Twiggy's Invex Therapeutics | The Imminent Coin Flip, page-36

I actually think it is a really good question and one which I have looked at before. I don't have a answer but I do have some thoughts/observations.

1) weight loss itself does not completley solve the IIH complications for a good number of people and you can see this with some of the research done with IIH and bariatric surgery. While it often seems to resolve the papilledma, it does not always resolve other issues like headache.

2) Many of these drugs also work on the GLP-1 receptors, however the weight loss results are quite variable and the early variants which are essentially converted diabetes drugs are not significantly better than exenatide at promoting weight loss. Also the higher the dose and some of these need very high doses the longer the period of titration and the lower the tolerability.

The newer drugs, coming to market have GLP-1 agonists but they are combined with other elements like GIP agonists. Again the results are quite variable from stunning to nowhere near enough to bring obesity down to a level that would cause a resolution of IIH symptoms. So there are clearly more factors at play here than are currently understood.

There is one other important risk factor for IIH that is not often discussed here, nor more broadly in fact, and that is socioeconomic status. The associations with deprivation are strong and typically the efficacy of most treatments is lower, in lower socioeconomic sectors. Also they are in section of society least able to afford/access these types of treatments.

- A typical IIH patient only turns up at a clinic when they have some sort of serious issue - sight or headaches.

- They are typically very obese and not of high social status and often with multiple health issues. Depending on where they are, they are most likely interacting with the most basic form of healthcare in their system

- First thing a doctor needs to do is reduce ICP. The only approved (I am projecting) non surgical treatment is to prescribe Presendin. It is cheap and safe and proven to bring down ICP within 2 hours.

- The patient will then be put on to a care pathway that will look at longer term lifestyle changes. At the lower rungs of the healthcare ladder this will take time. From many months to a year and during that time they remain on Presendin.

- Various low cost weight loss methods will be tried such as diet plans etc, this will be given a period of time to work (12 to 24 months) all the time they remain on Presendin.

- These efforts will likely fail at which point they will move to alternative (newer weight loss drugs or bariatric surgery which is actually probably more cost effective)

- Most likely they will remain on presendin until the beneficial effects are seen which is likely to be at least 12 months.

I think it is going to be a longtime until we see a significant reversal in the levels of obesity due to these new drugs, I also think the typical IIH patient, given their socioeconomic status, will be among the last cohort to benefit from these drugs, if indeed they are the answer to community wide obesity. Given the high cost of these treatments and their lifelong nature I am not sure they are going to be a cost effective option for much of society.
As such I do not expect these drugs to have any immediate/medium term impact on prevalence of IIH.

Given this view on prevalence and given that most diagnosis of IIH is in people who turn up with an acute issue of some sort or other the diagnosis rates will continue to rise and Presendin will be prescribed as the first line treatment to deal with resolving immediate ICP issues. Once the ICP is under control the healthcare system will take years to find a pathway/ solution to a patients weight/lifestyle issues, all the time they will remain on Presendin.