Dr. Ahmed
Mounjaro and Ozempic are the trending novel drugs indicated for diabetes and weight loss. They are considered “blockbuster medicines” because of their significant HbA1C reduction and weight loss.
In the manufacturer’s FDA labeling, it is stated that Ozempic does not need a change in the dose in patients with liver cirrhosis (or renal impairment).
It is true that Ozempic is eliminated from the body by proteolytic enzymes. There is no role of the liver and the kidneys in eliminating Ozempic from the body, hence the manufacturer says that dose adjustment is not necessary.
Similarly, Lilly’s Mounjaro has the same pharmacokinetics as Ozempic. It is not eliminated from the body by the liver or the kidneys and hence dose adjustment is not necessary in such patients.
However, does it worsen or improves fatty liver, NASH, Alcoholic Liver Cirrhosis, or Liver Cirrhosis caused by viruses or other drugs is not known.
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Here we’ll try to address the effects of Mounjaro and Ozempic on Liver cirrhosis due to the various conditions.
Mounjaro, Ozempic, and Fatty Liver Disease:
Fatty liver disease is a very common problem. It affects about one-third of the general population and 70% of those with underlying metabolic syndrome (diabetes, obesity, dyslipidemia, and hypertension).
Fatty liver progress to NASH in a small percentage of patients. NASH or non-alcoholic steatohepatitis is a term used when biochemical parameters such as liver enzymes ALT, AST, GGT, and Alkaline phosphatase become abnormal.
Fatty liver can be regarded as a Pre-NASH stage just like people have prediabetes. This is probably the most important stage where prevention will delay the progression to NASH and liver cirrhosis.
Ozempic and NAFLD (Fatty Liver Disease):
In one study, once weekly Semaglutide (Ozempic) was administered to 48 patients with fatty liver disease.
Among the study participants, 64.6% of patients had moderate or severe obesity. The severity of fatty liver disease at baseline was:
- Mild NAFLD: 12%
- Moderate NAFLD: 44%
- Severe NAFLD: 44%
Ozempic was given in a dose of 0.25 mg weekly as a subcutaneous injection for four weeks, followed by 0.5 mg weekly for five months, and 1 mg weekly for the next six months. All patients were also taking metformin at their maximum tolerated doses.
After one year of Ozempic treatment, there was a significant improvement in the glycemic parameters (Fasting and post-prandial sugars, HbA1C, Insulin levels, and Insulin resistance index as measured by the HOMA-IR).
A significant reduction in body weight, as well as improvement in lipid profiles, were noted.
There were significant improvements in the liver enzymes and parameters indicating the severity of NAFLD or fatty liver such as the APRI score and other scores.
Subcutaneous fat was reduced during the first six months of treatment but after one year, no difference from the baseline was observed.
It was observed that Ozempic resulted in significant improvement in the fatty liver score in 70% of the patients from baseline.
Mounjaro and NAFLD (Fatty Liver Disease):
Mounjaro is a relatively new drug and therefore, data regarding its use in NAFLD (Fatty liver disease) is very limited.
The SURPASS-3 Trial evaluated the role of Mounjaro compared to Insulin Degludec in patients with NAFLD (Fatty Liver Disease).
Patients who received 10 mg and 15 mg Tirzepatide weekly had a reduction in liver fat content by 8% from baseline compared to Insulin Degludec (3%).
Here are some experiences shared by people using Mounjaro:
| “Before I started taking Mounjaro, my liver enzymes had been higher than normal for about 4-5 years. However, since I started taking it, I’ve lost 75 pounds, and my most recent blood test showed that my liver enzymes are back to normal. I’m really hopeful that things are finally getting better and that my doctor will be able to figure out what’s been going on” |
| “Back in November, my test results showed that my levels were normal. But then I began taking Mounjaro. Last week, my doctor wanted to check on things and ordered some more tests. Unfortunately, this time my ALP (alkaline phosphatase) level was higher than before. It went from 118 in November to 161 now. I’ve been freaking out a bit because I looked it up online and found out that elevated ALP could be a sign of liver or bone disease. When I told my doctor about my concerns, all he said was that he’ll repeat the test in three months and advised me to drink more water. I’m feeling pretty worried and hoping that everything turns out okay” |
| “Since reaching my goal weight, my whole life has turned around. It’s amazing how things have changed. I no longer wake up with those intense cravings for sodas or M&M’s. Plus, my knees don’t hurt anymore, which is a huge relief. People even treat me differently now, and I’ve noticed a positive shift in how I’m perceived. Another great thing is that those random stomach issues I used to suffer from have disappeared. My blood pressure is back to normal, and my insulin resistance is completely gone. The good news—I don’t have non-alcoholic fatty liver disease (NAFLD) anymore, and my cholesterol levels have greatly improved. It’s incredible to think that I’m no longer at risk of being pre-pre-diabetic. I’m also able to exercise every day without any trouble, and here’s a weird bonus: even my ADHD seems to have gotten better somehow. I guess my body was really out of whack before, but now things are definitely looking up!” |
| “I used to have NAFLD, but thanks to Mounjaro, it has improved a lot. My weight has also gone down, and my A1C levels have significantly improved. It’s such a relief to see these positive changes happening” |
| “Back in January, I found out I had fatty liver, and they even confirmed it with an ultrasound. But then I started taking Mounjaro after they told me I was at risk for prediabetes. Guess what? After three months, I went for my blood test, and all my levels came back normal. No more fatty liver for me! It’s like magic how it fixed my liver, glucose, and cholesterol levels in just three months. Plus, I managed to lose 28 pounds along the way. I couldn’t be happier with the results!” |
In summary, our understanding is limited, but there are indications that both Ozempic and Mounjaro could potentially improve liver function and reduce liver fat content, either directly or indirectly.
