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misserabella · 5 months

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two geniuses (don’t get along)

enemies to lovers;; spencer reid x fem reader!

masterlist!

note; in this fic lila’s episode happens after elle’s departure to make the story have more sense. (S1 E18). also there have been some changes :))

synopsis; spencer reid; doctor spencer reid. some of them (mostly of them), would say he’s a genius. but if he was, then so you were. maybe that’s why you hate each other. maybe that’s why you can’t stand him.

cw;; +18 content! minors dni!, reader and spencer’s competitive asses, talk of murder, graphic scenes, weapons, guns, blood, shots being fired, lila flirting, spencer kissing lila, lots of fighting, lots of tension, teasing, apologies, reader getting hurt (mentions of stitches), threats, murder of secondary characters, talk about kinks and trauma (spencer being a smartaas), mention of spencer’s childhood and her mom… ( i bet there’s so much more but i can’t remember rn) angst, fluff and smut in upcoming chapters!!!

“another coffee, pretty boy? you wanna die?” morgan inquired the puppy eyed profiler, whose right hand held a cup of freshly brewed coffee.

“actually, the caffeine in coffee has been found in animal and cell studies to protect cells in the brain that produce dopamine. in a large prospective cohort of more than 500,000 people followed for 10 years, an association was found between drinking higher amounts of coffee and lower rates of death from all causes.” he easily spat in less than a mere minute, making morgan scoff.

“it’s not considered coffee if a 99% of it is sugar, reid.” you barged into their conversation, taking a look at the files of new cases.

“sugar is one type of carbohydrate, as are fiber and starch. carbohydrates are essential macronutrients.” he defended himself, taking a sip of his coffee-sugar.

“wrong. although carbohydrates are essential macronutrients since the body uses them in large amounts, something wrong about your thesis is that sugar is not one of those macronutrients. the body doesn’t use it. in fact, the effects of added sugar intake which are higher blood pressure, inflammation, weight gain, diabetes, and fatty liver disease, are all linked to an increased risk for heart attack and stroke. so yeah. technically, morgan was right. you might die.” you nodded towards the man, who smiled at you, walking towards you and taking your face in between his hands.

“have i told you how much i love that brain of yours?” he inquired, leaving a kiss to your forehead. “brilliant.” he smiled, raising his hands in victory since for once he had won spencer and his extensive knowledge. the profiler simply rolled his eyes.

“thanks.” spencer spat at you, to what you smiled.

“you’re very welcome, agent.”

“it’s doctor.”

“yeah, yeah. whatever.”

spencer reid. with an IQ of 187, an eidetic memory, and the ability to read 20,000 words per minute, he was considered a real walking genius. maybe that’s why the two of you seemed to despise each other so much. people say geniuses actually like each other. well, you and spencer were the exception. it was easy to get on his nerves. he was not used to having someone smart enough to actually suppose a threat to his intelligence. yet there you were. you had been jumping your way up to college since you were twelve, and at the ripe age of 22, and numerous phds later, you had found yourself working at the BAU.

you had been hired after elle had left the team, and everyone had seemed happy greeting you. you had specially made quick friends of penelope and morgan. something reid didn’t seem to like. well… he didn’t exceptionally like you. something that seemed stupid ‘cause you two were the perfect pair. there was nothing the two of you didn’t know, nothing you wouldn’t catch or realize. maybe that’s why spencer despised you. ‘cause now they had you too, not only him.

it was actually a pity. you liked smart people. you liked to share opinions and learn new things you might not know with the help of others. but spencer was borderline narcissistic, and that made your body cringe in disgust. and worst of all, he was really attractive. curly caramel hair, hazel puppy eyes, full lips, small straight nose, tall stature, pretty hands… also his voice…

well, anyways. you were losing focus.

so you’d decided to match his energy. and that only seemed to make the situation worse. sure, you two worked together, but only because you had to, if you could you’d much prefer to do everything alone rather than have to share office with reid.

hotch caught your attention as he pushed a file on your table.

“and what’s this…?” you sung as you took it, inspecting it.

“training program in los angeles.” you looked at him. he was leaning against your table. “want you to go with gideon and reid.” you let out a single chuckle, tossing the paper on your table.

