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All About Weight Loss Meds -- Craig Primack MD -- Scottsdale Weight Loss Center

This video is all about the use of phentermine, Contrave, Saxenda, Belviq, Qsymia and other weight loss medications. Weight loss medications are used as part of a comprehensive weight loss program.
When you have struggled to lose weight and to keep it off, see a doctor who has a specialty in weight loss and knows the newest and best medical ways to lose weight for you


Dr. Primack: Hi, there and welcome. My name is Dr. Craig Primack. The following that you’re about to watch is a video that I recorded a few weeks ago about weight loss medications. Several of the medications that I will talk about in this video are Phentermine, Contrave, Saxenda, Belviq, Qsymia, and several others. Enjoy.

Dr. Primack: First of all, thanks everyone again for coming. If you haven’t been here before, thanks for coming for the first time. The topic we’re gonna talk about tonight is weight loss medications. Most of you obviously know me. This is my passion. This is what I talk about more than I talk about anything else. There’s been four weight loss drugs released since 2012. I’ve been on the speaker’s bureau for all four of them. I’ve probably talked 50, 60 times with groups of doctors about weight loss drugs. Two times ago, we did the one about the science part, that’s kind of my second passion.

Dr. Primack: The talk tonight is actually … I adapted it. I actually gave it to about 1,000 medical people back in September at Camelback Inn. I changed a few of the words here and there to make it good for all of us, instead of using as much doctor speak with you, I’ll talk you through the doctor words and so forth there. So, let’s keep going. First, I just have a little agenda. I did release a book, which we’ll talk about. We do have a book signing event coming up. I do have a blog, which videos like this are now appearing on, if you haven’t heard about it yet.
Dr. Primack: Tonight’s big topic, weight loss medications, and what worry about them. If you remember, I always like to talk about something scientific, and then something to take home, what can I learn? What can I do? What can I be a better person besides just the science part? So, that’s about living a long and healthy life. I’m going to learn a little bit about blue zones. If you’ve heard about blue zones, there’s five areas of the world that they’ve identified people that live statistically more than a hundred years old. We can learn from them.

Dr. Primack: We have to move there to I think truly adapt to what they do, but there are things I think we can take away from that, that we can all do. Then the next one, I’ve already scheduled, Thursday, March 28th, the week after that since I like to … I call it practice on you guys. The last talk I gave was about malpractice. So, the week after I gave it at a big talk. The next one will be about sleep, and how it affects weight, and then all the other things that I’m learning very quickly is diabetes, heart disease, Alzheimer’s, and I’ve always been excited about for weight, but now it’s all these other things too.

Dr. Primack: That will also be the scientific side, but then the, “How can I sleep better side,” which I think we all need. Just to talk about this disease itself, or the problem itself doesn’t help us unless we have somewhat of a solution. That is the book, Chasing Diets. So, download it, read it, enjoy it. It was a labor of love by Dr. Ziltzer and myself over the last … I don’t know, probably since May when we started writing it. It’s really about what we do, and why we do what we do.

Speaker 2: Can I add something?

Dr. Primack: Yeah.
Speaker 2: You don’t have or use a Kindle as well. You can download the Kindle app for free on your phone, and then if you go to the link that they posted, it’ll download it straight to your Kindle, so you can have it on your phone as well.

Dr. Primack: Yeah, so your phone, or an iPad, or any kind of … I even think laptops, if you go and download the Kindle app, which is a free app, you can then go into the Amazon store and download it. It’s exciting that we are doing a book signing at the Barnes & Noble right over here at 90th and Shea. You’re all welcome. It’s Wednesday, February 6th at 6:30. This is the big sign as you walk in Barnes & Noble. This is the sign I think at the doorway. That’s kind of nice. Dr. Ziltzer and I will be … we’re talking about something for only 10 or 15 minutes.

Dr. Primack: Then the question is, are you social? I’ve become social, is my blog. I’m pretty original. I had to come up with it. No, just kidding. But I have put the first two talks, ended up with two videos a piece, so I’ve put both of those on there. I have a personal recipe on how to make a chocolate bar, which I told some of you guys. But the best way the chocolate bar with … if you like peanut butter with kiwi dew on top and then the microwave. That is the latest video that went up I think on Monday or over the weekend. This one hopefully will be up there by next week also.

Dr. Primack: Instagram, if anyone does Instagram, Facebook, I do have a Facebook doctor page. We do have a Twitter, and a LinkedIn. But I think even more important than that, Scottsdale Weight Loss Center itself has a Facebook page. For anyone who’s a patient, we have a private Facebook, only for patients. I think sometimes we talk about it, but I think sometimes some people have been patients for a long time and never heard about it. If you’re ever on Facebook, you go to … it’s a funny funky thing, The Village with the @ sign Scottsdale Weight Loss. You tell who your doctor is and then they sign you in. So it’s only people that we take care of, so all four offices. Good.

Dr. Primack: So, let’s get started. This is what we call the four pillars of weight loss. A lot of people will talk about it, and I talked about it before. This is the chair. There are four legs of everyone’s chair. If you go on one leg, and everyone seen that kid back in high school who balanced on the one leg of the chair and what happened? He fell over. It’s January. The number one thing … and we already talked about what happens in January, people start going to gyms. “That’s what I’m gonna do. I’m gonna lose weight. I’m gonna go to the gym.”

Dr. Primack: What happens in February if they lost weight? Not really. No. One aspect is exercise of some type. The second aspect is nutrition and diet. The third aspect is as we say behavior, changing what you do, figuring out what your triggers are, why I stress eat if I stress eat? Why I boredom eat, why I tired eat, and all those things. The last is medications. So that’s the leg of the chair we’re gonna talk about today.

Dr. Primack: When you put all four legs strongly on the ground, and then I say stress comes in and we rock your chair. So, we all have stress. We have somewhat little stress and it comes in here, it rocks your chair. Your stable ground keeps you better than if you had less pieces of the puzzle. That’s the philosophy behind that. There is a big algorithm. It’s now over 300 pages that I was one of the authors of. It’s called the Anyone can download it if you want. I don’t know that I recommend downloading it at that many things. It is doctor … but if you’re interested in the high level stuff, that’s it.

Dr. Primack: And we talk a lot. I mean there’s probably 75 pages of the 300 about weight loss medications. When you really start to talk about it, so our society now, we call weight a disease. The reason we call it a disease, I’ll get into. But if it was a personal choice, you could just push … as we all know, it’s not just pushing the food away, and be a little more active. If that were the case, none of us would be here.

Dr. Primack: Data collections, so doctors talk to our patients, we take measurements, we get on fancy scales like we have. We sit down at our first evaluation, and then we talk how it’s happened before where your weight is and where you started? Do you work out? Are you on medicines? All those things. Then we make decisions based on these four, and we added one more bariatric procedure. So, nutritional intervention, some kind of diet. Physical activity being active, which you’ll hear time and time again.

