1 September 2026 • 42 minute read
Analysis of online pharmacy advertisements for non-FDA-approved treatments
Executive summary
Unapproved compounded drugs are often widely advertised online, exposing consumers to treatments that have not been evaluated by the United States Food and Drug Administration (FDA) for safety or efficacy. Consumer survey findings suggest that some consumers may misunderstand the level of regulatory review associated with online prescription services.
- Nearly two-thirds of US adults believe that all websites offering online prescription services are reviewed and approved by regulators.
- Half of US adults believe that only safe sellers appear on the first page of search results.
DLA Piper conducted a survey using structured search terms and artificial intelligence (AI)-assisted analysis to identify vendors promoting non-FDA-approved treatments online across four therapeutic areas: obesity, erectile dysfunction (ED), hair loss, and hormone replacement therapy. The study evaluated the types of messages and safety information provided to potential consumers.
Among the 23 vendors analyzed that advertised non-FDA-approved medicines in at least two of the four therapeutic areas, key findings include:
- Promotion of formulations the FDA has not evaluated for safety or efficacy, including sublingual and "microdose" versions of glucagon-like peptide-1 (GLP-1) drugs
- Marketing of multi-drug combination products the FDA has not evaluated for safety or efficacy
- References to brand-name drugs when promoting compounded drugs
- Gaps in safety disclosures, including limited or absent information about contraindications, warnings, or adverse event reporting mechanisms
Among the vendors studied, 52 percent included unsupported efficacy statements about non-FDA-approved drugs, 43 percent included incomplete or misleading warnings and safety claims, and 26 percent failed to include prominent safety warnings.
Although the FDA has increased advertising-related enforcement activity, including issuing more than 100 warning letters since September 2025, current monitoring mechanisms, including FDA's Bad Ad Program, do not expressly cover non-FDA-approved medicines. The proliferation of potentially misleading advertisements may highlight an area for further monitoring of consumer-facing promotion for non-FDA-approved medicines.
This report summarizes the study’s findings and identifies potential considerations for oversight of non-FDA-approved medicines, drawing on strategies already used to regulate advertising for FDA-approved drugs.
Consumer-risk considerations for online promotion of non-FDA-approved treatments
Background and motivation for research
Despite warnings from the FDA, non-FDA-approved compounded drugs continue to be widely available and advertised, with growing consumer use in the US. As defined by the Food, Drug, and Cosmetic Act, compounding is allowed in limited circumstances to serve patients with distinct medical needs, such as those with allergies.
Compounding, however, was never intended to mirror or replace drug manufacturing. While some cases require compounded medicines, the distribution of these drugs may present safety concerns, as they lack FDA review and approval for safety and efficacy.
When promotional materials do not clearly distinguish these treatments from FDA-approved versions or explain relevant quality or adverse event reporting, consumers may have insufficient information to assess product differences and associated safety risks. The FDA has advised that compounded drugs should only be used when an FDA-approved drug cannot meet a patient’s medical needs.
When compounding medicines from bulk drug substances, pharmacies may, under certain circumstances, obtain active pharmaceutical ingredients (APIs) from sources outside the FDA-approved supply chain for a specific product. The law requires that APIs be purchased from FDA-registered establishments subject to current good manufacturing practices (cGMPs). However, in practice, the drug substances used in bulk drug compounding may present quality or compliance questions if sourced outside these regulations.
Scope of evaluation
The study evaluated medicines prescribed in non-FDA-approved combinations. This includes treatments with two or more ingredients that the FDA has not tested for safety and efficacy in their given combination, dose, or strength.
The FDA requires testing of combination drugs to assess how they work together and potential drug interactions. FDA-approved combination drugs must demonstrate in clinical trials that each constituent actively contributes to the combined effect to a greater degree than each of the components dosed separately. Unapproved, untested compounded combination medicines do not undergo FDA review. These drugs do not have robust clinical evidence of whether their combinations are safe and effective or whether they interact with other drugs.
