Conquer Your Weight

Dr. Sarah Stombaugh: This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast, episode number 31. 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 everyone, thanks for joining me today. It is January now, which I honestly cannot even believe. I took an unexpected pause in December and ooh, sorry. But it was just a lot. Our whole family was sick, including our three month old, which is just really miserable. We bought a house at the end of the month. We traveled for 10 days over the holidays and so on top of our usual life and medical practice, it's just been busy. And next week actually in our next episode we're going to talk a bit about time management and talk about choosing priorities in life because there's times in life when you simply cannot do it all and you have to pick and choose what your priorities will be. So as we move into the new year, my biggest goal is to reflect on my time. We all get the same amount each day and we get to choose how we spend it. I've had a lot of great thoughts. I'm gonna put those together and I cannot wait to share them with you in the next episode. Today though, we are talking about a long awaited topic, which is weight loss medications and I have had this episode outlined for a while, so I am really grateful to be finally sharing it with you. And this is a great opportunity to remind you that while I am a doctor, I am not your doctor since I don't know you or your medical problems, I can't say if these medications will be right for you, but I can give you some good information so you feel prepared to talk with your own doctor. So with that disclaimer, let's go ahead and get started talking about weight loss medications. I do wanna go through a bit of terminology so we're all on the same page. So I do wanna talk about what it means for a medication to be FDA-approved for weight loss, as well as then discussing what it means to have off-label use of medications. So in order for a medication to be FDA-approved, it must go through clinical trials to show that it works for its spec specific and intended purpose and that also that it's safe. So for example, if you wanted to get a blood pressure medication FDA-approved, the pharmaceutical company would do clinical trials to show that medication does actually lower blood pressure and that it does so safely. If a company wanted to get a headache medication, FDA-approved, that pharmaceutical company would do clinical trials to show that the medication decreases headache frequency and then it does so safely. And so if you wanted to get a weight loss medication, FDA-approved exact same thing, the pharmaceutical company does a clinical trial specifically for the purpose of proving it shows weight loss and that it does so safely. The complicated thing here is that our bodies are really complex. So when we think about things like blood pressure or headaches or weight loss, those things are not regulated by just one system within our body. So any medical condition might be caused by a number of different issues or a number of different systems within the body. And the exact opposite is true too. So a specific system like your neurological system may play a role in different types of condition, but it's not the whole the whole picture. So if we're talking about headaches for example, it's not like, oh, okay, you go and take this one type of pill and now your headaches are resolved. There are dozens of different medications to treat headaches and different people are going to respond to different medications because there's so many different systems that may play a role in it. So many different neurotransmitters and signaling pathways that are being targeted in order to reduce headaches. And so sometimes we have to use multiple medications and like I said, different people may respond differently or improve with one medication or another. And so similarly it is common that a medication is FDA-approved for one condition, but it's also helpful for a totally separate issue. So maybe a person who has headaches is prescribed a medication that is FDA-approved for seizures or maybe they're prescribed a medication that is FDA-approved for blood pressure control. Over time we learn that medications often work beyond just the reason that they're FDA-approved. And so when this happens, this is known as off-label prescribing. If you don't know much about off-label prescribing, it honestly might sound a little bit sketchy, but the reality is off-label use of medications is very common. And the reason is that the only way to get FDA approval is the pharmaceutical company does that clinical trial specifically for that medication. And while it sounds simple, that's a really time and cost intensive process. And so if there's a medication that's been around for a while, it's gone generic. So now it's cheap, it's been on the market for decades. You know, let's go back to that headache example and seizure medications. So let's say there's this cheap medication, I'm thinking of a specific medicine but cheap medication, it's been on the market for decades, it's effective for seizures and we find out, hey, this is actually working pretty well for headaches. There's no incentive for the pharmaceutical company to go back and prove that so that they can get the FDA approval. A lot of times there do end up being studies. So an academic institution for example, may give this medication and say, okay, we gave this group of people this specific seizure medication and we saw that it works well in headaches. But the only way for the medication to get FDA-approved for headaches is that there's a pharmaceutical company doing a specific clinical trial for that purpose and then they go through the application process to be approved for that medical indication. So it gets a little confusing here, but I want to point that out because in the weight loss world a lot of medications are FDA-approved for weight loss, but some of them are FDA-approved for other things. We know that they work for weight and this is a big difference I wanna point out between a medication that is not FDA-approved. So there's a lot of supplements in the market and that type of thing that are not FDA-approved at all and that's an entirely like other ballgame. So we are today com talking completely