“no.” you simply said, watching the man sigh. “tell jj to go! or prentiss!” you offered.

“can’t. jj is helping penelope to trace an unsub and prentiss is new, need someone who has been on the ropes longer.”

“then what about morgan? he’s not doing anything.” you pointed at the man who played with a mini football.

hotch looked at you. “please? you are the only one who gets reid. you know how he can be…”

“a narcissistic, egocentric, babbling, childlike, fourteen looking mess? yeah, i know.” you smiled. “but what do i win in this situation? i mean i must gain something if i’m gonna spend more time than necessary with him.”

“a free weekend.”

“done.” you gave him your hand. “a pleasure doing business with you, sir.”

“spencer! spencer reid!” you hear someone call for your work-mate, a tall smiling man approaching him and shaking his hand just as the three of you entered an art exhibition. “look at you. you look just the same.” he chuckled as he gives him a quick hug. “nothing changed… spencer was the only 12-year-old in our graduating class. just the same.”

“thanks.” spencer awkwardly says, giving the man a tight smile. “these are special agents jason gideon and (y/n) (l/n). this is parker dunley. we went to high school together as you can probably gather.” he introduces all of you.

“hey. it’s a beautiful gallery.” jason gives him his hand in a shake.

“oh, thank you, thank you. parker smiles, later on turning towards you.

“contemporary art… right?” you inquire offering him your hand, to what he nods. “contemporary modern art includes a wide range of mediums and genres. it is often characterized by its use of new media, such as video and installation art, as well as its rejection of traditional art forms. contemporary modern artists often experiment with form and content, and their work can be highly conceptual.” you say, making the man chuckle.

“i see you brought your computers.” parker jokes with gideon about spencer and you. “another genius like spencer?”

“oh no, men are just smart. woman are the geniuses.” you smile, making him chuckle.

“and funny, huh? i see, i see.”

spencer coughs to grab the man’s attention. “jason’s a big contemporary art enthusiast.”

“well, we’re exhibiting four up-and-coming artists in this show. everything is for sale. and i could definitely swing a nice discount for a friend of…” he loses focus as a blonde beautiful woman enters the exhibition. “lila! hey. guys, come on.” he invites you three towards his friend, coming up to her to say hello.

“do i look 12-years-old to you?” spencer inquired gideon, to what you scoffed, thanking the waiter that offered and served you a glass of champagne.

“oh, totally.” you said as you took it, taking a sip as you heard spencer crack a fake laugh.

“real funny.”

you three made your way towards parker and… lila. she was a beautiful blue eyes-blonde young girl. the basic american beauty standard.

“spencer. you ever met a real movie star?” the man asks, to what the girl beside the blonde scoffs.

“movie star? please. she has a supporting role on a television series about beach volleyball. totally blue-collar.” your eyebrows slightly rise.

“what a friend…” you whisper to your glass, taking another sip of the champagne.

“i’m lila.” the girl gives a sweet smile to spencer, and you almost roll your eyes.

it’s only a matter of time.

“hi, im doctor spencer reid… i’m spencer. you don’t have to call me doctor.” he corrects himself.

lila chuckles. in 3… 2… 1… and tucks her hair behind her ear. there we go.

“cool.” you say, turning around without even introducing yourself, it’s not as if she’d pay attention to you. she’s too focused on spencer to care as you make your way through the gallery, taking the artwork in, trying to scape the probable flirting that was about to go down.

later on you found the two of them chatting in front of a picture in which the blue and green dominate.

“does it make you feel anything?” the blonde asked him, and you silently expect an answer from spencer.

“like what?” he asks. god he sucks.

“i can’t tell you how to feel.” lila chuckles at his frown.

“right now i feel pretty good.” he smiled and you roll your eyes.

“lila? can i talk to you for a moment?” parker interrupts their chatting and the girl nods, quickly glancing at spencer.

“excuse me.”

“sure!” he gently says, and you make your way towards him.

“feeling pretty good, huh?” you inquire him, teasingly, and he groans. “you totally suck.” you take a sip of your glass and he looks at you. “poor girl seems desperate.”

“desperate for what?” he inquires, frowning.