Dr. Primack: Unfortunately, in literatures they say, “Be more active.” And I think that’s a misnomer. I think a lot of people are active enough. People have run marathons. It doesn’t make their weight normal. I would say run more marathons. I mean, how much can you do. So, I think the word is adequate exercise to feel good. Behavior therapy, Pharmacotherapy again our topic today. And then there are very bariatric procedures.

Dr. Primack: And I think you just have to be careful about your bariatric procedures. There is new and unproven ones and there is really good ones that have been around for a while. Unfortunately, one of my patients who I’d been taking care for a while stopped coming in the clinic. I saw her again this last week. She went in, had these balloons placed in their stomach and she has lost 10 pounds net unfortunately since August. And so you have to be careful at the proven things.

Dr. Primack: Although, there are some bariatric procedures that are very good that being said. Principles, why do we even think about using weight loss drugs? Because this is a serious and chronic disease. Serious means it causes health problems, if we do nothing about our weight overtime it will cause problems. We can name all of those things, blood pressure is higher, cholesterol is higher, joint problems, sleep apnea, cancers, all of them. And then chronic is it doesn’t just go away. It’s not a sinus infection and we don’t treat it with an antibiotic for two weeks and then all of a sudden we’re thin.

Dr. Primack: Unfortunately back in the 1950s … and we’re gonna talk a little bit the 1950s, when the weight loss drugs first came out that was the belief. You treat something short three months, and then we’re all normal after that. That wasn’t the case. They actually did some studies in the opposite. They forced certain people, made them gain 40 pounds, 50 pounds and then they said, “Well, now that you’ve gained the weight …” and that didn’t happen either you didn’t keep the weight. Those people because they were naturally … what they were normally doing in their normal lives, they lost all that weight again for the same reason.

Dr. Primack: Medications as a consideration should be prescribed chronically meaning I’m not gonna just do this for three weeks or four weeks and then stop them. Because when we … ooh, please welcome. When we stop them what happens? Weight goes back. So a lot of people say that’s a failing of weight loss drugs. But is it? Think about some of the other medicines we use, blood pressure medicines, cholesterol medicines. We know when we’re taking our blood pressure medicine what happens? Our blood pressure is good.

Dr. Primack: We go to our doctor and he say, “You know what, your blood pressure is good. Stay on what you’re staying.” You come back and see him in a couple of months and what do they say, “You’re doing great. Stay on your blood pressure medicine.” A couple of months later, what do they say, “Stay on your blood pressure medicine.” When we stop our blood pressure medicine, the next day we go into doctor and where is our blood pressure? It’s high. Our cholesterol? It’s high.

Dr. Primack: And so the fact that we have to use these medicines for a long time is no different than any other chronic disease. But why people think that, I’m still not understanding. They’re not really just appetite suppressants, although that is probably the main indication we use them. Some of them also help metabolism, some of them work on the bodies regulation of weight piece. When the FDA studies or when companies study them and the FDA approves them, they’re not approving them for appetite suppression. They’re approving them for weight management. That is their indication.

Dr. Primack: And I talked about anti-hypertensives. They’re suggested to be used when or with diet and adequate exercise. That is when we should be thinking about using them. In someone who’s been unsuccessful in losing weight on their own, the average person we now know is trying to lose weight two and a half times every couple of years and they’re unsuccessful when done on their own. And so that person is number one, a candidate. When you’re unable to maintain your weight loss. So, a lot of people can lose weight just fine. And then what happens? Goes back up, sometimes we call it the Nike Swoosh, comes down goes back up, comes down … and so they help maintain your weight. Even if you don’t use it in the beginning, you can use weight loss drugs later.

Dr. Primack: And then the last, meets labeled indication. So the FDA has put out some guidelines on who and when we should use these. So that’s what we’ll talk about. Next, so the FDA has guidelines for the last several years. This is when weight loss drugs are to be used. So they say people with a BMI greater than 30, people with a BMI greater than 27 who have other risk factors.

Dr. Primack: So I call this as like staging the disease. We stage the diseases and cancers that give it stage all the time. So if your weight is BMI of 30, above, it’s enough disease to start using medications. If it’s 27 with blood pressure, or cholesterol, or sleep apnea or any … we’ve listed three. Diabetes, hypertension and cholesterol problems. But is not the only ones.

Dr. Primack: And then I think the other piece and that’s where it starts to be an art and not only an FDA science, is a lot of people know that BMI is a lousy measure of what our weight is doing. If you will remember back Arnold Schwarzenegger is always the example everyone will use in their thing. Back in the day when he was Conan the Barbarian, his BMI was 33 or 34, falls way above the 30 line. And how much body fat did he have? Probably 1% or 2% if that. Now he did use steroids. It’s a whole another thing which wasn’t good for his probable health overall. But that being said, he would not be someone who we’d consider has problems.

Dr. Primack: The other opposite, and I see it every day in the clinic as we put people our fancy Tanita scale, if someone has a BMI of 24.9 or 26 or something, but their body fat is enough that they fall into these categories. So we use body fat just as much as we use BMI.

Dr. Primack: So, sulfur drugs, has anyone tried Orlistat, Xenical, Alli in the past? Heard of it? So back before 2012, there were only two drugs on the market for many years for weight. This was one of them. The other one has come off the market. So it started out as Orlistat or Xenical, Xenical was the brand name. And then they made it over the counter. You can buy this still I think probably even at Costco for a while called Alli. What does it do? It’s a light paste inhibitor. Anybody knows what a light paste inhibitor is? It blocks the absorption of fat.

Dr. Primack: And so they said, “As you eat fat, about 30% of the fat that we eat, which has a lot of calories 9 calories per gram doesn’t get absorbed and you pass it out.” So if you eat a lot of it, you pass a lot of it. If you don’t eat a lot of it … the problem was if you was you didn’t eat fat, now everyone was eating more carbohydrates. We know eating carbohydrates is not good either and so this is not the best of all medications. It wasn’t very successful for most people. It was 120 milligrams three times a day to do it. And then when they made it over the counter, all they did is drop the dose in half and they sold millions of this drug.

Dr. Primack: And I still remember one of the first people I’d … So when I started this, it was 2003 or 2004. So we only had really two tools that we used commonly. This one and the one that went off the market. And so I put a woman on this. She was working in an office, was in her ’60s and it happens when you have fat that you don’t absorb and now you pass, the medical word is called steatorrhoea. But I will tell you that is greasy diarrhea. And you can’t sometimes tell if you’re passing gas or passing this. And she worked in the office and you can just say, “She had to go home and change her clothes.” And again, who would ever take this drug a second time? Never took it again.

Dr. Primack: I don’t know that I prescribed it more than one or two other times after those kind of incidents. Never prescribed it much anyway, but we didn’t have a lot of tools. So we used those and the others was [inaudible 00:15:58]. So this drug is still available, but never been something that was a good answer. 1959 was a big drug, I probably already mentioned 1950s. Happy birthday this year is 60 years loved. What is it? What’s the drug? Phentermine, absolutely one of the first weight loss drugs on the market. The only problem at the time was it was not known about weight, it was known about the drug. It’s still the number one prescribed drug in the United States by far.