Individuals purchasing medicines from online pharmacies are not always aware of these implications. In a survey, 65 percent of US adults reported believing that all websites offering online prescription services are reviewed and approved by the FDA or state regulators. In addition, 51 percent of US adults believe that only safe sellers are listed on the first page of internet search results.[1]
To evaluate the extent and types of promotion of non-FDA-approved drugs at scale, the study used a methodology to identify vendors promoting such treatments online across the selected therapeutic areas. The study evaluated the extent and breadth of promotion and noted key attributes the FDA has identified as concerning, including unsupported or potentially misleading branding claims.
This analysis focuses on advertisements for medicines that are not FDA approved, including compounded medicines or treatments offered in combination or dose formats that have not been evaluated for safety and efficacy by the FDA. While FDA's Bad Ad Program website allows healthcare providers to report misleading advertisements for approved medicines, it does not cover non-FDA-approved treatments, a gap this analysis seeks to address.
History of recent FDA action related to advertising
In September 2025, the FDA announced expanded efforts to address deceptive advertising in pharmaceuticals. As previously noted, the agency has since issued more than 100 warning letters, primarily to telehealth providers, about the marketing of compounded GLP-1 medications. By comparison, one warning letter was issued between 2023 and 2024.
Also in September, the FDA warned telehealth platforms selling compounded GLP-1 medicines and other drugs for making unsupported and potentially misleading statements in their promotional materials. In February 2026, the FDA announced its intention to take action against non-FDA-approved GLP-1 drugs and issued 30 warning letters to telehealth companies promoting those treatments.
Of the vendors analyzed in this study, two had received warning letters from the FDA about concerns that compounded GLP-1 product claims were unsupported or potentially misleading. Since the conclusion of this analysis, those companies have discontinued public advertising of compounded GLP-1 medications.
Methodology
Study design
This study used online market surveillance and content analysis to evaluate advertising practices for non-FDA-approved medicines in selected therapeutic areas. The objective was to characterize the scope and nature of marketing claims made by online pharmacies and telehealth providers offering compounded formulations of the active ingredients in FDA-approved products.
The analysis focused on four therapeutic areas:
- Obesity
- ED
- Hair loss
- Hormone replacement therapy
Preliminary research indicated that these categories account for a substantial share of products marketed online and frequently involve compounded or non-FDA-approved formulations.[2],[3],[4],[5] See Table 2, Appendix, for a list of drugs and the molecules included.
Vendor data collection began in October 2025. At that time, researchers primarily focused on compounded GLP-1 medicines. Since then, several vendors have stopped advertising compounded GLP-1 medicines. However, they continue to sell compounded medicines in other therapeutic areas.[6]
The study consisted of three phases:
- Identification of relevant online vendors through structured search engine queries
- Compilation of vendor characteristics and advertising content into a database
- Coding and analysis of marketing claims, disclosures, and safety information on vendor websites
Identification of online vendors
To approximate typical consumer search behavior, and drawing on peer-reviewed methods, our study used a search protocol using AI-generated consumer queries related to obtaining prescription medications online.
The AI-generated search terms were categorized into the following:
- Core telehealth and pharmacy terms
- Compounding and generic framing
- Marketing and sales language
- Regulatory and risk-flag wording
Terms were chosen from each category, and the brand name and molecule name were added to each of the search terms as separate search strings.
Examples include:
- “Buy compounded alternatives online Sildenafil”
- “Buy compounded alternatives online Viagra”
- “Custom compounded treatments online tirzepatide”
- “Custom compounded treatments online Mounjaro”
Searches were conducted using a single search engine for consistency. For each query, researchers reviewed only the first page of results. This approach reflects evidence that users rarely review results beyond the first page and therefore aims to capture the most visible vendors consumers encounter online.[7]
Search results were screened to identify companies selling medications to US consumers through online pharmacies or telehealth platforms. Sponsored search results were noted when identifiable. See Figure 1, Appendix, for sponsored versus non-sponsored search results.
Companies identified through these searches were entered into a tracking database for further review.
Inclusion criteria
This study sought to focus on vendors with meaningful market presence and product breadth. The included companies:
- Marketed non-FDA-approved versions of FDA-approved drugs in at least two of the therapeutic areas
- Sold or promoted non-FDA-approved medications directly to US consumers through an online pharmacy or telehealth platform
Companies selling only over-the-counter products, prescription-only FDA-approved products, or non-prescription supplements were excluded.
