Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and to sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today’s episode. This is Dr. Sarah Stambaugh, and you are listening to the Conquer Your Weight Podcast. 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 Stambaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this week's episode of the Conquer Your Weight podcast. Today we are talking about microdosing GLPs. This is something that people have been asking about. I see it a lot on social media. There have been even some journalists who have reached out to ask me this question. I've had some friends ask me this question recently and I thought, you know what, let me just bring this to the podcast, address this. Let's talk about microdosing GLPs. What does that mean? When is it used? Who may be a good candidate for it? What are the risks of microdosing? Because certainly it may not be the right fit for everyone. So let's dive into it. So microdosing in general, we're typically talking about taking a lower than standard dose of medication. Now, interestingly, I have heard microdosing in the GLP context to mean both a very low dose of medication as well as sometimes in between doses, but basically going outside of the standard dosing protocols. So when we look at We're going to really be talking about the semaglutide products and their tirzepatide products today. So semaglutide products, brand names are Ozempic and Wegovy. Then there also is semaglutide as the compounded version. Then the tirzepatide products being Zepbound and Mounjaro. Tirzepatide also then sometimes referring to the compounded version of these medications. So when we look at the FDA branded doses of those medications, when we look at a standard dosing protocol. When we're looking at Wegovy, for example, which is the FDA-approved version of semaglutide for the treatment of weight reduction, the doses of this medication are 0.25 milligrams, 0.5 milligrams, 1.0 milligrams, 1.7 milligrams, and 2.4 milligrams. Then when we look at the doses, the FDA-approved doses of the Zepbound medication, this is the FDA-approved version for weight reduction of the tirzepatide medication, the FDA approved doses there are 2.5 milligrams, 5 milligrams, 7.5, 10, 12.5, or 15 milligrams. Now, many of these medications, especially when we're talking about Wegovy, we're talking about Mounjaro, we're talking about Zepbound, many of these options are offered in single dose pens. So let's say you got a prescription for Wegovy, for example, every month, whether you're on, let's say the 0.25 milligram dose, you have a Wegovy 0.25 milligram pen. If you go to the pharmacy and pick up a prescription for that, you get four of those. Each week when you go to inject yourself, you use one pen, you dispose of it when you're done. The next week, you use a new pen, you dispose of what you're done. If you move up to another dose, you get new pens that deliver a higher dose of medication. And so with these single dose pens, those... are really nearly impossible to split. Now there's all sorts of crazy things happening. I'm sure someone will say, oh, but I've heard you can inject into a vial and draw up a smaller amount. I think that that is simply too complicated and too dangerous to do. I have personally attempted to do it and I broke the vial in the process of trying to take the lid off of it. And I'm like, I do not feel safe offering such an option to my patients. So when we look at the single dose pens, those deliver a single dose of medication and those really then you need to and have to use the FDA-approved dosages of the medication. So when people are talking about microdosing, what they're typically referring to is sometimes the Ozempic pen. So Ozempic pens are semaglutide. This is the medication that's branded for the treatment of diabetes. Certainly people can still buy this medication with a prescription off label. It's not going to be covered by insurance, but there are people who buy this medication and deliver a partial dose of medication. So sometimes people will use what's called a click counting technique with the Ozempic pen to deliver a partial dose of medication. A lot of times, though, when we're talking about microdosing, people are talking about using compounded versions of medication. So they're talking about getting compounded semaglutide. They're talking about getting compounded tirzepatide. And the reason why this most commonly is the case is we're often talking about people for whom these medications may not otherwise be FDA approved. So when we look at the medications for the weight reduction indication or even for the diabetes indication, we have these very few specific reasons, but by which they're FDA approved, by which insurance may or sometimes may not cover these medications, but they are FDA approved for type two diabetes. They are FDA approved for weight reduction. So in patients with a BMI of 30 or higher or patients in a BMI of 27 to 29 with weight related comorbidities, they are covered for that purpose or maybe rather maybe approved or FDA approved for that purpose. So when we look at compounded medications. These are used in a variety of contexts, and we're not going to get into that too much, but they're delivered in vials. So patients get a vial. It's typically a multi-dose vial. And so they are instructed to draw out an amount of that medication to get a desired effect. And so you may be able to more easily draw out a smaller amount or even a larger amount, but you can sort of more easily adjust your dose of medication. So with the compound medications is really where microdosing has evolved from is this idea of, can I take a partial dose of medication? Can I draw up instead of, let's say I'm supposed to take half of a milliliter, could I instead draw up a 10th of a milliliter, for example? Can I draw up a fraction of this amount in order to deliver a smaller amount of medication? So who would want to do that? What would be the benefits of doing that? So when we look at the FDA approved medications. Starting at the starting doses of medication, for people who do have chronic metabolic disease, it is very common that these doses of medications may be appropriate for them. But even for people with, maybe they have mild excess weight, they're limited weight loss