Conquer Your Weight

Dr. Sarah Stombaugh: This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast, episode number 59. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hey, welcome back today to another episode of the Conquer Your Weight podcast. Today we are talking about medications for the treatment of obesity. This is a topic that we have talked about before, but I'm going to talk about it today in a little bit more depth. And what inspired this is that last weekend I gave a talk at the Virginia Academy, a family physicians meeting. They have two meetings every year and at their winter conference they invited me to come and talk to other family medicine physicians about medications that we can use for treating obesity. I thought especially with the advent of Zepbound or at least the FDA approval of Zepbound, which is our newest medication for the treatment of obesity. This topic deserves an update from the time that we last talked about it. We are also going to talk about some of the medications in a bit more depth. This is often a topic that I stray away from a little bit in or shy away from, rather a little bit in the podcast because I'm focused on tools that may be applicable to a broader population. But the reality is is that many people use medications. Most of my patients use medications to support their weight loss journey. And so I want you to be thinking about this as just one of all of the potential tools that you could use in order to support your weight loss. So we are going to talk about this topic in pretty good detail just similar to how I presented it to some of the physicians this weekend. And so I want to spend a little bit of time and go ahead and get in. Everybody is talking about the GLP-1 medications. These medications are medications like Wegovy, Saxenda, and Zepbound. They are the newest kids on the block. But I want to take a step back and really talk about all of the medications that are FDA approved for the treatment of obesity because while some of these newer medications are hot and everybody is talking about them, and that is great, some of these other medications can be really quite effective. And depending on the patient, they may actually be the better choice depending on what are the other medical history that this person has, what is the reason for which they study or struggle with their weight? So I wanted to share with you a really interesting story that looks at obesity phenotype. So what this means is that we know that everybody who struggles with their weight may struggle with it for different reasons. So in this study, they categorized four people in four different phenotypes talking about what is the reason by which they struggled with their weight. So were they dealing with hungry brain? So they had decreased satiety, so really feeling sort of thoughts of food hungry all the time. Were they dealing with emotional hunger or hedonic eating where given a stressful situation, they were really turning towards food and feeling that any sort of emotional trigger would drive them to eat? Were they dealing with what the study called Hungry Gut, which was an abnormal satiety where not necessarily in their brain but in their body they're feeling maybe a couple hours after their meal, their stomach is grumbling, they feel like they can't fill up all the way, so they're eating a meal and they just want to eat and eat and eat and it takes a long time before their stomach feels full or slow. Burn was the last group people who have a decreased metabolic rate. So the interesting thing, they took 450 participants and they identified these phenotypes in most of the participants. So in 383 participants, they identified at least one phenotype in 85%. So 383 people. So 15% of people, they weren't really to identify a specific phenotype. And then interestingly, for some of the patients, about a quarter of the patients, they actually identified that they were dealing with two or more of these phenotypes. So interestingly, when we look at the treatment of obesity, and if you pair a medication that is working on one of these specific pathways to the reason by which someone is struggling with their obesity, they're more likely to have success compared to when we just give sort of any medication to any person. And that makes sense, but it's also really good to see this actually play out because when we talk about some of these older medications, and this study was done, I forget the exact year, but probably at least five or 10 years ago now, these medications were not the newest medications, not the most effective medications, and they took their effectiveness from eight or 9% effectiveness on average actually up to 15 or 16% effectiveness, which is really, really interesting. So with that in mind, we are going to take a step back and took about really all of the medications that we can use for the treatment of obesity, starting even with what I will call the oldies but goodies. So when we talk about medications for the treatment of obesity, the reason that we are treating weight loss, we are treating obesity and supporting patients to lose weight is because we want to be able to reduce any of the potential complications that can come from obesity as a chronic disease. And it just makes sense, right? If someone has type two diabetes, we treat that in order to reduce their risk of chronic kidney disease to reduce their risk of nerve damage, to reduce the risk of heart disease. If someone has hypertension or high blood pressure, we treat that in order to reduce their risk of heart disease or stroke. And so if someone has obesity, shouldn't we treat that when we know that we could reduce the risk of diabetes and high blood pressure, cardiovascular disease, cancer, arthritis, all of these conditions at which obesity may at the root? And so when we think about treating obesity, let's take a look. Of course, it's going to take a multidisciplinary approach. We're thinking about diet, we're thinking about exercise, we're thinking about sleep, we're thinking about stress management. All of those things are important and medications may play a role for some patients. So when we look back at the medications, there are the first generation anti-obesity medications, and these are medications on average that produce about 10%, maybe slightly less percent of body weight loss total. So that means if someone weighs 250 pounds, that they