“oh come on, reid. and you call yourself a profiler? it’s obvious she likes you. she was trying to flirt with you.” you obviously state. “she was trying so hard and you were not catching on…” you laugh, and he sighs.

“you know ogling on other’s business is rude, right?” he questions you.

“we’re the fbi. we’re on everybody’s business. that’s our job, reid.” you ignore him, taking a look at the photograph lila and him were staring at. “calming, isn’t it?” you say and he looks at the photograph as well, taking it in.

“sometimes, the color blue is associated with loneliness and sadness. it usually happens when you combine it with specific elements, like rain.” he spits and you chuckle.

“i know that, genius. the thing is not how it’s supposed to make you feel, it’s how it really makes you feel.” he looks at you as you sip from your cup. “with lila, you might feel good, ‘cause you enjoy her company, with me on the other side, you might not even want to be here, staring at a photograph that you’ve probably seen before. that’s because you focus on everything too much. you need to see what the picture actually tells you, not focus on the person you’re staring at it with.”

spencer’s hazel eyes go back to the picture, trying to focus on it, not on your presence, or the amount of voices that surrounded him.

the exhibited photograph shows an empty gas station, lights of green engulfing it as the nightlight blue sky surrounds it. it takes spencer back to his childhood. to those days in which even if he loved his mother, he couldn’t spend another minute by her side and left his house late in the afternoon for a walk. it helped him get out of his head. he remembers watching the sun go down as the night took over the sky, studying and calling out the constellations above his head, trying to find a solution to his mother’s illness. the stars never worked, and he was always left…

“it makes me feel alone.”

“you know, we really can get ourselves to the airport.” gideon said, reid and you trailing behind him as the police officer guided you to his car.

“i didn’t invite the fbi here to let them make their own way around town.” he says, never minding gideon.

“we really appreciate it.” reid says and you whistle.

“so you have manners, huh?” to what he groans.

“oh, shut up.”

“hey, i can’t thank you guys enough for conducting the seminar.” kim smiles.

“well, don’t hesitate to call if there’s anything we can help with.” gideon offered, putting his bags on the trunk of the car.

you stretched your arms after having pushed in your own. “can’t wait for that free weekend.” you muster happily, to what spencer frowns.

“free weekend? what are you talking about?”

“a special thanks from hotch for coming all the way here and putting up with you.” his mouth falls open at your words.

“i didn’t get any free time and i had to put up with you!”

“that let’s you know who’s the problem in this equation.” you falsely smiled at him, patting her shoulder, and you relished on the way his jaw tightened.

your conversation ends as the three of you watch officer kim end a phone call with a not very enthusiastic ‘great’.

“everything alright?” jason asks.

“double murder at hollywood bungalow.” he informs. “a celebrity. a young movie star, natalie ryan, and her fiancé shot to death.”

“very romantic.” you mutter.

“it’s gonna be a major pain in the ass. hey, you guys care to take a quick look before i drive you to the airport? it’s on the way.” he asks, and gideon accepts the offer.

“absolutely.”

you sigh as you get on the back of the car along with spencer.

“seems like that weekend is gonna have to wait.” he happily and teasingly smiles and you send daggers in his direction.

“i’ll choke you with my bare hands.”

“did you get that kink by exposure or trauma?” your mouth falls and your eyes widen.

“what?” you almost yell, watching him ponder.

“maybe it’s because you like to have power and control. have you talked about this with a therapist?”

“you’re gonna have to see a therapist after the torture i’m gonna put you through if you don’t stop that fucking nonsense.” you warn him, and he raises his hands.

“i’m just saying, there’s nothing bad about seeking mental help-”

“spencer!”

“no sign of forced entry.” reid points out as the four of you enter the murder scene.

“same weapon.” gideon informs watching at the two bodies.

you stare at the female, getting closer. “the girl was shot execution style, once in the head. the male three times in the torso.”

“so you have two different MOs.” jason wonders before going back to officer kim, talking about the case. you crouch down to take a better look at the man’s corpse.

“what? you found anything?” spencer inquired from behind you, to what you shook your head.

“nah. just fantasizing.” he frowns.

“fantasizing. what the- what would you possibly be fantasizing about in a murder scene?”

