for IP, Indians just copied the drugs, but they achieved their goal - selling affordable medicine with good enough quality to an average Indian.

[mise_en_place]

They already are. Weight loss clinics will send the Rx to a compounding pharmacy.

[hollerith]

>clinics will send the Rx to a compounding pharmacy.

I think you are confused about what a compounding pharmacy is -- at least if you refer to how it works in the US.

[adam_arthur]

Not sure what you mean. You can sign up for compounded semaglutide from many online services (e.g. Ro https://ro.co/weight-loss/compounded-semaglutide/)

It's still expensive, but far cheaper than brand name with similar efficacy. Competition from these programs will likely drive costs much lower over the next few years.

[pbj1968]

Absolutely nowhere on that page is mentioned what you’ll actually pay for the compounded drug. Spoiler - $300+/mo

[adam_arthur]

Yes, less than half the price of brand name, and competition hasn't even really started.

These are first mover prices.

What's the monthly health cost of being obese?

[hollerith]

Semaglutide is still under patent in the US till at least Dec 2031 (say Wpedia).

Blockbuster drugs still under patent usually don't have alternative avenues of supply that are significantly cheaper than the main avenue. I wonder what law or regulation allows this alternative avenue to persist.

[bilsbie]

What is compounding? What raw ingredients do they start with? How is it possible?

[Tuna-Fish]

They are compounding the useful, active ingredient which they are purchasing from some mass manufacturer with some pointless thing they happen to have on hand and that provides a legal fig leaf that the medicine was tailored specifically for you.

The reason compounding pharmacies are very useful in the US is not because the process of compounding is useful; it's that they have carveouts in regulations that make it hard for the FDA to control them. When there is a drug that is useful and safe, but not approved by the FDA for the purpose you want to use it, you can often get it from a compounding pharmacy.

Semaglutide is a GLP-1 agonist. There are many other GLP-1 agonists, of varying efficacy and side effects, and many of them which a compounding pharmacy can purchase in bulk at very reasonable prices. However, only Semaglutide has been FDA approved for the indication of weight loss, and being the sole approved product means they can milk their patent-granted monopoly for a ridiculous amount of money. Simply because without FDA approval, you cannot get the other similar drugs for the purpose of weight loss. Unless you go to a compounding pharmacy, which, for dumb historical reasons, happen to have loopholes in FDA regulation, so long as they are artisanally producing compounded drugs tailored to a specific individual.

[bilsbie]

Do they still require a prescription?

[tomohelix]

Many reasons. One of them being doctors won't prescribe an off brand drug and insurance won't cover anything related to it.

The other reasons are:

1/ Even the manufacturer doesn't know everything about how the drug was made. They characterize the final compound but the compound was made by some sort of living cells so each one has different properties. For the same molecule, one cell line may produce a drug with entirely different toxicology profile compared to another. You need a full manufacturing chain with different departments analyzing it at different stages to guarantee the desired effect.

2/ Patents make sure that the vanishingly few groups with the capability to do the above characterization would not want to risk their business doing it.

3/ For every one molecule that made it to market, dozens or hundreds of others were discarded. They all cost about the same amount to develop up to the point they were thrown away. Due to the amount of regulations in place, the cost to research is obscene and the final manufacturing cost is peanut compared to the price of the pipeline what the drug went through.

[A_D_E_P_T]

Utter nonsense, especially point #1. Drugs absolutely are not random mixtures. Semaglutide's molecular structure is completely characterized -- on its wikipedia page, in its patent application, and elsewhere -- and it's very easy to make identical molecules in the lab.

Novo Nordisk's patent -- US8129343B2 -- lays out the process, which is nothing more than Fmoc solid state synthesis. "The protected peptidyl resin was synthesized according to the Fmoc strategy on an Applied Biosystems 433 peptide synthesizer in 0.25 mmol or 1.0 mmol scale. . ." So they don't make it in cells, but by totally conventional peptide manufacturing techniques.