about FDA-approved medications, but some of them specifically for weight loss, other ones would be then off-label prescribing when we're talking about them for weight loss. Alright, hopefully I did not make that too complicated, but I think it's worth worth saying explaining because it actually ends up having implications sometimes for how an insurance covers a medication. And unfortunately when a medication is prescribed off-label it may be less likely to be covered by insurance. So worth just keeping that in the back of your mind really not something that you need to remember but it's something that your doctor is probably thinking about in the context of prescribing medications for you. So with all of that background, let's dive into the medicines. So over the last decade or so, the medical community has really began to embrace that obesity is a real medical problem. I feel like there certainly sometimes still, but a lot of times in the past it was looked at like a character flaw. People were given advice like oh just eat less and move more. And that's often not the solution for people who have struggled with their weight for years. When we deal with chronic excess weight, there end up being changes within our hormones and our physiology that make it really difficult to lose weight. And as such we've started to look at how medications might be able to help people along their weight loss journeys and we've been slow to adopt the use of weight loss medications. And to be honest, when you look at the early history of weight loss medications, it makes sense. So if we go way back, the first FDA-approved medication for weight loss was phentermine. It was approved in 1959. Phentermine is a stimulant and thereby an appetite suppressant. And then a few years later in the mid sixties a medication called fenfluramine was also F D A approved for weight loss. So interestingly, over the next few decades through the seventies, eighties and nineties, it became really popular for doctors to prescribe phentermine and fenfluramine together. It was actually never FDA-approved to use that combination, but it was pretty well known that people were using these medications together such that this cocktail was called fen. You've probably heard people talk about it with the idea that these two medications together would help to suppress one's appetite by two different mechanisms. Unfortunately though, after many years of use, so in the late nineties we learned that the fenfluramine component was leading to heart issues and it was pulled off of the market so they revoked the FDA approval. The other half of that medication though phentermine is actually a very safe medication when it's used appropriately. Unfortunately I feel like its name was a bit tarnished by being associated with a combination fenden medication. So phentermine the oldest medication out there, it is still FDA-approved for weight loss and it's used by itself for appetite suppression and thereby weight loss and it honestly can be a pretty effective medication. It's important to note though its effects are short-lived so it works well while it's in your system. If you take it in the morning, you'll feel the effects of it through part of or you know, depending on the dosage. Sometimes it's given once two or even three times per day. But you'll feel it that day and when it's combined with things like therapy or coaching, it can be a really excellent part of your weight loss treatment plan. However, because it's a stimulant because of its history, it is a controlled substance and some states have very strict laws about the prescribing of phentermine and then a lot of physicians sort of as a result of all of that may not feel comfortable prescribing it. The next medication that came along was Orlistat. It was FDA-approved for weight loss in 1999 and this medication works to block the absorption of fat. It's available in a higher dose as prescription xenical and at a lower dose as over the counter ally. And this medication was designed entirely on the premise that fat is bad for us back when were all really excited about low fat diets. And this medication is actually still on the market because it's totally safe, but it is a disgusting medication. When you are on this medication, the best course of action is to avoid fat completely in your diet. When you're taking the medication, you either need to follow a low fat diet or you have to suffer the consequences if you do eat fat because this medication prevents the absorption of fat, it causes some serious, serious gross, nasty side effects. And this was my first introduction to any of the weight loss medications. Long before I was in the medical field, I worked as a lifeguard in a waterpark. It was a medium sized waterpark. We had probably about 75 lifeguards and at any time 20 lifeguards would be working on a given day and we had this rotation schedule. You would go to three different slots every 30 minutes. You were out rotating around for 90 minutes and then you would have a 30 minute break. And it was generally accepted that during that 30 minute break you should go to the bathroom, you should eat anything, any of those needs that needed to be handled should be done during your break. But certainly if an emergency came out, came up and you were out on your 90 minute rotation and you needed to go to the restroom urgently or something like that, you could call over a supervising lifeguard and they'd cover your post for a couple of minutes. But that was generally didn't happen super frequently. So my last two years at the waterpark, I was a lifeguard supervisor and during that time there was a group of female lifeguards who decided they were going to start ally, which is the over-the-counter version of Orlistat. And remember, this medication works by blocking the absorption of fat. But what happens if you do eat fat when you're taking the medication is that it goes right through you, like completely through you such that eating fat when you're on this medication will cause diarrhea, greasy stools, loose stools, flatulence and leakage. Y'all, I mean that , that series of side effects right there, I actually read directly from the package label. These lifeguards were taking ally, they didn't change their diets at all and then they were using the bathroom