goals, they're just starting the medication for the first time, it can be common that in starting these medications, whether we're talking about the semaglutide products like Ozempic, Wegovy, whether we're talking about the tirzepatide products like Zepbound, Mounjaro, that even the starting dose of the medication feels like a lot there may be significant side effects from the medication as they're starting the medication they may notice that they're having um almost too significant of appetite suppression. So for a couple of days after taking the medication, they're like, oh my gosh, I don't want to eat anything at all. And that side effect piece, you know, whether it's just like, oh, feeling really nauseated, maybe even having vomiting, having diarrhea, feeling like, oh my gosh, this is too much. It's understandable to think that there are some people who are like, hey, could I take a smaller dose of this medication? And then that may be something that persists where they continue on a very low dose or a smaller dose of medication, or they may decide that they're just taking a slower escalation and following a, you know, a lot of people describe it as a personalized adjustment through the doses. Now, I think one of the things that's really important here is that these are not studied. So we look at what is FDA approved, the reasons that the doses and the dosing schedule that we have The reason for those dosing schedules is that's because how these medications have been studied. They've looked at what is the effectiveness of this medication, if you take it for a year, if you take it for a year and a half, what happens on these medications, if you stop, what happens. So we have really good data for large groups of patients when they've taken different dosages of medications, what's happened from a side effect standpoint, what's happened from an effectiveness standpoint. We don't have any studies about microdosing. Certainly there's a lot of anecdotal data right now, So people talking about their own experiences or maybe their experiences in doing this with patients. But we don't have large scale data to say, you know, who is or is not appropriate for micro dosing. Now, when we think about micro dosing. I don't want to be closed off to any idea completely. When we look at the GLP medications, they've got these indications for diabetes, for weight reduction, and we've started to see so many other health conditions for which these medications may be helpful. We've seen improvements in kidney disease, in heart disease, in dementia, in cancer, in so many different sleep apnea, in so many of these different areas in addiction and substance use disorders that these medications are being studied, that people are finding, even if they're using them for an on-label indication, that patients are finding and we're starting to study them for other indications, we'd know that there's an anti-inflammatory effect of these medications. So people who have chronic inflammatory bowel disease like Crohn's or ulcerative colitis, people who have certain inflammatory skin conditions like psoriasis or eczema even, people with different rheumatological conditions, that people are noticing improvement in these different inflammatory conditions. So when we think about microdosing It makes sense that people are wondering, okay, maybe I don't have chronic metabolic disease. I maybe even tried a medication before at the starting dose and it just felt like way too much for me. Could I benefit at a lower amount of medication? And I'll say the answer is maybe. Is it possible that that's the case? Of course. And there's absolutely a lot of examples of people who've been trying this, people who want maybe just sort of a light touch. They want the support of the medication while feeling like it allows them to make the decisions in line with their goals while not having too significant of side effects or too significant of appetite suppression. I will say that one of the things I really worry about is that when we think about our society's obesity bias and we think about the idea of using medications to support our weight loss goals, to support our underlying metabolic health, for example, is there a problem with that? One of the things I worry about with microdosing is there's this sort of implied idea of, well, you should only take the tiniest amount. And if you need more, then that's bad, or that maybe you failed in some way. And so recognizing that while trialing microdosing may be appropriate, and certainly when we think about personalized medication, individualized medication, making decisions that make sense for the person in front of you, great. You know, can we trial this idea, but also let's be really careful that then, you know, let's say someone starting on, you know, a quarter of a starting dose of medication and finding that it's not effective for them, or maybe they feel like, oh my gosh, I'm not even doing anything on this medication. This medication is having no effect for me. That could be really frustrating, recognizing that, okay, no big deal. You've started on a quarter of the starting dose of medication, what happens if we nudge up to a half dose or to the full starting dose of medication, that we're not looking at that as some sort of failure, for example. And so I do think we want to be really careful just how we're thinking about this, how we're supporting our patients, and really being clear about who could benefit from this, who's worth trialing it versus who is more likely to benefit from those FDA approved doses. When we look at the FDA approved doses, even the starting doses of medication, when we look at someone who's had chronic metabolic disease, these doses of medication are honestly very appropriate places to start. People, you know, commonly I'll have people who at a starting dose of medication have some side effects, but they kind of get into the groove of it. They're feeling good. They're feeling like, okay, I don't need any, you know, too much of additional appetite suppression. My side effects are managed. I have good appetite suppression, but I'm still able to meet my nutritional goals. I'm hitting my protein goals. I'm seeing movement on the scale and hitting weight loss goals as well. I absolutely believe in taking a taking the titration at a