Based on the available information, it appears that Ozempic has gained an advantage over Mounjaro. Some individuals have reported having to switch back to Ozempic or Wegovy due to concerns about impaired liver function while taking Mounjaro (Tirzepatide).
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Mounjaro, Ozempic, and NASH:
NASH is one step closer to liver fibrosis than Non-alcoholic fatty liver disease (NAFLD). When the liver is inflamed, the biochemical markers become elevated. Important biochemical markers include GGT, AST, and ALT.
NASH is followed by fibrosis and then end-stage liver disease. Thus, this is the critical stage, and management to reverse it is very important.
Ozempic has been associated with an improvement in NASH but the initial trials conducted no improvement in the fibrosis.
The following results were obtained when Ozempic was evaluated in patients with NASH and Fibrosis [Ref]:
| Treatment Group | Improvement in Liver Fibrosis (%) | Resolution of NASH (%) |
| Semaglutide | 10.6% | 34% |
| Placebo | 29.2% | 20.8% |
The results of other studies conducted recently showed a beneficial effect of Ozempic in NASH patients.
A placebo-controlled trial evaluated the role of Ozempic in biopsy-proven NASH patients. There was a significant improvement in terms of the resolution of NASH in patients treated with Semaglutide compared to placebo [Ref].
The table below shows the percentage improvement observed in the Semaglutide group vs placebo:
| Treatment Group | NASH Resolution (%) |
| 0.1 mg | 40% |
| 0.2 mg | 36% |
| 0.4 mg | 59% |
| Placebo | 17% |
Similarly, improvement in fibrosis and weight loss was much greater in the Semaglutide group compared to placebo. Here are the results tabulated:
| Treatment Group | Improvement in Fibrosis Stage (%) | Mean Weight Loss (%) |
| 0.4 mg | 43% | 13% |
| Placebo | 33% | 1% |
The role of Mounjaro (Tirzepatide) in the treatment of NASH has not been evaluated. However, people have posted mixed responses in their social media comments.
Although some people have noticed a resolution in their symptoms, others noted worsening in their LFTs and had to switch back to Ozempic.
There is a need for randomized and head-to-head trials comparing Mounjaro and Ozempic in the treatment of NASH.
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Mounjaro, Ozempic, and Alcoholic Liver Cirrhosis:
Alcoholic liver disease and non-alcoholic fatty liver disease (NAFLD) share similar histopathological characteristics. The key distinguishing factor between them is the consumption of alcohol, specifically in moderate to heavy amounts.
From a biochemical standpoint, the ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) is typically greater than 1 in these conditions. A value exceeding 2 strongly suggests the presence of alcoholic liver disease (ALD).
The treatment approach primarily focuses on abstaining from alcohol, avoiding sugary beverages, adopting a Mediterranean diet, achieving weight loss, and considering bariatric surgery when necessary.
Notably, research has shown that a weight loss of 10% or more can lead to an 81% regression of fibrosis in both alcoholic liver disease and non-alcoholic steatohepatitis (NASH). Similarly, a weight loss of 5% or more may result in a 45% regression of fibrosis.
Medical interventions for these conditions may involve the use of certain medications. These include Vitamin E, Pioglitazone, Obeticholic acid, SGLT2 inhibitors such as Jardiance or Farxiga, and GLP-1 analogs like Ozempic and Victoza.
Among these treatments, GLP-1 analogs (Ozempic and Victoza) have demonstrated direct and indirect improvements in NASH due to their effects on weight loss. Similarly, the potential benefits of SGLT2 inhibitors are also being investigated.
Studies have indicated that Ozempic can completely resolve NASH in 29% of patients. However, its effectiveness in improving liver fibrosis has not been established.[Ref]
One important observation with both Ozempic and Mounjaro is that people have fewer cravings for alcohol. In fact, GLP-1 analogs may be considered for patients who have alcohol dependence.