This process identified 35 companies, including 27 telehealth platforms and eight online pharmacies.
Vendor classification
Each vendor was classified by organizational type based on publicly available website information and verified against the National Association of Boards of Pharmacy (NABP) Safe Pharmacy program to assess whether it had been flagged for potential safety concerns. See Figure 2, Appendix, for companies organized by type.
Company type categories include:
- Online telehealth: Purportedly offering clinical consultations with licensed providers and prescribing services for FDA-approved and/or non-FDA-approved medicine
- Online pharmacy: Dispensing medications prescribed by licensed providers
- Verified online pharmacy: Audited and recommended by NABP
- Online pharmacy: Not audited by the NABP
- Not recommended online pharmacy: Audited and flagged by NABP
- Verified online pharmacy: Audited and recommended by NABP
This classification allowed examination of whether advertising practices varied across vendor types. See the Appendix for detailed information about what was included in the database.
AI-assisted coding of advertising themes and target audiences
AI-assisted analysis tools were used to extract advertising themes and identify target audiences exclusively from website text without evaluating other promotional materials, such as ads on other social media sites, using a published GLP-1 ad discourse framework. This approach supported a consistent comparison of marketing strategies across vendors. An AI rationale field was added to preserve explainability for tags applied across companies.
The criteria for evaluating the messaging in the advertisements were not the same as those required by the FDA for FDA-approved medicines. For FDA-approved drugs, the FDA requires structured, clinically based language, including additional information such as specific limitations on use. When describing a vendor’s messaging regarding safety risks, the study assessed whether the online promotion included any mention of precautions, warnings, contraindications, and adverse effects, but it did not confirm completeness.
Marketing themes included:
- Health and safety framing, such as references to clinical supervision, effectiveness, or safety
- Consultation and medical support, such as references to licensed providers or online consultations
- Ease and affordability, such as references to convenience claims, subscription models, or pricing incentives
- Emotional and psychological benefits, such as references to confidence, transformation, or lifestyle improvement
Target audiences included:
- Women 51 years or older
- Women aged 18 to 50
- Women of color
- Female teenagers
- Men aged 51 years or older
- Men aged 18 to 50
- Men of color
- Male teenagers
- N/A (e.g., healthcare professionals)
Analysis
Overview of the online advertising landscape
Structured internet searches produced an initial set of vendors appearing on the first page of search engine results. After screening for relevance and product breadth, the dataset included 35 companies offering drugs in two or more of the selected therapeutic areas. These included a mix of online telehealth providers and pharmacies selling prescription medications through digital platforms.
The analysis was structured to identify a set of vendors that offered non-FDA-approved medicines across two or more therapeutic areas without requiring additional user-initiated steps, such as completing a form.
Although search terms focused on compounded drugs, not all companies appearing prominently in the search results appeared to offer compounded or non-FDA-approved medications. However, they may have done so with additional user engagement, such as an intake form or appointment. Some companies required user engagement to confirm availability and were excluded from this analysis.
As a result, approximately one-third of the initially identified vendors were excluded after further validation, leaving a set of 23 vendors in the analysis that offered compounded drugs in two or more therapeutic areas.
Patterns across advertised products
Across the final 23 companies analyzed, recurring patterns emerged in the types of products marketed to consumers. See Table 1, Appendix.
Non-FDA-approved formulations of existing drugs
Companies in the sample promoted formulations differing from those of FDA-approved versions of branded medications. See Table 1.
For example, companies were observed advertising:
- Sublingual formulations of GLP-1 drugs, such as compounded semaglutide products that are marketed as alternatives to injectable weight-loss medications
- “Microdose” GLP-1 formulations, promoted as lower-dose alternatives for weight management and other indications, including non-FDA-approved indications
In other cases, medications were offered in novel dosage formats, such as chewable tablets, gummies, or dissolvable tablets. These alternative dosage forms appeared to be used as marketing differentiators that emphasize convenience.
Combination drug products
A recurring finding was the promotion of multi-drug combination products. These products combine multiple active ingredients, including one or more that are also found in existing FDA-approved drugs, although not necessarily at the same dosage or in the same combination. See Table 1.