would lose an average of 25 pounds on these medications. Now remember though to that study that we were just talking about regarding obesity phenotype, if we are able to pair a medication for someone and the reason by which they're struggling with their weight, we may find that these medications produce even more weight loss than that. And furthermore, just remembering that these are averages, there are patients who lost no weight. There are patients who may be lost 20% of their weight, so 10% is really just an average. The medications that fall into this category or phentermine, and I want to talk about each of these a little bit. Phentermine is one of the, or really the oldest medication that we have for the treatment of obesity. This medication was FDA approved in 1959, and it has a little bit of a bad reputation because for years, phentermine was paired with fenfluramine. Those medications together were known as fenden. That medication was actually pulled off of the market in the nineties due to this realization that the other component, the fenfluramine contributed to heart valve disease. And so obviously we did not want to be causing other medical issues in the treatment of obesity. What we do know from then and as we've continued to use phentermine as a medication is that phentermine alone can be a really powerful tool in the treatment of obesity. It works to suppress appetite. It can't have some side effects that can be related, sort of like a stimulant where you may feel trouble sleeping. Sometimes people feel like their heart is racing or they're a little bit keyed up, but most people tolerate this medication really pretty well because of its history. It is actually a controlled substance. So a lot of prescribers may have some more caution in prescribing it. There are some states in which there's really strict rules about prescribing this medication, but the reality is it's very common from people who are obesity medicine physicians to use this medication in order to support their patients. And for the right patient, it can be a really good tool and it's affordable, which is really important, especially when we're thinking about some of these newer medications that are out of reach for a lot of people, especially if their insurance does not cover them. The next medication I want to think about is Orlistat. It has two different doses, the lower doses over the counter as ally, the higher dose is available as a prescription. It is called Xenical. It was approved in 1999, so it's been around for 25 years now and it is a very effective medication, but it is a nasty medication. So this medication works by reducing pancreatic lipase, which basically means our body is not able to absorb the fat that we eat. What ends up happening though is that when we eat fat and we take this medication is that we can have really severe side effects. So it's common to have loose stools, greasy stools, whey leakage from your GI tract. And as my kids would say, when you're on this medication, you quote cannot trust a fart. So I just want you to be aware this medication works. It's available over the counter so people not in frequently, people come across this medication and may take it even on their own, but just know that the side effects from this medication can be really significant. It is effective though. So if you are following a low fat diet, if you're not worried about those side effects, you certainly could use it. I rarely use this patient alone in the treatment of obesity. The next medication I want to talk about is Qsymia. This medication is a combination of phentermine and topiramate. So these are two different medications. The phentermine we talked about just a moment ago, it was paired in this medication with topiramate. Topiramate was actually a medication initially used for the treatment of seizures. We often use it also for conditions like anxiety or for migraine prevention, and one of the things that it does is it reduces hunger, and so it involved in these neuropathways in the brain so that we have less hunger. So those two medications work together to reduce hunger, and that can be really pretty effective. I want to point out that this is actually the most effective of all of the medications that we used to have. So when we look at five years ago before some of these newer players like Wegovy and Zepbound were on the market, Qsymia was actually our most effective medication in general. So it is really for the right person, still a good tool. I do want to point out there are some side effects you have to think about worth talking to your doctor about if you're considering this medication. Most importantly, this medication cannot be used in pregnancy because there's an increased risk in cleft palate. So any woman who is of childbearing age should be on effective birth control if they are using this medication. One of the great things about it is though it's decently affordable, so many insurances do cover it. And even for patients who do not have coverage for medications for the treatment of obesity, this medication is $98 a month even if your insurance doesn't cover it. So you do need a prescription from your doctor in order to get this medication. But the pharmaceutical company has partnered with a mail order pharmacy to make this medication affordable or at least moderately affordable compared to some of these medications that are more than a thousand dollars or up to $1,500 per month. The next medication is contra. This is a combination of Bupropion and naltrexone. Bupropion was initially a medication for the treatment of depression. We know that it works sort of in that reward pathway though because we also use this medication for smoking cessation, so it can be really good for reducing cravings. The Naltrexone component of this medication is primarily a medication to combat opioid addiction, but it also works in that craving aspect. So there's two different medications here, both working on cravings and two different pathways within the brain. And honestly, even though the effectiveness is not as effective compared to some of the other medications, this medication reduces those cravings. And so for people who are having a lot of food cravings, this medication actually can be pretty effective. I have a lot of experience prescribing this one particularly because it was the preferred medication for the treatment of obesity with my last