Dr. Primack: It’s sympathomimetic. It mimics or is a mild stimulant and it works on the hypothalamus. Hypothalamus is the culprit in our weight problem. It’s about the size of a blueberry, it sits in the center of our brain and it regulates our hunger. In the thousands of years humans have been around, when there’s been famine and there’s been a lot of famine minus the last industrialized times, last 120 years-ish, although there’s still parts obviously of the world that have that. When we had a famine, the hypothalamus is very good. It’s turned your metabolism down, which we all know happens and turned our hunger up.

Dr. Primack: So we hunted, we gathered and with lasted longer because our metabolism was slower. And our body can’t tell the difference between famine and diet. Essentially we’re giving it less food, it doesn’t know the difference. And so this is working directly on the hypothalamus to stimulate it, to decrease our appetite that we can measure by hormones, that is changing. The dose as you know for many of you who are on it, it starts as a 37 and a half milligram size tablet. Most people will start with a half a tablet or either work to two half tablets, is what I really like, about three to four hours apart. Sometimes going up to a full tablet.

Dr. Primack: It comes in a few other strengths and we don’t see very often, but they’re available. There’s an eight milligram short release that you can take up to three times a day. There’s a 15 milligram and a 30 milligram. 37 and a half seems to work well, if you break the a half, it’s pretty close to the 15. It is a mild stimulant, so biggest side effect, a little sleeplessness especially the first three nights. If you’ve heard me talk about it, I always say you have a little problem sleeping potentially for the first three nights and then after that your sleep is well or is lousy as you currently do. Because we don’t sleep as a society any longer.

Dr. Primack: And 95% of people who take this drug after three nights can sleep just as well as lousy as they used to. Because it does increase metabolism a little bit, we are cautioned with active heart disease. That CAD is Coronary Artery Disease. So if you have active going on, Angina, and things like that where your doctor is looking at your heart, we are cautious with it. Sometimes we use it in people who’ve had other heart problems, sometimes we don’t. We always run it by the cardiologist and clear those kind of things. That’s really the biggest thing that we watch for with this.

Dr. Primack: It is a scheduled or a controlled drug. What does that mean? The FDA watches it and you can only prescribe it certain ways for certain amounts of time and so forth. Approved in 1959 as we talked about. The label said, “Use it for 12 weeks …” I have another slide that we’ll talk about here. “Use it for 12 weeks and then stop.” Hopefully none of us moved to the state of Ohio. In Ohio that is actually still the law. And our society has been trying to fight that since I’ve been a member since 2005, I think we’ve been fighting it since then. But in the state of Ohio, if you have Phentermine, you can take it for 12 weeks in a lifetime and that’s it. And so John don’t move to Ohio. And we’ll talk a little bit more about that as we go on. So that’s Phentermine.

Dr. Primack: Lorcaserin or Belviq. This was one of the next ones to hit the market 2012. It is a selective serotonin 2C agonist that’s a lot of words. It’s a back up. So who remembers fen-phen? So fen-phen was a combination of two drugs, Phentermine the one we just talked about and a drug called Fenfluramine. Fenfluramine did two things. It was really good working on the brain to decrease appetite. When you put it with Phentermine it was very good, but it also worked on the heart to cause some thickening of heart valves. People needed valve replacements and such and so it was taken off the market. It’s never coming back.

Dr. Primack: We knew that it worked really well on the brain. So they found a molecule that worked on the brain, but not on the heart. So that’s what this is. It’s almost like a heart healthy … you put it with Phentermine almost like what we call a heart healthy fen-phen. And so it increases satiety, it increases fullness that’s its job. It is not a stimulant at all.

Dr. Primack: So, it’s good for a lot of people who either have insomnia or have other heart problems, very safe in that. It’s well tolerated. In my experience, if anyone has any side effects of this drug, it’s a headache on the first day and I think it’s less than 10%. I don’t think I’ve seen almost anything else. 99% for sure of the people I’ve prescribed it for, have tolerated the drug quite well.

Dr. Primack: Controls appetite without raising blood pressure causing anxiety or insomnia which in a very small percent, Phentermine can do. It comes in two forms. It came out initially as a 10 milligram twice a day drug and then a 20 milligram once a day drug. I’ve had people on both. If it works in you, it may work in both. I think … and this is only my experience, some people tend to do better on the twice a day than the once a day drug, but I haven’t had enough people kind of try both so to speak to be sure.

Dr. Primack: It’s an interesting one because it decreases hemoglobin A1C. Hemoglobin A1C is how we monitor diabetes. It’s doing something more than just weight loss for our blood sugar. We don’t know what that mechanism is. But if your weight goes down, call it 10%, we expect some other things to come down the same amount. But we’re seeing the blood sugar and the diabetes get even better than we’d expect by the amount of weight loss. So that’s obviously one of the benefits that when we try this drug for when someone who has diabetes.

Dr. Primack: And then all the drugs … and we’ll talk about the other three in a second, that have come out since 2012. Because of then Fenfluramine or that bad drug, they’ve come out and said, “We need to prove that this is heart health.” So not only do you do your study showing that it has weight loss, we need another study showing heart health. And so they’re the first of the four to publish something called a CVOT or Cardiovascular Outcomes Trial.

Dr. Primack: So basically doing a study of weight loss, but really looking specifically at the heart to see if it is safe. So if you remember also Fenfluramine had heart valve problems. When they need the initial Belviq, they did 30,000 echocardiograms on people’s hearts as they were taking the drug in the study and they did not see any problems. Then they came out with this other study the Cardiovascular Outcomes Trial. There’s not a heart problem they could see.

Dr. Primack: Possible interactions with other drugs that affect serotonin. So primary care doctors and they’ve talked about, “Oh, my gosh, this is a serotonin type drug.” All the antidepressants, typically we use, Prozac, Zoloft, all those are serotonin drugs so we’re gonna have a problems when you put these both together. The problem if it was there would be called something serotonin syndrome. Serotonin syndrome if you think of something that calms you, serotonin syndrome would be the exact opposite. Your blood pressure would be high, you feel hot, your heart would beat fast, you would be irritable, you wouldn’t sleep all those things.

Dr. Primack: And so we started in the first year watching for that. Didn’t see it at all. And then I had people who were on high doses of other serotonin drugs and I recall they’re psychiatrists and they’d say, “I’m thinking of putting them on this. What do you think?” They interestingly enough were never afraid of serotonin syndrome. And so my experience is now after since 2012 … what are we in? 2019. Then if you are on what I call standards doses of serotonin drugs. If you’re on a Prozac at 20 milligrams or a Zoloft at 50 milligrams or something like that, I have not seen any interaction with this type of drug.

Dr. Primack: And we’ve pushed the dose higher on those of some people on, and we watch them closely. The psychiatrist watches from their side, I watch from my side, we haven’t seen any serotonin syndrome yet. Can’t say it doesn’t happen, but we haven’t and I’ve used a fair amount of this drug for patients. It is also a Schedule IV Control drug. And then as we talk about, it is more moderately priced in somewhere of the $80 range for most people. And then few insurances that covered it $25 or $30 or $5, but most of time it’s in that range. And then as we said it was approved in 2012.