Examples observed in the analysis include:
- Weight-loss medication kits combining drugs such as bupropion and naltrexone with additional medications (e.g., metformin or topiramate)
- GLP-1 combinations that add substances such as vitamin B12 or glycine to semaglutide formulations
- ED treatments combining multiple phosphodiesterase inhibitors (e.g., sildenafil and tadalafil) or adding other drugs such as apomorphine or oxytocin
- Hair-loss treatments combining drugs such as finasteride, minoxidil, tretinoin, and other products in topical formulations
Some products combine medications across therapeutic areas. For example, ED treatments have been combined with drugs used for other conditions, including statins or hair-loss medications. Another example is a medication from a “hair loss product generator,” which allows customers to choose from a menu of up to six ingredients to create their own compounded combination product, including hair loss treatments such as finasteride and minoxidil along with hormones like progesterone and estradiol.
These combination products are frequently marketed as “custom” or “personalized,” yet some sellers offer the same compounded combination product for all their customers. Combination products are also marketed as “doctor-trusted” or “safe and effective,” despite the fact that such formulations may not have been evaluated through clinical trials or the FDA approval process, including for the specific combinations or dosage forms being promoted.
For example, tests of compounded tirzepatide with added vitamin B12 discovered a widespread impurity resulting from a chemical reaction between the two ingredients.[10] These marketing practices may be misleading to consumers.
Brand-name referencing and consumer framing
Another key pattern is the frequent reference to brand-name drugs when promoting compounded or alternative formulations.
For example, some vendors explicitly state that their products contain the same “active ingredients” as well-known branded medications, such as Viagra or Cialis, but instead offer a compounded formulation of the FDA-approved product. While these drugs may have been developed using chemicals thought to be similar to FDA-approved drugs, non-FDA-approved medicines have not been compared to FDA-approved medicines to determine structural similarity and bioequivalence. There have been numerous reports of compounded versions of medicines containing the wrong active ingredient or no active ingredient.
In other cases, product descriptions simultaneously describe medications as both “generic” and “compounded,” which may blur the distinction between FDA-approved generics and compounded formulations. These drugs have also not been shown to be bioequivalent to an approved generic drug, as determined by bioequivalence or other FDA standards.
These marketing tactics may create ambiguity for consumers attempting to distinguish between FDA-approved branded drugs, FDA-approved generic drugs, and compounded medications that have not undergone the same approval process. The FDA has issued warning letters to compounders and online telehealth providers for making the same or similar claims.
Safety information, disclosures, and adverse event reporting
Review of vendor websites revealed variation in the extent and prominence of safety information presented to consumers, including how contraindications, warnings, and adverse event reporting mechanisms are displayed.
As discussed, the analysis did not determine whether the online vendor messages aligned with FDA requirements for FDA-approved drugs or whether the information was correct. The study only noted whether such information was present. For example, research did not confirm that all contraindications were listed.
Of the vendors:
- Seventeen had at least one visible safety warning on their websites
- Fourteen listed one or more contraindications
- Fourteen had directions for use
- Seventeen had customer support mechanisms
Observations included misleading or incomplete information, especially in marketing claims and safety disclosures, which the FDA has raised as a concern in warning letters to telemedicine companies selling compounded drugs.
Examples from vendor advertising
Of the 23 vendors:
- Twelve had false, misleading, or unsupported efficacy statements, such as “clinically proven” or “proven ingredients”
- Ten had incomplete or misleading warnings or safety claims (e.g., warnings or claims for combined medications only listing individual drug risks, but not for interactions of the combined medicines or safety information links to FDA labels for branded and generic medications)
- Five had missing contraindications or the absence of safety warnings
- Four had no obvious ways for consumers to report adverse events, such as links to email addresses or phone numbers
- Eight had ambiguous labeling of medicines, where it was not clear whether the medicines offered were compounded or FDA-approved generics
- Twelve included misleading quality and sourcing assurances, such as “FDA-approved pharmacies” or cGMP-like assurances
Advertising themes and marketing narratives
Analysis of website content identified recurring marketing narratives consistent with documented patterns in online pharmaceutical advertising.[11]
Across vendors, advertising frequently emphasized:
- Convenience and accessibility, including online consultations and direct-to-consumer delivery
- Affordability, often highlighting subscription pricing models or discounted packages
- Medical credibility, through references to licensed providers or physician supervision
- Lifestyle improvement, particularly for conditions related to weight loss, sexual health, and cosmetic concerns
Case studies
ED medications
Online advertising for ED medications highlights how companies market compounded and non-standard formulations (e.g., non-FDA-approved combinations and dosing) using familiar drug references and convenience-focused messaging. Across multiple vendors, ED products are offered in alternative dosage forms that differ from FDA-approved versions, such as chewable tablets, dissolvable tablets, and flavored mints. These formulations are often framed as more convenient or lifestyle-friendly, positioning ED treatment as part of a broader wellness narrative despite a lack of FDA approval or evidence of safety and efficacy.