As for #2, you must be unfamiliar with the existing gray market for pharmaceuticals. Among others, both the bodybuilding community and the nootropics community experiment extensively with pharmaceuticals -- and they do drug synthesis and distribution in a way that's actually extremely cost-effective! (Necessarily, because their customers are humans who pay out of pocket directly.)

#3 is trite and overstated. It's a standard drug industry talking point, but it really has no bearing on this discussion.

[mcphage]

> insurance won't cover anything related to it

If the grey market is cheaper than you would pay for the real drug after insurance’s contribution, who cares?

[loloquwowndueo]

Patents?

[redwoolf]

When it comes to pharmaceuticals, the patents are ridiculous. Take for example Contrave[0]. It is a combination of Naltrexone and Bupropion, both of which are no longer under a patent. Put them both in the same pill and it's under a new patent.

[0] https://en.wikipedia.org/wiki/Naltrexone/bupropion

[3abiton]

So buying them separately and mixing them in your mouth is legal? It's like combining 2 pieces of open-source software and selling them under one product.

[redwoolf]

Totally legal. You can have your doctor prescribe 50mg Naltrexone and 300mg Bupropion and you can take them at the same time every day. It's the same drugs in the same ratios. Contrave is not novel in any way. There's substantial prior art. And yet a patent was granted to cover this combination and prevent anyone else from taking two generic drugs and combining them into one pill.

[clipsy]

> It's like combining 2 pieces of open-source software and selling them under one product.

That describes a decent chunk of the tech industry!

[shawn_w]

Interesting. I'm pretty familiar with both drugs in the context of addiction treatment and mental health (and seen plenty of people taking both as separate pills), but I've never heard of them indicated for weight loss.

[ggm]

I believe the most likely outcome is a price curve downwards as Novo nordisk is quietly forced info JV with US manufacturers under implicit threat of some one-off ruling akin to an IPR eminent domain action.

Nobody in government wants to accept IPR is broken but they'll find a way to bend it's ruling into a hoop, for the specific needs of the moment.

[bananapub]

> Why not just bootleg the stuff?

because the US is largely responsible for the rich world's tyrannical patent and copyright laws?

[voisin]

> I'd argue that there's a moral imperative to bootleg the drug and distribute it to those who would benefit from it at a fair price.

Why not do away with patents and IP altogether if the standard is that as soon as someone makes something needed it can be stolen?

[nsagent]

I'm not sure what the right solution is, but making 160x the manufacturing cost seems a bit obscene. Not sure what the total cost of R&D was, but at that rate of return those R&D costs have to be recovered relatively quickly and then it becomes a pure profit machine.

[ericd]

Do you similarly object to the insane gross margins on software?

Like in software, pretty sure the main expense is R&D.

[nsagent]

The consumer costs are significantly lower for software. For example, the cost of ChatGPT is minuscule in comparison, while the R&D costs are still quite high.

The real difference between the two sectors is that for medicine, you have a captive audience. People are willing to give up their life savings for certain medical interventions. That same cannot be said for software.

[ericd]

The other real difference is that the addressable market for most drugs is quite small in terms of number of customers. The vast majority of people just don’t need a particular medicine, especially the life-saving variety. The more niche, the more you have to charge to make up for the large R&D costs.

There are, of course, also instances of gouging. But it’s not like these things should inherently cost $20/mo, or whatever, if you want to be able to pay biomedical researchers enough not to go do something else highly compensated like finance/consulting/whatever. Sadly, I had a lot of classmates in engineering school who went that route instead. We urgently need more nuclear reactors, but one of the smartest guys I know, a nuclear engineer, is doing healthcare private equity.

A lot of saas is more like $200+/mo for businesses, and chatgpt might be $20/mo for consumers, but there are companies paying $1m/mo or more for that api.

[throwaway-blaze]

No one is mentioning the liability costs (and liability insurance costs) here in the US vs other western countries, which is playing into the costs of these new-to-market drugs. In 10 years or so, when there's an established history of non-issues with the drugs, premiums will be lower for the companies. Plus these initial versions will begin to lose patent protection and generics will flood the market.