Dr. Primack: Questions?

Speaker 3: Can you go back to the migraine meds?

Dr. Primack: Yes.

Speaker 3: What issues?

Dr. Primack: So, with some of the migraine meds, they are serotonin type drugs. The Zomigs and [inaudible 00:25:07] and so if you take a lot of those at the same time you’re taking that, there is the potential for serotonin syndrome. Again, I haven’t seen it. But goal of I think for migraines is to take lots of those migraine meds than more.

Dr. Primack: Phentermine with Topiramate extended release. So Phentermine and Topamax. It did initially come out as a drug or is out as a drug called Qsymia in one pill but as you know here we combine the two separate pills all the time so we can titrate the two doses separately. So, it comes as a fixed sympathomimetic or mild stimulant in Phentermine and the effect on hypothalamus and then topiramate. When we talked about migraines, topiramate came out 20 years ago I believe as a antiseizure drug. It wasn’t any better or worse than the ones around the market, so it never took off.
Dr. Primack: Somewhere someone figured out that it actually prevents migraines. So, of medications that prevents migraines, it’s the number one most commonly used. When they were studying it, I believe for migraines, they said, “Oh my gosh, the people on the drug are losing weight, people not on the drug are not losing weight. There must be a weight loss piece there.” And so they started initially just as a weight loss drug. They did a six months study and placebo or not. So on the drug or on the fake drug and they lost weight, 6% or 8% of their weight.

Dr. Primack: Then they did a two year study to prove that it worked and yes, it continued on for two years. They did a study where you had to lose 8% of your weight first, just diet and then you went on the drug or placebo. The people on the drug continue to lose weight additionally and the people on the placebo started to gain their weight back. And then they started combining with Phentermine and they’ve done a lot of studies, the way the FDA in 2012 or ish likes to see studies and it is a good combination of medications

Dr. Primack: And it is the most potent weight loss drug combination that has been studied, we’ll talk about that. That isn’t for everybody but for more people than not, it is the strongest combination. It’s a great option for people who want one pill per day ’cause it’s only one in the morning. It’s generally well tolerated, the dose of Phentermine is a little bit lower than what we do, it’s basically what we could use as a half of Phentermine at the top dose.

Dr. Primack: But we started very, very low. The Phentermine starts at 3.75 miligrams, which is like licking a normal Phentermine pill, really. And 23 of the Topiramate, or Topomax, then it goes up to 7.5, and that’s what they call kind of the standard dose. So most people will go there and they’ll be on it for a while.

Dr. Primack: If they don’t keep losing weight, or enough weight after twelve weeks, they go through a titration dose, which is now only 11.25, and then the next dose which is called a top dose of 15 milligrams of Phentermine and 92 of Topiramate. Of the Topiramate we use here, it’s a 15 milligram, so, a half of one would be 25 milligrams, a full tablet would be 50, two full ones would be 100. So it’s pretty equivalent dosing.

Dr. Primack: There is a requirement that came out interestingly enough for Qsymia of this term that they now call FORP, Females of Reproductive Potentiaal. So, women who can’t get pregnant need to do pregnancy testing or have two forms of birth control while on this. Now it’s an interesting thing by the FDA because of Topiramate. And if you’re on Topiramate for seizures or headaches, which is a different part of the FDA, there’s no pregnancy testing, no recommendation because it’s a disease. And then it comes to weights, and we change the requirements and we have to do this extra testing.

Dr. Primack: And so it was a little problem obviously got, when it first came out that FDA tracked physicians who were writing it all the time. They tried to train us differently. It softened a little bit, but it’s a still recommendation that we follow. It is moderately expensive. For most people unfortunately it’s about $200 to $230 a month. And so the separate ones are significantly less expensive. It approved 2012 as we talked about, and we could do generic or off label Qsymia by combining the two drugs. And it’s scheduled for control because of the Phentermine in there. Questions?

Speaker 3: Can you use short acting topiramate or?

Dr. Primack: So we usually do short-acting topiramate or we dose it twice a day. There is some long-acting ones which I guess we can use, I haven’t found much need for.

Dr. Primack: Bupropion extended release with Naltrexone or Contrave. Well, the ones where you tend to use a fair amount, a lot of. And this an interesting drug, so it’s a combination of two medicines, but it decreases cravings by blocking two parts of the brain. One part is the same hypothalamus that we were been talking about before.

Dr. Primack: But then there is a whole part of the brain called the reward center. When we’re, “Look at that food,” and I’m, “I’m not really hungry, but that desert looks really good.” That’s just part of the brain and it’s working on that. So this drug I think 100% of the time, this is a cravings drug, which is interesting. So, benefits 24 hour a day appetite, hunger and cravings controller.

Dr. Primack: They did some stuff … interesting in the studies besides the weight loss, they did some studies or questionnaires on cravings. And if you have a lot of cravings for certain foods and you took this, the cravings as you measured it later on, the cravings went down which was nice. It’s very different effects from other medication that work just on the hypothalamus, so it’s good in that sense.

Dr. Primack: Moderately Priced. If your insurance doesn’t cover, and most don’t. Four week titration, you take one pill in the morning for the first week. You take one pill in the morning and a second at 5:00 PM in the second week. So, the two medicines in this. Bupropion ER is Wellbutrin. Wellbutrin is a medicine that has an anti-depressant that’s been out for a long time. Some people who take that on too close to bed have trouble falling asleep. And so that’s why the 5:00PM dose is there. I tell most people, “Aim for 5:00PM,” they’re gonna forget one day, “And that one day you forget, take it right before bed.” If you have trouble falling asleep that night, we know you have to take it at 5:00PM. If you have no trouble, just take it right before bed and so forth.

Dr. Primack: Interestingly enough, so Bupropion is also used for a smoking sensation. So, Zyban, if you’ve heard the name Zyban. Naltrexone was used for alcohol sensation. And so you kind of put the smoking and the alcohol and together we get fooled which I think is really … it is a craving or an addiction at some level just the same. Generally well tolerated, it can ’cause nausea and that’s probably the most side-effect.

Dr. Primack: The Naltrexone and the reason we start slow and build it up over four weeks is because of nausea. There are a few people that with the first dose, they’ve had really significant nausea, I have not been able to get them on the drug. Some people take it for two or three days, they’ll feel a little quizy, I can then back the dose off, and then maybe we go every other day, or we go every third day for a week or two and then we slowly build it up over instead of a month we build it up over six weeks, eight weeks, even three months. And we can get them successfully on this drug which is nice.

Dr. Primack: If you have other seizure things Bupropion, the Wellbutrin decreases seizure threshold. So if you had a tendency, it’s only come up one time, I think in Benadryl. So, the biggest thing, and that’s one of the reasons we wouldn’t use it is ’cause it cannot be used as opioids. Naltrexone is an anti-opiod drug. So, opioids are pain medicines like Vicodin and Percocet and Codeine and such. And so people who have chronic pain can’t use this ’cause it blocks that. If you were on it and you had or have, like say you have back pain, you had knee surgery, we stop the drug, when it’s out of your system for about 48 hours, you can then take pain medicine.