A notable feature of the ED market is the prevalence of multi-ingredient compounded products. Some vendors offer combined phosphodiesterase type 5 (PDE5) inhibitors, such as tadalafil (Cialis) and vardenafil (Levitra), with other active ingredients such as oxytocin or statins. These products are described as “custom” or “doctor-designed.” Examples include multi-drug dissolvable tablets and chewable products that combine multiple mechanisms of action.
One example is a 4-in-1 dissolvable mint-flavored tablet that combines tadalafil, oxytocin, apomorphine, and vardenafil. This combined product is offered in three different strengths. When taken together, these PDE5 medications may not provide added benefit but instead may significantly increase the risk of adverse side effects, such as low blood pressure, dizziness, headache, and flushing.
Advertising practices further include references to branded drugs, such as Viagra and Cialis, with some products described as containing the “same active ingredients” while also being labeled as compounded. One company’s website quoted Men’s Health, stating that “Viagra has stiff competition” and the combined ED treatment being offered is “faster acting, longer lasting” than sildenafil and tadalafil separately.[12]
Combined with claims of medical oversight and convenience, these practices may make it difficult for consumers to distinguish between FDA-approved medications and non-FDA-approved compounded alternatives, as well as their associated risk-benefit profiles.
GLP-1 mixed and microdosed
GLP-1 compounded medicines were the most commonly promoted treatments in the analysis. There were multiple instances of GLP-1 medicines being offered in non-FDA-approved formulations, including sublingual formulations and doses not evaluated by the FDA for a therapeutic benefit.
Compounded GLP-1s were also offered in untested combinations mixed with vitamins, including B12 and glycine – typically in injectable forms, but sometimes in pills or sublingual forms.
In one advertisement, that GLP-1 vitamin combination was described as the vendor’s “most successful product,” claiming that “our patients have found the most success” and “our product will change your life!” The advertisement did not include clinical support for the combination or the company’s claims. The online advertisement stated that “B12 is a very common nutrient deficiency caused by GLP-1s like Ozempic, Wegovy, Mounjaro and Zepbound.” However, there is no clinical evidence to support this claim, and no such warnings are offered on the labels of the FDA-approved drugs.
GLP-1 medicines were also offered as “microdosed,” with vendors promoting their compounded drug’s ability to “maintain a healthy weight.” The “microdosed” treatments were described as personalized. While some vendors indicated that the medications were not FDA-approved, they did not note that the amount of drug in the “microdose” had not been proven to have a therapeutic benefit.
These advertisements referenced information about the FDA-approved drug but did not distinguish it from the non-FDA-approved drug sold on the website. This included statements such as “tirzepatide has shown promising results in clinical trials.”
Hair-loss medication
Online advertisements for hair-loss treatments promoted custom ingredient combinations offered as topical solutions or sprays, only some of which are FDA-approved for hair loss. FDA-approved finasteride, an approved hair-loss treatment ingredient, includes labeling warnings related to exposure during pregnancy.
One company offered six or more ingredients that could be combined into a single custom hair-loss treatment product, although many of the listed ingredients have no FDA-approved use for hair-loss treatment. The NABP had verified the company as an NABP-verified online pharmacy.
Two other companies sell finasteride-containing products, one as a spray and one as a topical solution. Both advise women not to use or touch the product, consistent with FDA’s warning regarding unintentional transfer. However, a pregnant woman may come into contact with the product by touching a man’s hair, unaware of the transfer risk present that is associated with this non-FDA-approved topical formulation.