Personally I'd rather have a system where these kinds of innovations are made and where they eventually become widely available than a system where govt or others forcefully take or force-price an innovation, thus harming future innovations.

[moate]

>Why not do away with patents and IP altogether if the standard is that as soon as someone makes something needed it can be stolen?

laughs in anarchist don’t threaten me with a good time!

We also need to differentiate “theft” (actually taking a tangible thing) from “ripping off” (stealing an idea and making that thing yourself).

Theft is bad (depending in who you steal from and why), ripping off is only bad if you believe current economic models/practices are good. But

I’m only talking about conceptually since this doesn’t account for the consumer’s safety. In practice one downside to unregulated markets is they get exploited by bad actors for profit by making inferior products that harm consumers, unlike regulated markets that get exploited by bad actors for profit through regulatory capture.

[JKCalhoun]

Why not make an exception for life-saving patents/inventions?

The irony that, were it not priced outrageously, it could save the health care industry billions as these people with obesity will otherwise require epesneive treatments if the remain obese.

[A_D_E_P_T]

There are already exceptions for technical products that must be licensed on fair, reasonable, and non-discriminatory terms. (RAND or FRAND. See: https://en.wikipedia.org/wiki/Reasonable_and_non-discriminat... )

Why not carve out a new exception for breakthrough drugs that have the potential to add X% to the GDP or save X lives/annum?

[swatcoder]

> it could save the health care industry billions as these people with obesity will otherwise require epesneive treatments if the remain obese.

"Could" is doing a lot of work there. We don't really know what to expect for these patients 20 or 40 years out.

Long-term outcomes and population-scale polypharmacy risks are not really clear, and won't be for decades.

These drugs enable a valuable intervention for individuals at high risk of health hazards and it's fantastic that they're available, but the perspective changes when you look at outcomes for tens (hundreds?) of millions of people over long spans of time -- there are a lot of inescapable unknowns. One can't actually be sure that the benefits of fast, widespread use will outpace the costs, or at what scale.

Many genuinely effective drugs have gone through exactly this kind of hype cycle only to lead to regret, embarassment, and/or skepticism later on.

Good science, and the good public policy that's informed by it, moves slowly.

[bryanlarsen]

Liraglutide has been in wide use for 14 years and trialled for a decade before that; we do have a good idea of what to expect for patients 20 years out.

Semaglutide was approved in 2017 and been very widely used (>9 million people). That's been wide & long enough to determine that risks are either exceedingly rare or significantly slow acting.

OTOH the risks and costs of obesity are massive and well known. We're weighing massive known benefits against risks that are either rare (likely less than 1 in a million) or take decades to manifest.

[moate]

Exactly. I’m old enough to remember the Fen-Phen fallout.

A truly harmless weight-loss drug is the white whale of the pharmaceutical (assuming it can be profitable enough to offset the losses that would go along with the decrease in needed treatment for problems ancillary to obesity). These drugs, so far, seem pretty good but some of the side effects should take the shine off for people who thing this is ”The Cure” for obesity.

[mech422]

check out the DES babies (0) or Thalidomide if you want to see how little we understand long term effects...My mom was a nanny and one of the girls she raised was born sterile due to DES her mom was given _to support pregnancy_ !

0) https://en.wikipedia.org/wiki/Birth_defects_of_diethylstilbe...

1) https://en.wikipedia.org/wiki/Thalidomide_scandal

[BurningFrog]

If it can actually save the health care so many billions, you'd think it was worth paying high prices for it.

[andsoitis]

> Why not make an exception for life-saving patents/inventions?

This ain’t it though.

[alphazard]

It's possible to believe that the best system of laws to operate in contains concepts like patents and intellectual property, and that the best thing for you to do individually is to take advantage of poor enforcement. This probably matches the attitudes of most people here about Piracy for example.

[ClassyJacket]

I'm in favour of doing away with patents entirely. Or maybe make them 3 years and not 20.

[voisin]

And what about the second order effect of nobody wanting to do billions of dollars worth of research and trials for the slim possibility of hitting a safe and effective drug, only to have exclusivity for 3 years?