Dr. Primack: When the pain medicine is out of your system for 48 hours, you can go back on your Contrave. And so it hasn’t stopped anyone from using who doesn’t use it if they don’t use pain medicine on a chronic basis. Approved in 2014, but really came out in 2015.

Dr. Primack: So we’ve only had three or four years of experience with the combination. I had tried the … we call it the separate combination is there are two different drugs, I haven’t found it to work quite as well as the one pill together. I’m not exactly sure, it may be the extended release part of the Naltrexone also, so it’s a little bit longer. And the nice thing, it’s not a controlled substance, the FDA doesn’t follow it up at all. Questions?

Dr. Primack: Liraglutide 3.0 milligrams or Saxenda. So, this one of the newer most now kind of growing really quickly drugs. There’s a GLP-1 agonist, anyone know? I’m just kidding. So, we have a hormone that comes from our small intestine called GLP-1, it goes through the blood to the hypothalamus and some other areas of the brain and says, “I’m full.” So as the food gets there, and it keeps sending more signals, that half-life of the signal that you and I all have at some level, only last two or three minutes. And this drug, the half-life is 13 hours. And so it’s causing it to be for longer.

Dr. Primack: So it actually is also some people around on medicine called Victoza. So, this is basically high dose Victoza. Victoza is at 1.2 milligrams to 1.8 milligrams. So it’s used for diabetes, pre-diabetes. And when you go up to 3 milligrams, then it’s used for weight, you don’t have to have any diabetes at all. Benefits, it is long-acting appetite control. So it’s a 24 hour a day drug, you put it in the morning.

Dr. Primack: It’s not like … when I talk about long-acting, so, Phentermine, we need to come up in the day time, but we needed to go down as a de-stimulant so we can all sleep in the night. So the last couple of hours of the night, if that’s when your cravings and your hunger happen, Phentermine is not going to be there to help us. Margin like this achieves steady state after about four days or five days. And then it’s always on board.

Dr. Primack: Extra benefit in those with diabetes obviously because it’s used at smaller doses for diabetes. Considerations you build it up over several weeks. This does have significant nausea in about one out of three people. And it has heartburn that goes along with it. In some people, it slows the stomachs emptying as a side effect. It causes a little constipation in some people also.

Dr. Primack: Again with titration over 0.6 the first week, then 1.2, 1.8. 2.4 and then 3 milligrams, so that’s over weeks. We can slow that down also and go over more weeks. And again, I haven’t had anyone really who can’t take this and that Contrave we talked about, I’ve had a few people first dose, “It’s just not for me.” This one we start really small. So if I’ve showed anyone the pen, the pen has these little click noises. And ten clicks equals 0.6 and 10 more and so forth. So I put people on two clicks and three clicks or a 10th of 0.2 of the dose, 0.3 of the dose to start out with. And they seem to tolerate it fine if we go up really slow.

Dr. Primack: We talked about the side effects. They’re watching this whole class of drugs, although there has not been any signal in humans, although we saw it in rats and mice. Humans remember we are not big mice or rats. There is something called medullary thyroid carcinoma or any into and potential pancreatitis. So, if you’ve had pancreatitis, or you have a family history of medullary thyroid carcinoma, they say, “Do not take this.” The pancreatitis happens probably from gallstones although we haven’t proven that. In the study, 12 people had pancreatitis, six of them had gallstones that were found. So as people don’t eat, your gallbladder doesn’t squeeze, when your goal bladder doesn’t squeeze, it causes more gallstones. And so it’s a precaution at this point.

Dr. Primack: There has been history I think since 2009, or 2010 on GLP-1 drugs. And I don’t think we’ve ever seen a case of medullary thyroid carcinoma. And so, I talked about the other competitors in the space which are used for diabetes, and those are okay for weight. But when you look at weight, the Liraglutide is the strongest one that works on weight.

Dr. Primack: Very very expensive and that’s the biggest precaution or not precaution, the biggest problem with this drug. At full price, it’s $1,250 a month. At $1,250 we can do a lot of other things for that. If insurance covers it and that’s been my biggest concern or a problem with this, Jamie here in my office, probably three a week, she is putting in preauthorization so we get this discovered. And I think if I have to guess, it’s 1 out of 8 to 1 out of 10 people in Arizona who can get this covered.

Dr. Primack: It all has to do not on your insurance, it’s not United or Blue Cross Blue Shield, it’s who the employer is and if they check the box for weight loss drugs and most have not [inaudible 00:38:35]. It’s a healthcare problem not a think problem. If it is the subcutaneous injection which I guess I didn’t say, it is think tiniest little three inch, if anyone knows needles, 32 gauge is about … it looks like your hair, two hairs together. If I pinch myself, this hurts more than this tiny little needle, it’s pretty easy. And then it was also approved in 2015.

Dr. Primack: The next weight loss drug that hits the market from now is probably in 2021 or 2022. It is a drug that’s related to this one. Today it’s called Ozempic, and it’s a once a week diabetes drug at high doses much like this is a diabetic drug at low doses. It will be the next weight loss drug I believe if it hits the market.they’re in the studies right now to prove it’s also a weight loss drug.

Dr. Primack: Other medicines that we use, that are not directly approved for weight. So, we use a lot of the ones that help with weight, but may not be directly approved. The first one and probably the most common one I use is Metformin extended release. Metformin has been out for again over 20 years as a diabetes drug. It’s the number one diabetes drug across the world I would guess. They found it worked in diabetes very well. So they did some studies and well, does it work in prediabetes? Can we prevent diabetes?

Dr. Primack: And so they started putting people on it for that. I don’t know if it was the primary study to later on studies. Instead of studying teenagers who have weight problems, who have no sugar or diabetes problems, does it work as a weight loss drug? And the answer is, yes, it actually worked pretty well. And so if we study something on, I say on kids and it works well, we should be able to use on anyone, and now we do.

Dr. Primack: Only about two or three years ago, we figured out one of the mechanism that is working on weight, is through that same GLP-1 mechanism that we talked about on the last drug. So it is amplifying our natural GLP-1 signal at higher doses. And so what my experience is is you have to get up to at least 1,500 milligrams per day of this drug. So, two 715 milligrams. One doesn’t seem to do enough. And the max dos is about 2,000, so we’re close. I haven’t found much benefit from going from the 1,500 to the 2,000 per say.

Dr. Primack: Topomax, so by itself through the Qsymia studies and such Topomax was studied several times by itself as a weight loss drug and it is actually very good. I have a lot of people, for whatever reason we’ve chosen to just use Topomax, and Topomax works very well as a weight loss drug even though it’s that seizure and headache drug or what it was indicated for.

Dr. Primack: Tenuate. Tenuate came out in 1959 like Phentermine, it’s a cousin like Phentermine. It’s a short-acting relative. So it only lasts about 4 hours in its 25 milligram form. It doesn’t have as much stimulation, it doesn’t have as much insomnia. It’s just a milder drug. And as you’ll see the slide coming up, the weight loss is pretty close.