constantly so they were calling for a backup because this group of young healthy women literally could not hold their bowels for the 90 minutes that they were out on rotation. So with that background, like I said, it's very safe. It's been on the market now long enough to prove that it's safe but it's just a nasty medication and I know people do still buy it from time to time because of its over the counter access, but my recommendation is just to not to. And if a physician recommends to you that you take it, you should probably ask some more questions about why that's being recommended for you. So we got through some of these medications and then there was a lull. A few more years went by and there was a little bit of an explosion of weight loss medications in the early 2010s. We had three medications that came on the market, actually four medications only three of them are still FDA-approved. So the first one was belviq, which is serin, then Qsymia, which is a combination of phentermine and Topiramate. Those were both FDA-approved in 2012. In 2014 contrave which is a combination of Bupropion and naltrexone was FDA-approved for weight loss. And then Saxenda, which is generic liraglutide was FDA-approved in 2014. And so all of a sudden within the course of a couple of years, we now have four medications on the market for weight loss. I do want to mention belviq but it's worth pointing out it's no longer FDA-approved. So Belviq or Lorca Serin worked on the serotonin system in the brain to reduce appetite. It ended up being pulled off the market in 2020 due to an increased risk of cancer. So like I said, it was initially approved in 2012 for weight loss and it shared some qualities, some chemical properties with the medication fenfluramine, that one I mentioned that was pulled off the market in the nineties. And if you remember, that medication caused heart problems. So when Belviq or Lorcaserin applied for their FDA approval, the FDA required that they completed a five-year study to assess for potential side effects from Belvere Locaserin and they were specifically looking for cardiovascular disease. Interestingly, after that five-year study, there was no increased risk of heart disease but they did start to realize that there might be a slight increased chance of cancer. So for patients who were taking the medication, there was a 7.7% chance of cancer during that study period, which might sound a little bit high recognizing though that people get cancer. And so when you compare that to what was the number of people who got cancer who were not on that medication, it was 7.1%. So people taking the medication had a 7.7% chance of cancer. People not taking the medication had a 7.1% chance of cancer. I don't remember the exact number of people who were in that study but high enough that it was statistically significant and therefore the FDA removed their approval. So that medication is no longer on the market was being used though for eight years before they ended up pulling it off. The other three medications that were approved in the 2010s qia Rave and Saxenda, these were actually not new medications at all. These three medications were actually just combinations or rebranding of medications that were previously FDA-approved for other uses and all three of these medications then it's worth noting. So they went through the process of getting FDA-approved specifically for weight loss and they're all still on the market and still being used frequently. So I want to talk about them a bit. So Qsymia is a combination of phentermine and Topiramate. The phentermine component we've discussed just a couple of minutes ago as one of the first or the first weight loss medications on the market. So it works as a stimulant to reduce appetite. And in the Qsymia medication, phentermine is paired together with Topiramate, which was originally an anti-seizure medication which is known to decrease appetite. So together these two different components work to suppress appetite through two different mechanisms and it can be a fairly effective medication when it's used together with lifestyle changes. I will mention when brand name Qsymia is not covered by a patient's insurance company, it is common practice to prescribe either or both of those components. And so that's an example of that off labeling prescribing that I was describing before. Next we have contrave. So CONTRAVE is a combination of Bupropion and Naltrexone. Bupropion is an FDA-approved medication for depression for that purpose it's known as brand name Wellbutrin and it works on the norepinephrine and the dopamine centers within the brain. Basically it works within the reward center of our brain. Years after Welbutrin was approved for depression, it was observed that people who were taking bupropion for depression actually began to quit smoking. And it became so common for people who were taking that medication to quit smoking that the FDA or that the pharmaceutical company actually went through the process of getting it FDA-approved for smoking cessation and it's still now used under that purpose as the name Zyban. Now that whole cravings pathway that played a role in smoking, people begin to think, huh, I wonder if this can play a role in appetite suppression. And we did learn that it works to decrease cravings. And so interestingly Bupropion by itself is not FDA-approved for weight loss, but it is commonly used off-label in the treatment of obesity. But Bupropion combined with naltrexone, that is FDA-approved for weight loss. The naltrexone component is an opioid agonist so that or antagonist rather that works within the brain to reduce cravings. This medication by itself is most commonly prescribed for opioid use disorder or alcohol use disorder. But together as this FDA-approved medication for weight loss is supporting people who struggle with cravings for food. And similarly to what I mentioned with the qsymia, if brand name contrave is not covered by a patient's insurance company, it is common for physicians to sometimes prescribe either or both of those components. As another example of quote off-label prescribing, the next medication approved for weight loss in that early 2010s was Saxenda, which is generic liraglutide and this is a GLP one agonist. These medications are a big deal. So