“oh you know… you… in that position… you know? it’s really sexy, you should try it. here don’t move let me get my gun.” you offer while getting up, and he just rolls his eyes, leaving you behind.

“what do you think?” gideon asks the officer about the case, wanting his insight.

“i’ve had a couple other cases recently, past few months. same type of weapon, 22 caliber handgun, both shot in the head.” you look at the bodies. “the first was an established film producer, wally melman, and the second was chloe harris, another young actress. though not as well-known as natalie here.”

“any forensic evidence?” reid asks as you step away from them, taking in your surroundings.

“no, and the guys have been going through this place all morning and haven’t come up with anything.”

“so he clearly knows how to cover his tracks.”

“or hers.” you mutter to yourself.

“twenty-two’s are small but efficient. they bounce around inside a person like a pinball.” jason said.

“preferred weapon of the mafia.” spencer added. “you know, there’s no obvious sexual component to these crimes, which is usually the case with serial murders.”

“so you’re thinking this is a serial killer?” kim asks.

“well, it’s certainly a series of murders. we don’t know enough yet to call them serial.” you step into the conversation.

“would you consider hanging out in LA a little while? let me lean on your expertise until we do figure out what we’ve got?” the officer inquires and gideon nods.

“yeah, just cancel the flights. we’ll have the rest of pit team out here ASAP.”

the unsub seemed to follow his victims, since he knew their schedules. there was not a single witness, he knows how to blend in and hide in plain sight. he’s meticulous.

and everybody is watching.

just like everybody was watching spencer and lila.

after finding out that the unsub was actually stalking the blonde, and killing people to help her with her career, she had somehow scurried her way under spencer’s protection. it actually bothered you. ‘cause spencer seemed so distracted. and it was totally unprofessional to get involved with a target being their agent.

you were on her studio, studying everyone surrounding her. but it was one person that caught your attention.

“who’s that?” you question prentiss.

“that’s maggie, maggie lowe. for what i know she just works here.” she answers you. “why?”

“they seem pretty close, don’t you think?” you ponder, watching her physical language. “she also seems nervous, she avoids lila’s eyes.”

“maybe she’s just shy.” she shrugs, but knows what you’re pointing out.

“maybe…” then, jj appears.

“what are you guys talking about?”

“lila and possible unsubs.” emily fills her in, accepting the coffee she offers her, you take the one she handles you too with a thanks.

“talking about lila… look who’s approaching her.” she devilishly smiles. you almost groan at the sight of spencer talking to the blonde. “they seem to have hit it off.”

“ugh don’t start. he’s so focused on her when in reality he should be focused on his job…” you sip at your coffee, not realizing the shared look the other two girls send each other. “so unprofessional.” you shake your head.

“are you really mad because he’s distracted from his job or by the fact that a pretty girl is distracting him?” jj asked you, taking in your frown and confused expression.

“what?”

“oh come on, really? do you really not feel it?” emily pushes in too, and you look at them.

“feel what? i-i don’t understand.”

“there’s this weird tension in between the two of you.” the brunette explains, being backed up by the blonde.

“it’s like when two little kids like each other and they don’t know how to show it so they just mess with each other.” you scoff.

“you’re saying that spencer and i are attracted to each other?” you inquired them both and they looked at the other. “come on guys, have you seen him? have you actually worked with him? he’s a fucking narcissist, he makes my life impossible just because i’m as smart as him. i don’t like him. at all. i can’t even stand him!” you rant. “he does this thing when he’s focused, playing with his hands and pencils, it’s so distracting. and when i state a fact, he just has to find something to actually make it wrong. every single time. and let’s not talk about how fucking childish he is, if you guys had been here for the training program, i swear to god he said this stupid things about kinks and me having trauma, oh my god i wanted to fucking kill him. he diminishes me, and thinks he’s better than me. and it just makes me sick…” you take a deep breath when you notice how much you had actually talked and your friends’ looks. “what i mean to say is, no. i don’t like spencer reid. and if he wants to fuck his job up, i’d be more than happy.”

morgan suddenly appeared, hotch right behind him.

“guys. there’s something you have to know…” the first talked.