very individualized level. If someone's doing well on a low dose of medication, do we need to bump them up to the next dose of medication just because that's the sort of FDA approved recommended way to do that? No, I honestly don't think so. And so let's say someone starts out at 2.5 milligrams of Zepbound, for example, that's technically a titration dose of medication. So it's not studied using that dose long-term. It's not studied for people to stay on that dose long-term, but as far as I'm concerned, what's the problem? If they're doing well, it's adequately supporting their goals, then we could keep them on that for long term. And so similarly, from a microdosing standpoint, does it make sense that there are patients for whom they would be responsive at a lower dose of medication? Sure, absolutely. There may absolutely be patients for whom at a very low dose of medication, they find that there is responsiveness, they find that they're finding that their side effects are really well managed. One of the things I worry about though, and some of the questions that I've seen being asked in the media recently is, you know, can this be an option for saving money? Can this be an option for people who do not have insurance coverage of the medications? And maybe, but really we're talking about who is the patient in front of you and the most appropriate dose is going to be the dose that supports the person in their goals. And so if they're able to take a partial dose of medication and that is adequately supporting them and their goals, then yeah, it may be cost savings to take a smaller, or it would be, right? You're just the math if you divide a dose in two or you divide a dose in four. Of course, there would be cost savings in doing that, but it's not going to be practical for many patients who've had chronic metabolic disease. And so really recognizing who is the person in front of you, who is the person that's going to respond best to this, the people who may benefit most from microdosing are those who don't have a chronic metabolic disease. So they have mild obesity, maybe they've noticed weight trending up as a result of other medications or maybe perimenopause or things like that. And they're looking at, you know, can I have a little bit of support from medication as I'm working on these other lifestyle changes, but not needing as much, you know, certainly I talk to people, whether it's patients or whether friends or sometimes other people will reach out with these type of questions of how Having taken even a starting dose of medication and felt like that was too much, it's very common that people who have a BMI of 25, 26, 27, maybe 28, either at the just really crossing into the overweight threshold, that they may not need a sort of full starting dose of medication and that that may feel like too much. So maybe these are people for whom they could start at a lower dose of medication, but again, recognizing that there's going to be potentially challenges there. So we're looking at maybe a less dramatic weight loss, which could be a good thing. We don't have data to say what happens. One of my biggest concerns, especially in the compounded medication space, a lot of that has changed recently. If you're listening to this episode, when it goes live in May or June, I don't know, it'll go live in June of 2025. Thinking about what is the compounded medication space right now, a lot of that has really decreased. In the compounded medication space, there's a lot more room for dosing variability. So are people getting the doses that they think they're getting? Is there a risk of changing potency or even changes in the medication potential So are there any risks there with the medication that's being delivered to them? And then that risk of underdosing or patient expectations. And again, just coming back to, are we creating a situation where if you start at a very low dose of medication and don't see a significant response to it, are we treating people like, oh my gosh, that you failed, you weren't able to respond to the medication? Oh, you're going to have to go up. Oh, you need a higher dose of medication. And that people who are starting on a fraction of the dose of medication that when or if that doesn't work for them, they feel like, hey, they kind of get this feeling of, I'm a failure, I can't believe this didn't work. And so making sure that we have very clear patient expectations and choosing the appropriate patient. So Lots of interesting things to consider in the microdosing space. Certainly worth having a conversation with your physician. You know, is this something that would be appropriate for me? What would it look like for me to do this? Is it even an option for me? For a lot of people, I will start them on, you know, in my clinic, we're seeing patients who have, do have metabolic disease, do have overweight with comorbidities, do have obesity and taking the FDA approved doses of these medications makes a lot of sense. So we are typically starting there. And let's take a patient-centered approach. If there is someone who is looking to use it maybe for another health condition, who doesn't have underlying metabolic disease, is open to trialing things out, and has a physician or provider who's opening to partnering them with them in it, I think it's reasonable to keep an open mind. But just being very clear about what are the expectations? Where are we going? What are our goals? Because microdosing won't be right for everybody. In fact, I think it's only going to be right for a very small subset of people. But it may be a valuable alternative in this toolbox that we have when we think about the treatment of obesity, the treatment of weight, the treatment of metabolic disease, and then the treatment of other conditions that may be benefiting from the use of medications like GLPs or GIPs. So with that, if you have questions about this, I'd love to create additional social media content or an additional podcast. If there's questions that you have that I can help answer or explain, feel free to always reach out to us at info at sarahstombaumd.com. We'll put that information in the show notes. We'd love to take any questions you have, create content around that. Thank you so much for joining us for today's episode. We'll see you all next time. Bye-bye.