Untested applications
Several examples of ingredients offered for indications and in dosage forms were identified as not FDA approved or clinically tested. One example is a vaginal suppository containing sildenafil, an ingredient approved only as an oral tablet for ED in men. Sildenafil has not been shown to be effective for female sexual dysfunction and has not been studied for intravaginal administration.
Another company promoted a weight-loss pill combining naltrexone and bupropion, with an option to add topiramate, which is approved as an anticonvulsant rather than for weight loss. Although extended-release naltrexone and bupropion are FDA-approved as a fixed-dose combination for weight management, the online product does not use the extended-release formulation, and its dosing differs from that of the approved combination.
Bupropion carries an FDA box warning, which is displayed prominently on the approved product’s labeling. Topiramate also carries a known teratogenicity risk, including an increased incidence of cleft lip and cleft palate in infants exposed in utero. This risk may not be adequately conveyed when the ingredient is offered as an optional add-on through an online vendor.
Limitations
The analysis relies on manual searches using a major search engine to identify online vendors advertising medications corresponding to FDA-approved drugs. Although search engines are designed to approximate typical consumer search behavior, their results vary over time and across users.
Given the focus on only the first page of results, findings represent the most visible segment of the online marketplace rather than the entirety of online pharmaceutical advertising.
Analysis was limited to vendors offering non-FDA-approved medicines in multiple therapeutic areas, which may further limit the sample or introduce bias in unknown directions. The study does not evaluate promotion beyond the vendor’s own website, such as advertisements on social media platforms.
Further, the analysis is based primarily on publicly accessible website content and advertising materials available at the time of review. Some telehealth platforms require users to complete intake forms before revealing the full range of products or detailed prescribing information, which was not completed during this study. Relevant safety warnings and reporting mechanisms may also be behind a customer login.
Some data was generated using AI-assisted tools to identify marketing themes or target audiences. Although outputs were closely reviewed by researchers and supported by explanatory rationales, automated text analysis may introduce classification errors or inconsistencies.
These claims were not checked for accuracy, such as related to contraindications or safety warnings; they were only noted as to whether they were included. Given that these medicines are not FDA-approved, there is no clinical data to confirm or support the vendors’ claims.
Finally, the online pharmaceutical marketplace is highly dynamic. Vendors frequently modify offerings, content, and marketing strategies in response to regulatory actions, market demand, and supply conditions. The findings represent a snapshot of advertising practices during the study period.
Key considerations based on findings
The FDA employs several approaches to monitor advertising. Given the growth in promotion of non-FDA-approved medicines and the use of those treatments associated with advertising, the FDA could employ strategies used for FDA-approved medicines to regulate advertising or to track the safety of those medicines.
This could include:
- Expanding existing initiatives, such as FDA’s Bad Ad Program, to cover non-FDA-approved medicines
- Expanding the remit of the Office of Prescription Drug Promotion to include promotion of non-FDA-approved medicines, including surveillance and consumer education
- Continuing enforcement actions and warning letters while also ensuring corrective action has been taken within a prespecified period of time (e.g., 30 days), as well as devoting additional resources to advertising enforcement
- Assessing whether existing prescription drug promotion principles could inform oversight of consumer-facing promotion for non-FDA-approved treatments, including telehealth firms, compounding pharmacies, and social media providers
Oversight considerations for non-FDA-approved medicine promotion
Conclusion
The study surveyed advertisements for non-FDA-approved medicines and identified promotion types that the FDA has noted could pose safety risks. Among the 23 vendors analyzed, 52 percent made unsupported efficacy statements, 43 percent had incomplete or misleading warnings, and 26 percent failed to include prominent safety warnings.
Observed practices included:
- Non-FDA-approved formulations, including sublingual and “microdose” versions of GLP-1 drugs that the FDA has not evaluated
- Untested multi-drug combination products marketed as “custom” or “personalized” without clinical evidence of safety or efficacy
- Frequent brand-name referencing that may blur the distinction between FDA-approved medications and compounded alternatives
- Products marketed for non-FDA-approved indications, such as sildenafil formulations for women’s sexual health
Sixty-five percent of US adults mistakenly believe that all websites offering online prescription services are reviewed and approved by regulators, and 51 percent believe that only safe sellers appear on the first page of internet search results.