“michael ryer’s dead.” the second finished.

“oh shit.” emily cursed.

“does lila know?” jj asked.

they shook their head.

“she’s gonna be devastated.” jj said to what you sipped at your coffee.

“well at least she has spencer, right?”

“oh, yeah. can we talk about that real quick?!” morgan inquired, astonished.

“no, morgan!” the girls stop him and he raised his hands.

“okay… but the kid has game.”

“woah. i like your house.” spencer said as you two entered lila’s house.

how had you managed to end up with the two of them alone, you didn’t know, and you didn’t like.

“i rent it.” the girl smiled.

“nice.” he nodded.

“lila, you should probably change all your phone numbers.” you said, messaging your team, they’d found something concerning nude photos of the young artist.

“i’m unlisted.”

“anytime you call an 800 or an 888 number your phone number’s put into a data bank that’s then sold to telemarketers. if someone gets your phone number they can go online and research all your records.” you actually responded.

“woah, are you a genius like spencer too?” spencer.

“no. i’m actually smarter.” you gave her a small smile, making her chuckle.

“uh… you should probably carry a piece of paper and pen with you wherever you go in case you see any suspicious license plates that often reappear.” spencer tries to change the conversation as you two followed the blonde towards her kitchen. “and a security dog too.”

“allergic.” she simply answered. “do you guys want some tea?”

you shrugged. “yeah, sure. thanks.” spencer nodded as well. it was already getting late, the sun leaving the city’s sky.

“i’m gonna go change while the water boils, make yourselves comfortable.” she said while making her way upstairs.

you went back towards the salon, your eyes wandering towards a collage on lila’s wall. spencer got your left side, his white stripped button up shirt’s sleeves rolled up to his elbows.

“feel anything yet?” you asked him.

“there is something definitely appealing about this one.” he said and you nodded.

“like lila?”

he looked at you, his mouth falling open to say something, but just as the words were to fall from his lips, the blonde returned in a a more comfortable outfit, making her way towards the patio of her house, beside the pool.

“what are you doing?” spencer inquired her.

“i just need some air. the tea is on the kitchen.” she responded.

“what? no, lila…” your eyes rolled to the back of your head as you watched him go after her.

you could hear them talk and spencer beg her to come inside since there was a psychotic killer aiming at her. you made your way back to the kitchen just as fast as you saw the blonde lean into him, one of her hands tugging at his tie to pull him down. great.

your hands took the cup of steaming tea that lila had prepared you, your eyes on spencer’s as you took a sip. but the warm liquid was poured all over the floor of the kitchen, your head spinning at the blunt trauma that stroke you. your hands went to the side of your forehead as you fell, taking in the sight of your blood. you groaned as someone took you from your hair, pulling you and dragging you across the floor, your hands getting cuts from the smashed cup of tea.

“come here.” the unsub said, taking away your gun, and… you knew that voice. your eyes met the blonde’s.

“maggie lowe?” you muttered to yourself. so you were right. she was the killer and stalker.

you got dragged all the way to the salon, where you could see lila and spencer kissing from the distance. but the kiss quickly broke when maggie fired a shot up into the ceiling, capturing their attentions. spencer quickly pulled out his weapon, pointing at maggie, whose gun’s barbell was right against your head.

“maggie?” lila inquired as they slowly made their way towards you two.

“why’d you have to bring these people here?” she asked lila. “put down the gun.” she ordered spencer, clocking the weapon that kissed your skin. he quickly lowered it, calling out for the killer. “don’t call me maggie! you don’t know me!” “come on lila, let’s go. we gotta go baby, let’s go.” she ordered the actress in a soft yet hurt voice.

“maggie don’t hurt her, you don’t need to hurt her.” you didn’t know if he was talking about lila or you. or maybe both.

“you don’t know anything. i would never do anything to hurt lila. i created her.”

“no, you didn’t.” lila said.

“yes, i did!” you closed your eyes when the barbell dug harsher against your temple. “i did everything for you! and you betray me by bringing these people here… to our house!!!”

“so ungrateful…” you say, loud enough for maggie to hear you. “look at you… you gave her everything and you saw what she did to you… she kissed him. she told him she loved him.” you lied, looking at spencer. he caught on.