Here are some of the patient’s comments about Mounjaro, Ozempic, and alcohol:
| I stopped relying on alcohol completely, and it happened pretty quickly, within a maximum of two weeks. I used to drink every day, but now, if I do drink, it’s only two drinks on Sundays, and I feel like I have to force myself to do it. This change has had a great impact on me, with the best side effect being the weight loss. It’s been a positive transformation for me overall. |
| I had the exact same experience! I used to drink a whole bottle of wine every night and have three cocktails with dinner, but now I only have one or two drinks a week when I’m out with friends. It’s been a significant change for me. |
| I was already working on my recovery from alcohol when I started using Mounjaro, but after about two months, any remaining thoughts or cravings for alcohol completely vanished. |
| Right after I started 2.5 Mounjaro weekly, something clicked in me. I distinctly remember not wanting a glass of wine with dinner that night, and from that moment on, I just haven’t had the desire for alcohol. It happened on August 15, 2022. Since then, I’ve only had one glass of red wine during Christmas dinner and half a beer about a week ago. It’s pretty amazing considering I used to drink wine every single day for many years. Even though my husband still drinks wine with dinner, it doesn’t bother me at all. |
| It’s incredible how quickly things changed for me after taking 2.5! Before I used to have 1-2 rum and diet cokes every day, and sometimes even more on weekends. But now, I’ve cut down significantly. I might have just one drink on a Saturday, and that’s it. My liver must be thrilled with the changes I’ve made. |
| I wanted to share my story because it’s truly mind-blowing. I struggled with alcoholism for years, but since starting Ozempic (Wegovy) a week ago, things have changed drastically. After just one night, I couldn’t even finish my last drink. Now, I can barely get through two drinks, and I don’t even want more. It’s a strange feeling, but it’s a relief I haven’t felt since I was a teenager. I hope this continues! |
| Yeah, it’s crazy. I’ve completely ditched beer, and wine just doesn’t do it for me anymore. I can only handle 2 or 3 vodka sodas now. It’s made a huge difference in my life, honestly. I used to down 10-12 Michelob Ultras in one go, three or four times a week. But now, I can’t even bring myself to touch that stuff. |
| That’s fantastic! I’m really thrilled for you. I truly believe that we’ve stumbled upon a group of peptides that will not only help tackle obesity but also work wonders in treating alcohol use disorder and other substance abuse problems. When everything is said and done, we’ll realize that GLP-1/GIPs are among the most remarkable scientific breakthroughs of our generation. It’s truly amazing to think about! |
| On September 15th, upon the recommendation of my gastroenterologist, I commenced the usage of Ozempic. Since 2014, I have been diagnosed with non-alcoholic fatty liver disease (NAFLD), which is evident through elevated levels of liver enzymes in my blood work. Additionally, I have experienced high triglyceride levels since the introduction of their testing in my early twenties (I am currently 40 years old). Furthermore, I have high cholesterol levels and am in a pre-diabetic state. Tomorrow, I have an appointment scheduled with my doctor for my monthly Ozempic check-in. As I have been taking the medication for a duration of 4 months, he requested that I undergo some blood tests earlier today. I recently accessed the results online and was pleasantly surprised. For the first time in 9 years, all my liver enzyme levels fall within the normal range! Moreover, my triglyceride and cholesterol levels have significantly decreased since May (however, my sugar levels were not examined for some reason). Undoubtedly, Ozempic has proven to be effective in my case. Additionally, for those interested in weight loss outcomes, I have successfully lost 25 pounds in the span of 4 months. |
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Mounjaro and Ozempic Use After Liver Transplantation:
Insulin is considered the preferred treatment for post-transplant diabetes. However, evidence is increasing in favor of using Ozempic and Mounjaro in post-transplant patients.
Not only do these drugs lower A1C and improve glycemic control, but they also prevent weight gain with insulin and transplant medications.
A clinical trial is currently underway to assess the efficacy of Semaglutide, Ozempic, in preventing weight gain in post-liver transplant patients [Ref]
In addition, post-transplant patients are at risk of developing cardiovascular comorbid conditions, weight gain, and diabetes (in those without diabetes before the transplant).
GLP-1 analogs lower body weight, may prevent the development of diabetes, do not have any significant interactions with transplant medications, and help in reversing histological changes with NASH [Ref]
Here is a proposed algorithm [Ref]
In Conclusion:
Ozempic and Mounjaro are novel diabetes medications. These medications directly or indirectly reduce liver inflammation by altering fat metabolism.
In addition to their effect on body weight, these drugs also reduce cravings for sugary drinks and alcohol.
Ozempic and mounjaro users who were trying to get rid of alcohol dependence and failed, have finally found a medicine that is helping them reduce their alcohol intake.
These medicines may likely be used in the near future for the treatment of ALD (alcoholic liver disease), ASH (alcoholic steatohepatitis), NAFLD (Non-alcoholic fatty liver disease), NASH (Non-alcoholic steatohepatitis), and Liver Cirrhosis.
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