While the FDA has increased its enforcement efforts, including issuing more than 100 warning letters since September 2025, only two vendors in the study had received FDA warning letters.
Current monitoring mechanisms, including the FDA’s Bad Ad Program, do not cover non-FDA-approved medicines and may leave gaps in oversight. As the FDA continues enforcement against the promotion of non-FDA-approved medicines, closer evaluation and tracking of consumer-facing information could warrant consideration.
For more information, please contact the authors.
Appendix
Table 1: Analysis of vendors and promotional behavior: Product patterns table
| Product pattern | Description | Illustrative examples | Concern | Number of companies | NABP company type |
|---|---|---|---|---|---|
| Alternative dosage forms | Products marketed in forms differing from approved reference products | Sublingual semaglutide chewable tablets, gummies, and dissolvable tablets for ED products | Consumers may infer equivalence to approved products despite different formulation characteristics; higher-than-approved doses may pose overdose risk; no evidence that altered doses offer any benefit | 13 | Ten online telehealth; one verified online telehealth; one online pharmacy; one verified online pharmacy |
| Microdose or modified-strength products* | Lower-dose or modified-dose products promoted as tailored alternatives | Microdose GLP-1 offerings | Consumers may infer that doses or strengths have been found to be clinically effective | 9** | Seven online telehealth; one online pharmacy |
| Multi-ingredient compounded products | Combination products containing two or more active ingredients | Weight-loss kits combining bupropion/naltrexone with metformin or topiramate; ED combinations; hair-loss multi-ingredient formulations | Combination products have not been found to be safe and effective in combination form; may also blur lines between customization and unsupported therapeutic bundling | 16 | Twelve online telehealth; one verified online telehealth; two online pharmacy; one verified online pharmacy |
| Cross-category combinations | Products combining ingredients associated with different treatment areas | ED products combined with weight-loss agents or other medications | May increase consumer confusion about intended risk profile and medical rationale | 6 | Four online telehealth; one online pharmacy; one verified online pharmacy |
| Non-FDA-approved indications | Products marketed for women using ingredients associated with other conditions | Sildenafil containing women's intimacy products or suppositories | Suggests possible promotion beyond well-established approved uses | 2 | Two online telehealth |
This table summarizes key product formulation patterns identified in the analysis of online vendors’ marketing of medications corresponding to FDA-approved drugs. The categories include alternative dosage forms (e.g., sublingual or chewable formulations), modified-strength or “microdose” products, multi-ingredient compounded formulations, cross-category drug combinations, and products marketed for non-FDA-approved indications (e.g., women’s sexual health uses of drugs approved for ED). For each category, the figure provides representative examples and associated concerns.
*For modified-strength products, analysis was limited to GLP-1 medicines.
**Of the companies marketing compounded versions of GLP-1 medications, two have since stopped offering those medicines.
Table 2: Products included in scope for the analysis
| Product types to select | Molecule name | Branded name |
|---|---|---|
| Obesity | Orlistat | Xenical |
| Phentermine-topiramate | Qsymia | |
| Naltrexone-bupropion | Contrave | |
| Liraglutide | Saxenda | |
| Semaglutide | Wegovy or Ozempic | |
| Tirzepatide | Zepbound or Mounjaro | |
| Hormone replacement therapy | Estradiol | |
| Conjugated estrogens | ||
| Progesterone | ||
| Medroxyprogesterone acetate | ||
| ED | Sildenafil | Viagra |
| Tadalafil | Cialis | |
| Alprostadil | Caverject | |
| Vardenafil hydrochloride | Levitra | |
| Hair loss | Finasteride | Propecia |
| Minoxidil | Rogaine |
This table displays the therapeutic areas and reference drugs used to define the search universe. The study focused on four therapeutic areas frequently marketed by online telehealth providers and pharmacies, including drugs for obesity, ED, hair loss, and hormone replacement therapy. Within each area, a set of FDA-approved reference drugs was selected using both molecule names and branded product names to guide the search strategy and identify online vendors advertising compounded treatments.