“what?” maggie incredulously said.

“i heard them. i saw them kissing each other like animals!” you yelled. “he abandoned me… and now i’m here. about to be killed because of him!” you spat, meeting maggie’s eyes. “you don’t have to hurt me. they don’t deserve us. i’m on your side maggie… i know how you feel. i know how it feels to be betrayed like this…” you nodded, seeing her eyes change. “give me my gun… i’ll kill him for you. and then you can have lila back. i’ll let the two of you go.” you promised, slowly rising up to your feet, extending your hand.

and just as she pointed her gun down, you tackled her, taking the weapons from her and throwing them aside as she fought against your hold.

“reid!” you called out for your work mate, who quickly came to you and handcuffed maggie, who just started crying and begging for you to kill her.

“i gave her everything…”

you looked at spencer, wiping off the blood from your eyes.

“and that’s why we need to stay professional.”

“are you okay, pretty girl?” morgan came to you as the paramedics wiped clean your wound.

“yeah, they say i have a light concussion. a couple of stitches and i’ll be alright.” you gave him a small smile.

“what happened in there, huh? we only got what the paparazzi had on camera, which is…” you nodded.

“yeah. well, maggie got into the house with lila’s spare keys, and basically almost killed me. it was good luck that spencer kissed lila, or else i don’t know what i would’ve done.” the rest of the team had gathered around you.

“you did good. spencer told me how you got into her head.” gideon said.

“thanks.” you responded.

“make sure you’re on the clear before getting up. we’ll be right back, gotta fill in the other officers.” hotch informed you, to what you nodded.

they all left except spencer, who silently looked at you.

“i’m sorry.” spencer said, looking at his feet. “this shouldn’t have happened, if i hadn’t…”

“… played barbie?” you finished off for him, catching his attention. “look spencer. i don’t really care about it. it’s your life and you make your own decisions, just… make sure to not put any of us in danger while doing it. even lila. one of us three could have died tonight.” he nodded. you reached on your back pockets, pulling out the films of the paparazzi’s camera. “i guess this is yours.” he called out for you once again, probably to apologize one more time, but you were still pretty shaken up and you were still pretty mad at him. “would you mind? my head is killing me.” you asked of him and he nodded, silently turning around and walking its way towards morgan and emily. your mind went back to her words the moment the needle punctured your skin. oh ‘come on, really? do you really not feel it?’ ‘there’s this weird tension in between the two of you.’. and then back to jj’s. ‘it’s like when two little kids like each other and they don’t know how to show it so they just mess with each other’. you couldn’t help but chuckle.

you liking spencer? no way.

if there was anything you felt for spencer reid that was hate.

a/n; im so excited for this series!!!! so much angst and fluff and smut yet to come!🤭

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scientia-rex · 1 year

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Because my most popular post is about weight loss and how it's a crock, I get a lot of questions about various things, including bariatric surgery--just posted the link to the post I did about that--but also Ozempic/Wegovy, the once-weekly injectable semaglutide medication that was developed for diabetes but was found to have independent benefits on weight loss.

I always said that weight loss was like Viagra: when a medication came along that actually worked, it would explode. We'd all hear about it. Fen-phen in the 90s worked, but it was bad for your heart. Stimulants, like meth, may cause weight loss, but they do it at the cost of heart health, and raise your likelihood of dying young. Over the counter weight loss supplements often contain illegal and unlisted thyroid hormone, which is also dangerous for the heart if taken in the absence of a real deficiency. Orlistat, or "Alli," works the same way as the Olestra chips Lays made in the 1990s--it shuts off your ability to digest fats, and the problem with that is that fats irritate the gut, so then you end up with fatty diarrhea and probably sharts. Plus Alli only leads to 8-10lbs of weight loss in the best case scenario, and most people are not willing to endure sharts for the sake of 8lbs.

And then came the GLP-1 agonists. GLP stands for glucagon-like peptide. Your body uses insulin to make cells uptake sugar. You can't just have free-floating sugar and use it, it has to go into the cells to be used. So if your body sucks at moving sugar into the cells, you end up with a bunch of glucose hanging out in places where it shouldn't be, depositing on small vessels, damaging nerves and your retinas and kidneys and everywhere else that has a whole lot of sensitive small blood vessels, like your brain.