we are going to spend the rest of the episode talking about GLP one agonist medications because in my opinion the use of GLP one agonist for weight loss was really the start of weight loss medications being taken seriously by the broader medical community. GLP one agonist medications work on the insulin and the glucose pathways within our body and so it helps to manage blood sugar and helps to increase satiety or fullness. There are also GLP one receptors in the brain and many people on these type of medications describe decreased cravings for food. And actually there's GLP one receptors in many of our systems, but for the sake of simplicity we're not going to go into all of those today. The GLP one medications were initially FDA-approved for the management of type two diabetes. So the earliest one on the market is a medication called BTA or exenatide. It was FDA-approved for the treatment of diabetes in 2005. So while some of the medications we'll be talking about are pretty new, we have really good safety data from this class of medications going back almost two decades now. And at this point there's quite a few different GLP one agonist on the market. So there is exenatide which was FDA-approved under the brand name byta for the treatment of diabetes. Next came liraglutide which was initially FDA-approved for the treatment of diabetes under the brand name Victoza and that was later FDA-approved for the treatment of obesity under the brand name Saxenda. Then there was Dulaglutide, which was FDA-approved under the brand name Trulicity for the treatment of diabetes. It is not FDA-approved for weight loss specifically, but it is sometimes used off-label for weight loss. I actually used to prescribe this one quite a bit back before semaglutide and Tze Peptide came on the market but not as often anymore. Then there's semaglutide that was initially FDA-approved for diabetes and that was approved under the brand name ozempic and then later it was also FDA-approved in the summer of 2021 specifically for the treatment of obesity under the brand name wavy. So Ozempic and wavy are actually the same medication and they are just in slightly different dosages And then for different indications, interestingly semaglutide does come in an oral version as well. I don't think I mentioned this. GLP one groups of medication is mostly injectable medications, teeny, teeny tiny needle. Most people honestly don't even feel it going in. I've poked myself with these needles specifically and it does not even cause pain but it is an injection. The glide though does have an oral version, uh, bel and that is an option as well. And then the most recent FDA-approved weight loss or the most recent GLP one medication on the market I should say is TIR Peptide, which was FDA-approved on the brand name manjaro that at least at the time of this podcast recording everybody has been talking about manjaro. It was just approved it almost a year ago in the spring of 22 and it's not yet FDA-approved for weight loss, it's just approved for diabetes. But I suspect over the next couple of years we're going to see that Manjaro is also FDA-approved specifically for weight loss patients and doctors are really excited about the GLP one agonist group of medications because they help directly impact some of the signals that get deranged in our bodies when we deal with long-term obesity. And this group of medications is very effective and patients are seeing excellent results. These medications do cause some side effects, predominantly GI side effects, so nausea or a sense of like fullness or sometimes even acid reflux type of symptoms. But partially it's because of how the medication works that it's causing that type of side effect. Otherwise though they're really thought to have a pretty excellent safety profile and it's been fun to see how quickly these medications are evolving and watching patients who have struggled with their weight for a long time finally be able to get the help they've been looking for. So if you are interested in considering medical treatment for weight loss, I would recommend to make an appointment with your primary care physician. It is best to have a visit that is dedicated solely to the purpose of discussing weight loss. If you go in for a physical for example, there's going to be a laundry list of other things your doctor needs to make sure to go through and you might not have more than a couple of minutes left at the end to discuss your weight. Or similarly, even if it's not a physical, if you have a checklist of a few different medical concerns, you won't be able to dedicate a sufficient amount of time to talk about weight loss. So my recommendation is schedule an appointment specifically for this purpose so that you can discuss it and at that visit your doctor will look at your medical history. We'll talk about potential pros and cons of medications for weight loss. I will say some physicians may not be comfortable prescribing weight loss medications and honestly if they say that to you, that's okay because it's important to work with a physician who is experienced with pro prescribing these weight loss medications who could help guide you through the process. Especially right now, at least at the time this podcast is being recorded, it's really common that we run into insurance coverage issues. There's been a lot of medication shortage issues as well. And so having a doctor who is familiar with navigating that can be really helpful. Additionally, weight loss medications are not just magical pills. All of the FDA-approved weight loss medications are designed to be used in combination with diet and exercise. And so for that reason, it might be helpful to see a physician who is board certified in obesity medicine if you live in Illinois or Virginia. I would love to see you as a patient in my telemedicine based weight loss clinic even if you don't live in one of those two states where I'm licensed to practice. Please do reach out. I would love to help get you connected with a obesity medicine physician who can help you along your weight loss journey. Alright, that is all today. Lots of great information. Hopefully if you have questions, please reach out. Please go see your doctor. Thank you so much for joining me today. I will see you back soon. Bye-bye.