Novo Nordisk (NVO) reported an earnings miss Wednesday, sending its stock down 4% in early trading, pressuring the stock further after a surprise management shake-up earlier in the year and sharply lowered guidance despite growing sales of its blockbuster GLP-1 drugs Ozempic and Wegovy.

The stock is down more than 46% year to date as a result.

CFO Karsten Munk Knudsen discussed some of the changes in recent weeks. He told Yahoo Finance that the leadership change — the ousting of CEO Lars Jørgensen and international head Mike Doustdar taking his place — was a surprise.

“I was surprised about the changes of CEOs back in May,” Knudsen said. “But … looking at other companies … when pressure is on, in terms of performance and competition, then it’s not unusual that bosses and owners assess what’s the right team to lead the company. In a macro setting I don’t think its extraordinary, but in a Novo setting it was indeed surprising.”

The US market has also proven a challenge for Novo Nordisk, as it lost its lead despite a first-mover advantage to competitor Eli Lilly (LLY). Executives blame the compounding market, in which copycats are allowed under special circumstances, with telehealth platforms taking advantage of the loophole despite the FDA ending a shortage of GLP-1s that previously allowed copycats to freely sell on the market.

Knudsen said the compounding market is about one-third of current GLP-1 prescriptions in the US market.

On top of the competition and copycats, Novo Nordisk, like other big pharma names, has been targeted by the Trump administration to lower prices for consumers. It was one of 17 companies to receive a letter demanding lower costs for current and new products.

“In reality, we’re not that far apart in the sense that we also drive for affordable access in products that we supply. Our GLP-1 pricing is already rather low,” Knudsen said, without revealing the actual numbers.

Outgoing CEO Lars Jørgensen said on an earnings call Wednesday that its prices for Medicaid, for example, are already lower than in Europe. Those prices are not publicly available.

The letter also asked the companies to price new drugs at the same low pricing found in other developed countries and to provide the lower cash prices more widely.

Some experts have expressed doubt about cash market success, however.

Craig Garthwaite, a professor of strategy and healthcare at Northwestern University’s Kellogg School of Management, posted on X in response to the Trump letters, questioning the strategy’s viability.