Glucagon makes your liver break down stored sugars and release them. You can think of it as part of insulin's supporting cast. If your body needs sugar and you aren't eating it, you aren't going to die of hypoglycemia, unless you've got some rare genetic conditions--your liver is going to go, whoops, here you go! and cough it up.

But glucagon-like peptide doesn't act quite the same way. What glucagon-like peptide does is actually stimulating your body to release insulin. It inhibits glucagon secretion. It says, we're okay, we're full, we just ate, we don't need more glucagon right now.

This has been enough for many people to both improve blood sugar and cause weight loss. Some patients find they think about food less, which can be a blessing if you have an abnormally active hunger drive, or if you have or had an eating disorder.

However, every patient I've started on semaglutide in any form (Ozempic, Wegovy, or Rybelsus) has had nausea to start with, probably because it slows the rate of stomach emptying. And that nausea sometimes improves, and sometimes it doesn't. There's some reports out now of possible gastroparesis associated with it, which is where the stomach just stops contracting in a way that lets it empty normally into the small intestine. That may not sound like a big deal, but it's a lifelong ticket to abdominal pain and nausea and vomiting, and we are not good at treating it. We're talking Reglan, a sedating anti-nausea but pro-motility agent, which makes many of my patients too sleepy to function, or a gastric pacemaker, which is a relatively new surgery. You can also try a macrolide antibiotic, like erythromycin, but I have had almost no success in getting insurance to cover those and also they have their own significant side effects.

Rapid weight loss from any cause, whether illness, medication, or surgery, comes with problems. Your skin is not able to contract quickly. It probably will, over long periods of time, but "Ozempic face" and "Ozempic butt" are not what people who want to lose weight are looking for. Your vision of your ideal body does not include loose, excess skin.

The data are also pretty clear that you can't "kick start" weight loss with Ozempic and then maintain it with behavioral mechanisms. If you want to maintain the weight loss, you need to stay on the medication. A dose that is high enough to cause weight loss is significantly higher than the minimum dose where we see improvements in blood sugar, and with a higher dose comes higher risk of side effects.

I would wait on semaglutide. I would wait because it's been out for a couple of years now but with the current explosion in popularity we're going to see more nuanced data on side effects emerging. When you go from Phase III human trials to actual use in the world, you get thousands or millions more data points, and rare side effects that weren't seen in the small human trials become apparent. It's why I always say my favorite things for a drug to be are old, safe, and cheap.

I also suspect the oral form, Rybelsus, is going to get more popular and be refined in some way. It's currently prohibitively expensive--all of these are; we're talking 1200 or so bucks a month before insurance, and insurance coverage varies widely. I have patients who pay anything from zero to thirty to three hundred bucks a month for injectable semaglutide. I don't think I currently have anyone whose insurance covers Rybelsus who could also tolerate the nausea. My panel right now is about a thousand patients.

There are also other GLP-1 agonists. Victoza, a twice-daily injection, and Trulicity, and anything else that ends in "-aglutide". But those aren't as popular, despite being cheaper, and they aren't specifically approved for weight loss.

Mounjaro is a newer one, tirzepatide, that acts on two receptors rather than one. In addition to stimulating GLP-1 receptors, it also stimulates glucose-dependent insulinotropic polypeptide (GIP) receptors. It may work better; I'm not sure whether that's going to come with a concomitantly increased risk of side effects. It's still only approved for diabetes treatment, but I suspect that will change soon and I suspect we'll see a lot of cross-over in terms of using it to treat obesity.

I don't think these medications are going away. I also don't think they're right for everyone. They can reactivate medullary thyroid carcinoma; they can fuck up digestion; they may lead to decreased quality of life. So while there may be people who do well with them, it is okay if those people are not you. You do not owe being thin to anyone. You most certainly do not owe being thin to the extent that you should risk your health for it. Being thin makes navigating a deeply fat-hating world easier, in many ways, so I never blame anyone for wanting to be thin; I just want to emphasize that it is okay if you stay fat forever.

#the attending dr. kristophine

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