employer. And so I did often prescribe this medication for patients and for the right patient it worked pretty well. Similarly to the Qsymia, the cost is not bad. It's $99 per month. Even if you don't have insurance coverage, if you use this specific mail order pharmacy, next come the GLP-1 receptor agonist. So this was really a major paradigm shift in the treatment of obesity because we're starting to look at medications that work both in the and in the GI system in order to treat obesity. The first one in the market was Saxenda. The generic is liraglutide. It's the least effective, but can really be pretty effective compared to at least some of the older medications. Very similar effectiveness actually to that Qsymia medication, maybe slightly less than it works. It's a daily injection that patients use. It slows our GI system, it decreases that food chatter. There can be some nausea, constipation that happens as a side effect, but really a pretty great tool. Then we've seen these newer generation, the second generation of anti-obesity medications that are producing at least 10%, but usually up to 15% or more weight loss in half of the patients or more in this study. So the two medications that fall in this category or Wegovy and Zepbound. Wegovy is semaglutide. That is the exact same medication as Ozempic. So people are often talking about Ozempic for the treatment of obesity. Interestingly, Ozempic is actually FDA approved for the treatment of type two diabetes. Ozempic and Wegovy are the exact same medication. The only difference is actually there's slightly different dosing, so how we're going to dose that medication. But most importantly, because of that FDA approval and that FDA indication, the biggest difference is going to be if and how your insurance covers these medications if they are covered though wegovy is a very effective medication producing about 15% on average reduction in body weight over a year. And again, remembering that is just an average. So there are patients who have less. There's patients who actually lose no weight on these medications, people who are non-responders, and there are people who lose 20, 25% plus percent of their body weight on these medications, again, can have those GI side effects, nausea, constipation, diarrhea, but can be very, very effective medications. The newest kid on the block is Zepbound. Zepbound is the same medication as manjaro. So Zepbound is tirzepatide. It has been approved for the treatment of type two diabetes under the brand name Mounjaro for the last couple of years. And then just in November of 2023, so just a couple of months ago, at least at the time of this recording. This medication is the newest medication approved for the treatment of obesity, and it just hit pharmacies in December. So really about six weeks ago Now, this is a dual receptor agonist that is targeting the GLP-1 receptor, so the same as that Wegovy or Saxenda. It is also targeting the GIP receptor. Those two are both working within the brain within the GI system to slow gastric emptying, increase, sat tidy. So we feel full longer. We have less of that food chatter, and this is our most effective medication to date. It is producing about 21, 22% total body weight loss on average when you're taking the maximum dose of this medication, which is really pretty phenomenal. There are some side effects that can happen with these medications as well. It does tend to be tolerated pretty well, expecting side effects as we start. And every time that you increase the dose for all of these medications, honestly, all of them, every single one that I've talked about, there's usually a progression where we start at a low dose and we slowly titrate that dose upwards in order to get to the dose that is helping a patient to best support their weight loss. And so that is something that people may, if they're having side effects, those side effects may flare back up as they increase that dose upwards. Alright, so that was quick. We went through a lot of medications, but I wanted you to have an overview of what are some of the things that may be effective for the treatment of obesity. When we combine these with intensive lifestyle modification, we are often seeing even higher rates of weight loss with these medications, and then we see a reduction in so many things. We actually have a study for semaglutide specifically that says we see a reduction in cardiovascular disease and cardiovascular outcomes, so things like heart attack, things like stroke, that over the study period, they were actually able to reduce the occurrence of those, which is just wonderful. And so if we can as a medical society and as a general society, start looking at obesity, no different than any other medical condition and using these medications in order to support our patients as one of many tools in order to support their long-term weight loss. This is so cool. I'm really excited for the field of obesity medicine because if you look 2, 5, 10 years into the future, there are a lot of additional tools that are coming down the pike, things that are in phase two and phase three clinical trials right now, and so I am so excited. If you are wondering, oh gosh, would I be someone who could consider these medications? Would these medications work for me? I want you to reach out even if you're not in Illinois, if you're not in Virginia where I'm licensed to practice medicine, I would love to point you in the direction of a physician who could help support you in your journey. So please reach out to me. The best way to do that is on my website at www.sarahstombaughmd.com. That's S-A-R-A-H-S-T-O-M-B-A-U-G-H md.com. I would love to connect with you. You could fill out the contact form on my webpage, and we will get you set up with someone who can help support you or even just go to your primary care physician, ask them, Hey, are these tools that would support me? It is important to do this in its own visit. You don't want to be doing this. Hey Doc, I have five different things to talk about, but if you set aside a visit specifically to talk to your doctor about how they can support you with your weight, they may be able to talk to you about some of these tools or refer you to someone who can give you more information. Thank you so much for joining me today. I'm glad we got a chance to talk about these medications. I look forward to talking to you all next week. Bye-Bye.