Dr. Primack: So, you can also dose it three times a day throughout the day. I have some people that call it, “The going out to dinner pill.” So they don’t take anything during the day, and 5:00 comes and, “Oh my gosh, we’re going out to dinner tonight. ” Let’s take a short-acting four-hour pill, it gets you through the dinner hour, it wares off before you go to sleep, very clean and nice.

Dr. Primack: For people who tolerate well, they’re using the three pills all the time, which is the kind of a maximum for most people. There is a 75 milligram extended release which you can get.

Dr. Primack: Phendimetrazine is another stimulant like Phentermine. It came up again in the same year, in 1959, it was a big year for weight loss drugs. So, three of them came out, actually three or four came out that year. So, this is another one. This is a different feeling for a lot of people than Phentermine. I have a few people that take it who it’s been the best drug they’ve ever taken. I’ve tried it on a lot more people. And they try it for a month, they go, “You know, the Phentermine was better.”

Dr. Primack: So, I do try sometimes in people, but it’s not been the winner so to speak. It comes as a 35 milligram, which you can take three times a day, and much like you would take the Tenuate, that’s 25. Or you can take 105 milligrams once a day. So, I usually start the 35 up to 3 times a day, and if people are taking it three times, I’ll go to that once a day, 105. 105 is just three of the 35s together.

Dr. Primack: Other GLP-1S do have something weight loss, decreasing the fat. So the other big ones … So the Victoza as talked about has some weight loss benefit. Bydureon is a once week, GLP-1 also. And there is two or three more on the market, anyone figures it it was important to list all of them, but they’re all GLP-1 drugs.

Dr. Primack: We’re seeing a little benefit in a drug class club, SGLT2. SGTL2 are drugs that are taken for diabetes that about 50 grams of carbohydrates that you eat each day, is actually just urinated out. So, you eat it, so it brings your blood sugar down and you get rid of it that way. It’s interesting. The combination of a GLP-1, and an SGLT2 drug is actually pretty descent for weight loss. But the two together, if you don’t have insurance to cover them, are ungodly expensive. I think one is 600 to 900 and the other one is another 900.So medicare is the hardest thing to get these kind of drugs for. They aren’t a lot of drugs that, or a lot of medicare that takes components that we can use in other commercial insurances.

Dr. Primack: Probably the last one to talk about is Vyvanse. Vyvanse is the semblance used in things like ADD and such. But is also used in binge eating disorder. So, it’s been approved specifically for binging, especially in the evening. It’s eating a large quantity of food more than … it’s not a scoop of ice cream, it’s a ice cream container on more than two nights a week for probably more than two or three weeks at a time, and so it helps with that. It’s kind of a long-acting mild, onset mild offset drug.

Dr. Primack: Any other drugs people have questions on that they’ve seen use for weights? Or that was all that came up in my list when I was putting it together. So, let’s talk about weight loss, so what do you get with these drugs? So that was all of them. So, this is weight loss graph, and percent pounds of weight loss above placebo. So, if you took nothing, we call that zero, and then this was above that. And so Phentermine in the studies way back in the ’60s gave about 8 pounds. Now, these are not with strong diets, this is not with exercise, this is just that. So, that’s why we put all these pieces together.

Dr. Primack: When you look at what the drugs did in these studies and look at what we get here, [inaudible 00:45:37] weight loss with new replacements, with exercise, with sleep and so forth, we knock any of those studies out of the water. So you have to take this all in to compare to the other drugs.

Dr. Primack: Tenuate as we see is six and a half, seven pounds. So even though it’s a milder, it doesn’t cause assimulation that Phentermine does, it’s still pretty good weight-loss rate. Interestingly enough, unfortunately in controlled studies when you’re doing it in a research situation, Xenical is about the same, that’s that one thing nobody takes.

Dr. Primack: Now the problem is no one takes it. Qsymia, the one I said is the most potent, look how high those go. And that’s the two different doses, the lower dose and the higher dose. So that if we can tolerate it for more people or not, that is obviously a really good combination together. Belviq, a little bit better than these, Contrave still up there.

Dr. Primack: This is an interesting study that the Contrave people did. So they did … all the study is basically for diet, do 500 calories less than their normal intake. And 30 minutes of exercise five days a week. It’s kind of a vanilla, diet vanilla exercise. They did intensive behavior modification much like the classes we do here. And they did it twice a week in the beginning and it went to once a month after that. And they just for the classes got a significant more amount of weight loss, which we’ll talk about why, the benefit of class, but that is the benefit of the classes. Learning what our triggers are, learning how to go to restaurants, things like that.

Dr. Primack: And then the last one was Saxenda, which falls in that same category here. With all these in under the right circumstances, we do combine medications all together, those have not been studied in a combined form. Phentermine is combined with many of the drugs that we’ve talked about here in the right portion for the right reasons.

Dr. Primack: Not only does the FDA look at how much average weight loss they have, they wanna know of the whole group of people that took it, how many percent lost five percent of their weight which kind of starts the medical benefits of weight-loss. How many lose 10% of their weight, which is somewhere in the middle of helping diabetes, of helping blood pressure and all those things.

Dr. Primack: And so this was Qsymia at the higher dose versus the … I think that’s switched actually. Oh yeah, Qsymia is 7.5 and 15. Belviq, Contrave and … so, they’re all about the same, which was good in that. The FDA when they approved a weight loss drug, they wanna know how much average weight loss you have. And then also how many people are getting that five 5%, and how many people are getting the 10`%. I have a slide that gets into that just a little bit of the why. So I have some case studies, I actually took these from a friend. And I’m gonna talk you through them, ’cause there is a lot of medical jargon. And it just talks about, with this particular patient, what is somethings that we think about as we’re going through.

Dr. Primack: So this was a 38 year-old female with a BMI of 31. So she has over 30 BM, type two diabetes, hypertension, high-blood pressure, insomnia. So that’s an important piece here in drugs that may ’cause insomnia. With Metformin, Glimepiride, which is diabetes drug that I don’t recommend for most people. Atenolol, Hydrochlorothiazide, a water pill, and Amitriptyline, Amitriptyline is used as a sleep aid. It’s used as a pain controller, and it causes weight gain, we know that.

Dr. Primack: She wasn’t on contraceptives, she had no insurance coverage for anti … the word the doctors uses anti-obesity medications. And this is a typical Arizona person who doesn’t have coverage. Her hemoglobin A1C was 7.0. So, someone has diabetes, we want it below six for sure, between six and seven we say is control, over seven we say is not, so she is right on the boarder line. And when you put classes or grades on her weight, it’s class one.

Dr. Primack: And so her best option, one was Phentermine. Why is Phentermine? It’s long-acting. It may inaugurate insomnia especially in the first three days, but if we can get her past that, it’s a very good drug for her. Diethylpropion is actually Tenuate. So that’s the trade name of it. So it’s low simulation, shorter half-life wouldn’t interfere with her weight, so another good choice for her.

Dr. Primack: Lorcaserin, Belviq the one we talked about, it’s not stimulating. It doesn’t raise her blood pressure or her heart rate. Good hemoglobin A1C reduction. So it helps her diabetes more than the weight loss. But it is more expensive. So we have to think about it that way.

