Testing the Efficacy, Safety, and PK of 20E in Patients With Obesity Who Are Starting Treatment With the GLP-1 Agonist Semaglutide for Weight Loss.

Prior treatment

• Participant not able to take medications by mouth (as capsules)
• Use of disallowed concomitant medications or herbal products: Any herbal products containing 20-hydroxyecdysone and derived from Leuzea carthamoides, Cyanotis vaga, or Cyanotis arachnoidea are not allowed and any other anabolic products, GH/IGF-1 products, spironolactone, metformin, chemotherapeutic agents, antidepressants, and systemic glucocorticoids within three months prior to study enrollment or strong inhibitors of the Organic Anion Transporting Polypeptide (OATP1B3) e.g. rifampicin and cyclosporine. Use of muscle strength-supporting food supplements
• Previous surgical obesity treatment or planned obesity surgery during the study period
• Use of anti-obesity (weight-loss) medication or use of any GLP-1 RA for diabetes within 90 days before enrollment
• History of stroke, myocardial infarction, life-threatening arrhythmia, or coronary revascularization within 6 months prior to screening

Other illness

• Any known hypersensitivity to any of the active substances (20E), and its excipients (the study medication) and the active substance and the excipients of semaglutide.
• Current diabetes (both insulin dependent and T2DM)
• A history of chronic pancreatitis or acute pancreatitis
• Uncontrolled hypertension (RR above 150/100 mmHg)
• Autoimmune/inflammatory disorders that may cause muscle wasting
• History of major depressive disorder within the last 2 years
• Any lifetime history of suicide attempt
• History of any suicidal behavior in the last month
• History of other severe psychiatric disorders, e.g., schizophrenia, bipolar disorder
• Patients with obesity due to other endocrinologic disorders
• Patients with clinically Recognized Eating Disorders
• Patients with clinically significant, uncontrolled hyperthyroidism or hypothyroidism, or those with newly diagnosed thyroid disease within the past 3 months.

Lab values

• Clinically significant liver disease, ALT/AST \>5x ULN, or total bilirubin \> 2x ULN, unless the patient has known Gilbert's syndrome
• Neuromuscular disorder or CK \>5x ULN
• eGFR ≤60 mL/min/1.73 m2, based on Cockcroft \& Gault formula OR Participant requiring renal dialysis

Other

• History or present cholelithiasis or cholecystectomy from medical history or sludge or stones observed on gallbladder ultrasound or any other method.
• Presence of contra-indications to semaglutide per current semaglutide Prescribing Information / Summary of Product Characteristics
• BMI \>40
• NYHA Class III or IV CHF
• Use of antipsychotics, amphetamines, or any other treatments that can affect weight
• Clinically significant ECG abnormalities
• Baseline PHQ-9 score ≥15 or any suicidal ideation of level 4 or level 5 on the Columbia-Suicide Severity Rating Scale
• History or current gastroparesis (from medical history)

• Willing to participate and able to sign an ICF
• BMI ≥30 or BMI ≥27 with one or more weight-associated co-morbidities (e.g. hypertension, dyslipidemia, obstructive sleep apnea or cardiovascular disease)
• Start of treatment with semaglutide for weight loss at Day 3 after the start of the study treatment
• Willing to maintain a diet with an average intake of at least 1 gr/kg body weight protein daily
• Willing to maintain sufficient exercise, i.e. at least 150 minutes per week moderate-vigorous exercise
• Body weight stable (within a 5 kg range) in the 3 months prior to enrolment
• Female participants should be at least 12 months post-menopausal) or surgically sterile OR have a negative urine pregnancy test at screening and be willing to use a contraceptive method from screening to 90 days after last dose.
• Based on Semaglutide long half-life, participants should consent to use a contraception method 3 months after administration of the last dose intake of semaglutide.