Figure 1: Sponsored versus non-sponsored search results
This chart shows the distribution of companies by whether they appeared as sponsored search results, which appear to be paid promotional advertisements. Researchers ran 944 searches, which returned 147 unique companies. Of the companies analyzed, 77.8 percent appear as sponsored listings, while 22.2 percent appear as non-sponsored results.
Figure 2: Companies by NABP company type
This chart shows the distribution of the original 35 companies included in the analysis. The majority (24) operates as online telehealth providers, followed by five online pharmacies. A smaller subset consists of two NABP-verified online telehealth companies and three NABP-verified online pharmacies. No companies in the sample were classified as not verified in either category.
Data collection and database development
Information about each company was recorded in a structured database. The following data were collected:
- Company name and website
- Company type (e.g., telehealth provider, online pharmacy)
- Therapeutic areas and medications offered according to the search results
- Whether the vendor promoted compounded, generic, or branded medications
- Presence of sponsored search advertisements
- Examples of advertising language or imagery
- Target audience characteristics inferred from marketing content*
- Marketing themes present on the website*
- Safety warnings, disclosures, and regulatory statements
- Whether the company had received an FDA warning letter
*Researchers used AI-assisted analysis of these fields as described in the following section.
Additional fields captured regulatory and advertising characteristics, including:
- Whether the website disclosed that compounded medications are not FDA-approved
- Whether compounded products were clearly labeled as compounded rather than generic
- Whether safety information, warnings, contraindications, or adverse event reporting mechanisms were provided
- Whether brand-name medications were referenced in marketing content for non-brand products
Researchers manually reviewed vendor websites to collect and verify this information.
[1] Alliance for Safe Online Pharmacies 2025 Survey https://buysaferx.pharmacy//wp-content/uploads/2025/11/ASOP-Foundation-2025-Consumer-Behavior-Survey.pdf
[2] https://www.niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity#:~:text=The%20table%20below%20lists%20prescription,%E2%80%94for%20long%2Dterm%20use.
[3] https://www.fda.gov/consumers/free-publications-women/menopause-medicines-help-you
[4] https://nctr-crs.fda.gov/fdalabel/ui/spl-summaries/criteria/924011
[5] https://www.mayoclinic.org/diseases-conditions/female-infertility/diagnosis-treatment/drc-20354313
[6] Six vendors ceased selling GLP-1 compounded medicines, including Sesame, Ro, Klinic, Hims, Hers and Call-on-Doc. The vendors still selling other categories that are not GLP-1s include Hims, Hers, and Ro.
[7] https://www.bernardjjansen.com/uploads/2/4/1/8/24188166/jansen_web_mining.pdf
[8] Per the NABP website, safe, verified online pharmacies meet the following requirements: are licensed by regulators in the jurisdiction in which they are located, as well as regulators in the patient’s jurisdiction; accept only valid prescriptions; comply with applicable drug laws and professional practice laws; provide readily accessible contact information for patient care inquiries; and comply with privacy laws and ensure patient confidentiality.
[9] NABP identifies a website as “Not Recommended” when, upon review, it appears to be out of compliance with NABP patient safety and pharmacy practice standards, or applicable law. Some “Not Recommended” websites do not sell drugs directly. Instead, they refer patients to websites that operate in violation of NABP patient safety and pharmacy practice standards or applicable law.
[10] Jordan B, Arbogast L, Clemens M, Huang L, Snyder M. A novel, widespread impurity in mass-compounded tirzepatide/B12 products: potential patient safety implications. Expert Opin Drug Saf. 2026 May;25(5):837-845. doi: 10.1080/14740338.2026.2663185. Epub 2026 Apr 30. PMID: 42010938.
[11] Rad J, Melendez-Torres GJ. Critical discourse analysis of social media advertisements for GLP-1 receptor agonist weight loss drugs: implications for public perceptions and health communication. BMC Public Health. 2025 Sep 1;25(1):2996. doi: 10.1186/s12889-025-24197-8. PMID: 40890660; PMCID: PMC12400570.
[12] https://www.rugiet.com/