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Despite the widespread benefits of GLP-1 agonists as an obesity treatment, the medications remain out of reach for many patients . 

The list price for GLP-1 drugs in the United States ranges between $936 and $1349. Even with insurance, more than half the patients still cover part of the cost, according to a recent KFF Health Tracking Poll. 

“Affordability is the main issue,” said Carolynn Francavilla Brown, MD, a family physician and obesity specialist based in Lakewood, Colorado. “These medications are highly effective. They are generally well tolerated [and] have a pretty good side-effect profile. Really, the biggest barrier is the cost of the medications.”

The problem has led a growing number of patients to turn to online sellers who promise the same results from cheaper, compounded versions of the drugs. But because such compounded medications are not approved or inspected by the US Food and Drug Administration (FDA), their safety and efficacy cannot be certain. 

Some online telehealth companies, like Zappy Health, have faced scrutiny in the past for using unlicensed pharmacies to supply compounded obesity medications. In December 2024, for example, the Florida Department of Public Health issued a complaint against Ousia Pharmacy for allegedly compounding without a sterile compounding license.

Ousia was one of several pharmacies used by Zappy Health, and the latter has since terminated its relationship with Ousia. Meanwhile, a recent study in JAMA Network Open found that semaglutide products are actively being sold without prescription by illegal online pharmacies, with vendors shipping unregistered and falsified products. 

The rampant online market for compounded GLP-1 agonists poses pressing questions for physicians treating patients for obesity. How can they help patients navigate the “Wild West” of online sellers and what red or green flags should they look for when identifying legitimate purveyors?

When patients approach Brown about compounded versions of GLP-1 agonists, she tells them she doesn’t have enough information about the compounds and can’t be certain they will improve patients’ health. Brown said she does not believe taking compounded GLP-1 agonists are worth the risk.

However, she believes physicians should be having open, honest discussions with patients about GLP-1 agonists and their affordability early in their treatment program. Brown, for instance, asks patients about their insurance and whether they would be able to afford the medications if they happen to lose coverage. 

“When I start these brand name medications, part of my consent process for these meds is a discussion with my patients about the fact that they are expensive,” said Brown, who runs Colorado Weight Care clinic and also offers weight loss resources for providers. “Those are fair conversations that we should be having when we start these medications for people knowing that they need to be on them long term.”

Compounding Pharmacies: Size, Safety Standards Matter

Patients who want to pursue compounded GLP-1 agonists should know where the medications are coming from, said Richard Joseph, MD, a practicing clinician in the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston and founder of VIM Medicine, a concierge practice focused on fitness. 

Encourage patients to do their homework and inquire about the pharmacies being used by telemedicine companies before buying the medications, said Joseph, who was previously chief medical officer for Restore Hyper Wellness, an interventional wellness provider based in Austin. While at Restore, Joseph worked with compounding pharmacies that supplied compounded versions of GLP-1 agonists and conducted research on the efficacy of compounded semaglutide. 

Joseph’s March 2025 study demonstrated that meaningful weight loss is achievable from compounded semaglutide outside of a closely controlled environment. It also showed that body composition improved with losses in fat mass and gains in overall proportion of lean muscle and skeletal muscle. 

“My recommendation is to learn who are the largest compounding pharmacies in the country,” Joseph said. “There are a few that are the biggest ones and that operate in all 50 states. They [generally] have the right incentives and safety protocols in place to operate. It’s really important to know the compounding pharmacy behind these direct-to-consumer options.”

Some questions patients can ask are: Which compounding pharmacy is supplying these therapies? Can I see your credential certificate of analysis? Can you show me evidence of your active pharmaceutical ingredient?

Some online companies may have this information on their website, but in other cases, patients may need to call and ask, Joseph said. Also helpful is to ask whether online sellers and the compounding pharmacies they use can provide safety data, he added. Reputable sellers should care about studying their products and illustrating how they work. 

It may also be helpful for physicians to tap their network of local compounding pharmacies when patient questions arise, Joseph noted. (Side note: In his current role, Joseph does not refer patients to compounding pharmacies for GLP-1 agonists but connects with local compounding pharmacies for other medications).

“Even now in my own private practice, we have built relationships with certain compounding pharmacies locally,” he said. “To me, there’s the benefit of knowing the people in the compounding pharmacy. I can feel much more comfortable saying [to patients], ‘Hey, go to this place because I know the people there, and I’ve checked out their stuff, and I’ve been to the lab, etc.’”

‘A Very Scary Approach’

Obesity Medicine Specialist Caissa Troutman, MD, said the practice of patients using compounded versions of GLP-1 agonists is “a very scary approach” and one that she steers away from. 

“Before patients join my practice, I am very open about my stance that I only recommend FDA-approved anti-obesity medications and that I do not prescribe compounded versions,” said Troutman, founder of WEIGHT reMDy, a direct care wellness practice in Camp Hill, Pennsylvania. “Affordability of medications is definitely an important factor that needs to be evaluated. I do highlight the option for generic FDA-approved options that are available and also effective.”

For instance, Troutman may suggest FDA-approved options like Qsymia, which is phentermine and topiramate, or Contrave, which is bupropion and naltrexone, she said. 

Troutman emphasizes that the compounded versions of GLP-1 agonists are not the same as the compounded counterparts of other medications, which is what makes it dangerous. For other medications, pharmacists compound using the available generic options, but for semaglutide or tirzepatide, there are no available generic options. 

“I always go back to safety and efficacy,” Troutman said. “Not just in the short term, but also in the long term. We just do not know what these compounded drugs are made with and how it will affect a person now and in the future.”

Patients, meanwhile, may soon be unable to get their hands on compounded versions of popular GLP-1 agonists after a recent court decision.

In early March, a federal judge declined to stop the FDA from declaring there was no longer a shortage of Eli Lilly’s weight loss and diabetes drugs Zepbound and Mounjaro. 

Compounding pharmacies have been allowed to produce versions of such anti-obesity medications if the drugs were considered in shortage by the FDA. Late last year, however, the FDA said the shortages were resolved after Eli Lilly and other drugmakers said they could now meet the demand for their anti-obesity medications.

The Outsourcing Facilities Association, a trade association representing 503B outsourcing facilities, sued over the decision, claiming the FDA was “abruptly depriving patients of much needed treatment and artificially raising drug prices.” The association asked a judge to issue an injunction against the FDA’s decision. The judge disagreed, enabling the agency to move forward. 

Smaller, state-licensed pharmacies had until February 18 to cease distributing or dispensing tirzepatide injections, while larger outsourcing facilities have until March 19. 

Another lawsuit by the trade association against the FDA for the removal of semaglutide from the shortage list remains pending.