Semaglutidonomics
In March of this year, the patent on semaglutide (Ozempic) in India expired. Forty Indian companies launched a version of generic semaglutide on the same day.
Prices collapsed immediately as you’d expect: branded Ozempic was around $95 a month beforehand. Now the cheapest generics cost $14 a month11. I think it’s really funny that this one is called “Sundae”..
This is pretty insane. These drugs cost hundreds, sometimes thousands of dollars in other markets. But now a huge chunk of the world’s overweight population has access to revolutionary weight-loss drugs at a huge discount. For the Indian middle class this is still somewhat expensive, but certainly within reach of the upper end of this group. Including those in higher socioeconomic brackets, is about 250 to 300 million people.
Realistically given how many people are clinically indicated, and factoring in cold chain requirements (keep reading for more on that) the total addressable population is closer to 50 to 80 million Indians. Still vastly larger than any Western market and similar to the total US market for GLP-1 drugs22. Hereafter referred to as “GLP-1s” for brevity; technically they are GLP-1 receptor agonists..
US insurance coverage for these drugs is falling, presumably as insurers have figured out that they’re going to go bankrupt given how many people could plausibly be prescribed these drugs; Indian medical organisations have largely adopted lower BMI cutoffs (25 and above) for these drugs which means the eligible market there is growing. This leads to a surprising situation where the two markets end up crossing over, with more Indians on GLP-1s than Americans.
Exporting generics
I’m going to share a secret website. Don’t tell anyone else about it.
It’s called United Pharmacies. Their website looks like it was made in the 2000s (in fact it probably was) and has never been updated. They say they are “Oceania-based”, which is pretty vague – I think they’re registered in Vanuatu, but their packages all come from (or are forwarded through) Hong Kong.
They sell an enormous range of generic drugs. Nothing illegal – so no Adderall, gabapentinoids, benzos or sleeping pills. It’s been running for years, so they’re obviously profitable and have robust infrastructure and supply chains. It’s legal in most places to import prescription-only drugs for personal use; the Medicines Act in the UK has a specific carve out for this, where you can import up to three months’ worth.
It’s tempting to think that these semaglutide generics could just be exported. Unfortunately peptides need to be kept cold, otherwise they start to degrade – the peptide chains start to fall apart if they’re warm, and the drug quickly loses its potency. This is why these drugs are shipped through a ‘cold chain’, where they’re refrigerated in transit. The requirement to ship through a cold chain makes exporting these drugs in small quantities (i.e. for personal use, rather than importing large amounts and breaking bulk) infeasible. SAD!
Why can’t you put these drugs in a pill?
At the moment all the blockbuster drugs (Ozempic, Mounjaro) are injectable peptides which are sold in solution, usually in an injector pen (varies by region; sometimes they’re sold in a multi-dose vial but always in solution).
They’re injectable because they’re peptides – basically small proteins. If you were to take them orally they’d just get broken down in your stomach just like any other protein. There is one notable exception: you can add absorption-enhancing compounds to improve oral bioavailability. Rybelsus is an orally-active version of Ozempic but you have to take it in much higher doses, and it’s formulated with an absorption enhancer called SNAC.
The problem is it doesn’t work very well. It has to be taken on an empty stomach with precisely 120mL of plain water, no food/coffee/other mediation for at least 30 minutes. Anything else drastically reduces its absorption as the way SNAC works is by producing a localised pH-controlled microenvironment in the stomach. Adherence to this is understandably very poor. A weekly injection frankly sounds much more convenient.
Oral GLP-1s
The latest oral GLP-1 agonist, orforglipron (brand name: Foundayo), isn’t a peptide: it’s a small molecule like most medicines. This means that it can just be taken as a pill, skipping all the rigamarole of injections or co-administering it with absorption enhancers. It can be taken at any time of day without the ridiculous precise dose of water/fasting thing, its bioavailability is much more predictable.
In head-to-head trials it’s been shown to be much more effective than Rybelsus. Side effects are similar, but real world adherence is likely to be much better because of the simpler administration.
It just got approved (April 2026) by the FDA for weight loss.
When generic oral GLP-1s?
The way the patents used to work in India was odd: the patent applied to the synthesis of the drug (so-called “process patents”), not the molecule itself. So you could just invent a different synthetic pathway and sell a generic without paying royalties. This was a deliberate political choice by the Indian government of the 1970s aimed at building a domestic generics industry.
This was changed in 2005 to bring India in line with international trade agreements (though drugs that were patented before the cutoff were grandfathered into the old system). The reason why semaglutide is now generic in India and not elsewhere is that India doesn’t grant patent extensions, so Novo Nordisk’s 20 years has expired and they can’t protect it any longer the way the can in other markets.
Given the patent on orforglipron doesn’t expire until the mid-2030s, we’re unlikely to see generic Foundayo any time soon.
There is a notable exception to this: very rarely, the Indian authorities will decide that if a patented drug is not available at an affordable price or the “reasonable requirements of the public” aren’t being met, they can grant a compulsory licence three years after the patent grant. They’ve done this exactly once in 2012, where the manufacturer of cancer drug sorafenib was granted a compulsory licence to manufacture a generic version for $170/month instead of the usual $5500/month.
This was understandably very controversial – essentially using price controls to force a drug to be sold at a huge discount – and so it’s never been used since. But I think a cheap oral GLP-1 agonist – a drug which can treat a medical condition which hundreds of millions of Indians have and which is a huge contributor to mortality – might receive a compulsory licence in this way.
There’s also another get-out clause, which is that a drug can be manufactured and sold in India while infringing a patent, with the patent holder having to file suit, the outcome of which might take several years (the Indian courts move very slowly). Some companies do this, bank the profit, and then accept it as a cost of doing business if they subsequently lose in court.
GLP-1s for everybody
Two things are happening at once here: India is on track to become the largest market for GLP-1s in the world by headcount, and this class of drugs is moving from peptides (tricky to manufacture and deliver) to small molecules. Currently the cold chain is the moat, but once these small molecule drugs start to go off-patent, you’ll be able to ship them anywhere in the world, and the price of GLP-1s will collapse.
The timing is uncertain. It’s possible but unlikely that the Indian government will exercise a little-used mechanism to put price controls on Foundayo. But at some point in the future, people will be importing gray market orforglipron from Hong Kong, and health services like the NHS will have to decide whether to catch up or be quietly routed around.