Dr. Primack: Buproprion ER and Naltrexone is the Contrave. When I gave this talk and you give it to doctors in a CME setting, Continuing Medical Educational you can’t use trade names. So you have to use all these other names and may raise blood pressure mildly but may make insomnia worse and it is again more expensive much like the Lorcaserin. Other options that are something that are something that kind of in the back of your mind you think of, the Phentermine with Topiramate so that’s the Qsymia.

Dr. Primack: It has good weight loss as we talked about, less stimulation in Phentermine high dose by itself, butit’s definitely expensive and she doesn’t have coverage for that. Liraglutide 3.0 again is another good one for her diabetes control but at $1,250 a month she is never gonna get this one.


Dr. Primack: Number two, this is a 40-year-old male, Body Mass Index of 45. He’s sent in from his orthopedic surgeon. So nowadays for knee replacements, if your Body Mass Index is over 40, the surgeons don’t wanna do surgery on you anymore because there are more complications and they are now responsible for those complications. So they wanna get your weight down.

Dr. Primack: So this is a common referral to weight loss centers. Needs a knee replacement. In the past he was on Phentermine but it caused insomnia and palpitations. So, his heartbeat is a little … that’s uncommon but again possible. He has sleep apnea and he uses CPAP., He has high cholesterol metabolic syndrome which is really prediabetes, his hemoglobin A1C is 6.3, so in the diagnostic criteriam if you are over 6.5, it’s diabetes. If you’re between 5.7 and 6.5, it’s prediabetes and if you are 5.6 or less you’re normal.

Dr. Primack: Osteoarthritis, probably of his knees and of his back, he has high blood pressure, he has excellent insurance for him. He is already on a atovastatin, which is Lipitor, a cholesterol drug. He is on metformin for his diabetes and Losartan which is a blood pressure medicine, very commonly used in a lot of people. Medical management is definitely something for this person, because he needs to lose weight to have his knee replacement.

Dr. Primack: Weight loss in this gentlemen because of all the things, he has a high BMI, he has sleep apnea, he has insulin resistance and he is unable to take one of the simple drugs which is Phentermine. So what do we do next? Liraglutide is a very good choice in him. High weight loss, reverses metabolic syndrome. It’s a non stimulant. It reduces his … So this is an interesting thing. In some study it was shown to reduce the Apnea-Hypopnea Index, AHI.

Dr. Primack: So when you have sleep apnea, the amount of times that you stop breathing every hour is called your Apnea-Hypopnea Index. Normal will be less than 5 times an hour and there are people that have 100 times an hour or 60 times an hour. All the time, so 60 times an hour is once a minute, 30 times an hour is one every 2 minutes. And so, it decrease his Apnea-Hypopnea Index by itself. We don’t know the mechanism through that. High odds of 5% and 10% weight loss, expensive but he does have insurance that covers it.

Dr. Primack: Lorcaserin is a another choice, lower weight loss, non stimulant, a little lower odds of 5% and 10% weight loss than the Liraglutide or Saxenda, but it is less expensive. And diethylpropion would be another one to consider in him because he has problems with Phentermine, diethylpropion doesn’t have the same problems. Last few, Contrave another possibility to him. But the problem is when he has his knee surgery, he is probably going to need a narcotic pain-based medicine for his knee for a while and so he could use it now to lose the weight, we’d have to stop it before the surgery. And lastly the Phentermine with Topiramate, because it does lower doses of Phentermine. If nothing else worked, it would be another option for him or the two separately.

Dr. Primack: I think this is my last person. This is another 56-year-old or a 56-year-old Body Mass Index of 43. He had a lapdan six years ago. He has type two diabetes. Bad enough to use on insulin. He has chronic renal insufficiency, so his kidneys are not working. He has 60% of the kidney function he should have. He has an abnormal echocardiogram and abnormal EKGs so his heart is not normal.

Dr. Primack: He is starting to develop congestive heart failure. This is a sick gentlemen. He has six medicines for blood pressure. Six, that’s up there. His sleep apnea is not controlled. He is on insulin at 50 units of glargine which is the long acting one, he is on Lispro also which is a short acting insulin. Pioglitazone is another diabetes medicine. Clonodine, Valsartan, Furosemide which is Lasix, Metoprolol, minoxidil, and Amlodipine are blood pressure medicines.

Dr. Primack: His Hemoglobin A1C, with all that is 6.8 so it’s okay but it’s at top end of normal, his creatnine is 1.2 where it should be less than 1.0, that’s his kidney function. So this was the doctors, how would you treat these patients? So he’s already had the gastric band. The nice thing about science is we learn and the lapdan is not being done almost anywhere in U.S any longer. There is still some centers because it doesn’t have good long-term effect.

Dr. Primack: By 5 years and 10 years, 50% to 100% of the people have taken their lapdan out because of complications and problems and lack of [inaudible 00:55:57]. He does have life-threatening weight problems. If he continues on, he will not live very long. Chronic renal insufficiency, congestive heart failure and hypertension. He is a high risk person. He has type 2 diabetes on a significant insulin. His weight loss is gonna be challenging, you get it? It’s gonna help save his life.

Dr. Primack: He has a abnormal EKG, so, we have to remember to keep that in mind as we treat him. So what do we do? He did a full meal replacement plan. Wean his insulin by half on day number one because his full knee replacement thing. We started Lorcaserin, that’s the Belviq at 10 milligrams twice a day. He isn’t a good candidate for Phentermine because of his heart, diethylpropion for the same reasons. He is not a good candidate for Phentamine/Topiramate, because of again his heart and his kidneys. He is not a good candidate for Liraglutide because at this time, he is on insulin and you can’t use the two together.

Dr. Primack: And he’s probably not a great candidate or maybe he’s a candidate for the big Contrave. So in two weeks he was down five pounds, he was feeling well on his Belviq and on his food plan, by then he had stopped his insulin. He was able to stop it completely. Two months later he was down 26 pounds, his cardiologist took him up or decreased by 50%, 2 of his 6 blood pressure medicines in this amount of time already. His sugar despite now no insulin is in the 120, the 140 range, I think he would have loved to have these numbers two months prior. He’s researching now the Liraglutide type because he’s now off of his insulin, so now potentially a stronger medicine for him, more potent, but couldn’t take it before.

Dr. Primack: Neat studies and what you can do with weight loss medications. When new generation of weight loss medicines came out, the FDA … so I mentioned that there was Xenical, that came out a while ago and there was another one, I’m completely blanking on the name of it. Meridia, I don’t know if anyone took Meridia. So Meridia went off the market in an interesting study called the SCOUT study. And what they found in that study is if you lost weight it was a great medicine, because it did cause some people’s blood pressure to come up a little bit by being on the drug. But as soon as they lost weight, the benefits of losing weight help them.

Dr. Primack: But the people who didn’t lose weight had the complications of now having the mildly higher blood pressure. So they said, “Well if you’re not losing weight on these drugs, we probably should stop them.” And so they are now … the new ones have recommendations that if you don’t lose a certain amount of weight in a certain amount of time you’re not getting the benefit, don’t stay on them.

Dr. Primack: So way back phentermine and diethylpropion, long before those kind of rules existed. So we don’t have recommendations. On Phentermine with Topiramate or Qsymia, if you don’t lose at least 3% weight at three months, the recommendation is either to stop it or build the dose ’cause there’s those four doses. So usually someone is at the second dose and now you build up to the fourth dose.

Dr. Primack: And then you get another six month or so, and if you haven’t lost at least 5% of your weight then it’s recommended this is not the drug for you. Lorcaserin is 5% at three months. If you don’t get 5%, again, you’re not responding to it. Now all these drugs have what we’re gonna call super responders, the same person if it averages 20 pounds, there’s someone who’s gonna lose 60 pounds or 80 pounds. And then there’s gonna be people who gain a few, I’m gonna talk about that in one slide as we come up.

Dr. Primack: Now instruction on Bupropion which is the contrary. You wanna lose 5% by three months at the full dose, but it does take four weeks to get to the full dose so you have to take that into account. And then Liraglutide, the last one, it’s usually 5% as the one we look at, this one is at 4% at 16 weeks, and it takes 5 weeks to get to the full dose.

Dr. Primack: Phentermine long-term use. So as I said, it came out in 1959. The belief was you take it for 12 weeks you can cure your weight and then it wouldn’t be a problem. So a lot of people have said, “We don’t have studies directly on Phentermine,” and probably unless the government decides to do them, no drug company on a generic drug since the ’50s is gonna do those studies.

Dr. Primack: We do have Phentermine/Topiramate, so Qsymia that shows one year and I think we have even more than that data showing that it’s safe. And that has come out as kind of a belief that we’ve been using this for 60 years now. There’s good case reports of the same person using it over 10 years, we have not seen any problems. And so because it’s used millions of people a year, for years at a time, and we haven’t seen any signal or problems, we pretty much are just gonna have to accept that it’s a pretty safe drug.

Dr. Primack: When you use medications, medicine as we talk about the four legs of the chair, you need to put more legs together. So Sibutramine was the one I talked about that went off the market, Meridia … thank you. And so if you were on it, you lost a little bit. If you did [liso-modification 01:01:20] alone, you lost a little bit, if you did Sibutramine with brief therapy, you did a little bit. But if you combined it all, Sibutramine with stronger therapy, what happens, more rate.

Dr. Primack: So not on drug alone is the first one. Drug plus lifestyle is the second one, combine all of it together, the more weight loss. The more things we do, the more legs of the chair we use, the better weight loss we get.

Dr. Primack: This one was done on Molkosan and Belviq, this curve right here is placebo, people who didn’t lose any weight. The first part of this curve up until here are the people who are under V, they lost a lot of weight. Then at this point right here, some of them were actually told, “Just go off it. Cold turkey, don’t take it anymore.” And what happens we know when you stop weight loss drugs, they go right up and they meet the other people who never took the drug.

Dr. Primack: Now the people who are on it still started gaining some weight, but not as much as the others. And that’s when you talk about what are you doing with your diet at that point, are you adding other medicines in at the same time, is your exercise staying together, is your sleep staying together. And all of those other things are not studied in studies, everything else is controlled.

Dr. Primack: This is one of my favorite types of charts that I’m gonna tell you is not done in weight loss, so this is called a waterfall clock. Each one of these little things is a person in a study. So if there’s 100 little lines, there’s 100 people in the study. And what it’s showing you and this isn’t any particular study I wanna show you. But it’s showing you in the same treatment, pick any of the drugs I’ve talked about, any diet we talked about, there are some people who lose a lot of weight. And there are some people who lose a medium a model weight and there are some people that only lose a very little a amount weight. Some people lose no weight and what do we see here, there’s people that gain weight in the same studies.

Dr. Primack: And so what does that say, “We are all different.” On the gene side, the genetics that’s causing our weight problems is different. And so if we talk about starting one medicine and we don’t see the effect of it, what do we do, we change to something else. If one diet doesn’t work, we change to the other. If one exercise doesn’t make me happy, we change to the other.

Dr. Primack: And unfortunately today and I think for the next 10 years, we don’t have the genetics that are going to be able to say, “You know like 23 me, I’m gonna swab the inside of my throats or my cheek. I’m gonna send it off. In three weeks later, I’m gonna get a result that says I should use this medicine and I should sleep this much, and I should do cardio three hours a day and so forth.” Currently there are the tests that exist, but they don’t tell you anything.

Dr. Primack: And so the last time I was at the conference, one woman who did research on this, this is her published study. She did the swab and they sent her back and said, “Eat less fast food, do cardio and you should be on a diet.” It was like, “Really? I gotta do a swab for?” Next, that’s where we are today, it’s not where we’re gonna be eventually, but it is unfortunately where we are today.

Dr. Primack: And so it’s educated guests, it’s listening to all the other things that people have going on, do you have migraines, do you have blood pressure problems, do also have knee problems, all those little things and kind of an art into science to figure out what we need to do. That’s weight loss drugs, questions.
Speaker 4: If you’ve got diabetes and you lose weight and you get your A1C below six, are you able to then go off the medication metformin or do you have to stay on that-

Dr. Primack: So there’s always a debate in that. My belief is if the medicine helped you get below your six, why don’t you just stay on it. So, when some people will do that, others will say, “Well let me try off of it. If my weight starts going up or my hemoglobin A1C comes up, let me go right back on it.” Metformin is a really well tolerated, inexpensive, used for years on people drug, to me that’s one book we should keep. Now if you’re on something else that caused you potential side effects or you were noticing, but you’re like, “I put up with it,” then we should stop and then see how it is.

Dr. Primack: The question then comes up to take it one step further, once your hemoglobin A1C is between under that, do I still have diabetes?
Speaker 4: That’s my next question.

Dr. Primack: And so I think the answer is, at that particular weight, no, you don’t have diabetes but if you regain your weight, your body will take over what it used to do and then it’s the same thing again.
Speaker 5: Is probiotics taking the … I know it’s not a weight thing, but does it help or harm or?

Dr. Primack: The five doctors in my practice get together every month and we have a little meeting, and we all know we have a little journal call, so we all take an article to review and so I actually just reviewed one on probiotics. And I think the answer is we don’t know. There are definite reasons to take probiotics, I think probiotics have gotten this … they’re great for everything, and I think the answer is there are not great for everything.

Dr. Primack: In certain times when you take probiotics after you’ve taken antibiotics and such, it takes longer for your normal bowel bacteria to grow back to normal when you’re taking that because you’re KO feeding one type and are … we have billions of bacteria in colon. So, the answer is I don’t know, that’s truly what the answer is. There are certain indications that you should take it if you have something called C difficile colitis, and they give you antibiotics for that, it has been proven that probiotics definitely help. For other reasons, I can’t say yes and I can’t say no. There is no verdict, unfortunately.

Dr. Primack: So, for a lot of people I say try for a month, if you think it does something, stay on it. If you don’t think it’s doing any, don’t.


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