Michelle Cusumano, MSN, APRN, ANP-C provides a thorough overview of the different weight loss medications available and the potential risks and benefits of each medication.
So Michelle Cusimano is a Washington University School of Medicine nurse practitioner that practices at the weight loss metabolism Center at Barnes Jewish West County Hospital and specializes in obesity management. She sees patients that need to medically supervised diets prior to surgery and or patients that want to pursue medical weight management and focus on pharmaceutical weight loss and lifestyle changes. So, thank you so much for agreeing to um come and educate us on this program. So we're gonna be talking on the use of weight loss medications for obesity treatment. Yes, thank you, Nicole. Um I don't have any disclosure, so we'll go ahead and get into the presentation. So, for the objectives, we're going to recognize the advantages of using anti-obesity medications for weight loss assistance. We're gonna describe how anti-obesity medications work and medication reconciliation to identify medications with the potential for weight gain. Just a little bit background and definition of obesity. In 1998 the National Institutes of Health had declared obesity as a disease. And in 2008, the American Obesity Society also declared obesity as a disease. The World Health Organization in 1997 announced obesity as a global epidemic. The Obesity Medicine Association defines the disease of obesity is multifactorial chronic relapsing and a neurobehavioral disease that is treatable. The diseases of obesity um is multifactorial and it increases body fat, promotes adipose tissue dysfunction and abnormal fat mass resulting in adverse metabolic bio mechanical and psychosocial health consequences. The indications for anti obesity treatment are A BM I of at least 30 or more than that or A BM I of at least 27 or more with comorbidities. Some of the comorbidities might be hypertension, insulin dependence, coronary artery disease, sleep apnea, uh gastroesophageal reflux disease and just lipidemia. It's also imperative to incorporate adjunct to nutritional and physical activity and also behavioral therapies. Um It's shown with medication that adding in intensive behavioral therapy as well does make a difference in the treatment. So it will also be important to set realistic expectations with the patient results may vary dependent on the medications that they're on physical activities of what they are um capable of doing nutritional changes and also behavioral changes a lot of times with treatment, we do see uh plateaus and this is fairly common. And so letting the patient know that plateaus can happen and not to get discouraged with this indications for anti-obesity treatment. Uh First, you wanna check with your state licensing board for their, your own regulations on anti-obesity medications. Documentation is necessary when prescribing anti-obesity medication, if it's decided to use the medication off label for weight loss, then do will be needed and it will need to be apparent that the patient has agreed to this. A documentation for off label use of the medication for weight loss assistance should indicate mutual decision making between the provider and the patient items to include in documentation or anti-obesity medication being prescribed. The rationale of why it's being prescribed, vital signs, appearance, mood, progress on the medication or a and or adverse effects and any reason for prescription changes including titration. Um in doses, the first medication we're gonna talk about is Orlo um also known as Alli or Zen. Zen. And I both have the parameters of the BM I of at least 30 or above or 27 or above with the comorbidities. Um It's for overweight adults age eight and over the zinal comes in 100 and 20 mg taken three times a day. L A actually is over the counter and it comes in 60 mg uh capsules and that's three times a day mechanisms of action. It's a gastric lipase inhibitor and also a pink lipase inhibitor. Contraindications for this medication will be pregnancy, chronic malabsorption and also reduce bio flow from the liver, usually due to infection gallstones or cancer precautions to take with the medication is low vitamin levels, ad E beta carotene. Also, um you wanna make sure that they don't have oxalate in the urine or history of kidney stones. Common adverse drug reaction can be diarrhea, oily stools, fecal incontinence, and also fat soluble vitamin deficiency in one year. Um It was shown that 3.9% did have weight loss in two years, 2.3%. And the actual um weight loss effects at least 5% of total body weight loss is seen in 21% of patients and 10% or above total body weight loss is seen in 12% of patients. So not a lot of movement here with weight loss, but it can help. I think the biggest thing to remember about ORSAT is warning patients that they could have those oily bowel movements and possibly even fecal incontinence. The next medication, Kimia uh is a combination of phentermine and topiramate again, the same parameters with the BM I. Um the dosage comes in a 3.75 mg of the phentermine in combination with 23 mg of the topiramate for 14 days, that's increased up to the 7.5 and 46 mg respectively. Um If there is less than a 3% weight loss, it 12 weeks, then you wanna increase even further. And so that dose will be the 11.25 mg of phentermine with the 69 mg of topiramate for 14 days and then that's increased up to the 15 mg, phentermine and 92 mg of topiramate mechanism of action. Um Phentermine is a sympathetic topiramate does increase Gaba and it decreases carbonic anhydrase contraindications is pregnancy, glaucoma hyperthyroidism. And if uh any ma ois are taken in the last 14 days. Precautions with this is specifically pregnancy fetal toxicity and six out of 1000 fetus could have cleft palate. So this is something to talk with the patient about, make sure that they are have several forms of birth control or something to make sure that they do not um get pregnant while on the medication. It also can increase the heart rate, uh suicidal behavior and uh suicidal ideation, mood and sleep disorders, cognitive impairment, hepatic impairment and kidney stones. Common adverse drug reactions of the Q or headaches, dizziness, fatigue. That can be from dehydration, paresthesia, which is the numbness, tingling in the hands and in the feet, nausea, dry mouth, constipation dys. So sometimes, um, food items or drinks may have a change in taste. This can help with soda a lot of times soda does not taste as good. Um, with the topiramate hypoglycemia if they're not eating very much, um, back pain and cough. So, an equal to or more than 5% weight loss in 67% of patients. And then placebo alone was 17% equal to or greater than 10% weight loss in 47% of patients. And then on placebo, 7% the next medication, phentermine was a combination of the previous medication and again, the same parameters for this as well. With the exception of, um, it's only used for three months or 12 weeks. If it's used beyond this point, it is considered off label. The dosage starts at eight milligrams with a half to one tablet every day. You do it three times a day, then there's an extended release. Um also which it comes in a 15 mg or a 30 mg or a 37.5 mg scored tablet again. Um It should only be used for 12 weeks. Uh Most come start with half a tablet of the 37.5 and then you can increase up to twice a day mechanism of action against sympathy, metic, centrally acting. It increases the norepinephrine, it releases to the hypothalamus and decreases reuptake and also decreases appetite. Uh This is not shown to cause cardio valvular disease or pulmonary hypertension, which was found uh in the fenfluramine contra indications for this medication. Again, pregnancy, glaucoma, agitated state history of drug abuse that I'm gonna add in here. You wanna be careful with bipolar on the manic side as well as it can exacerbate those symptoms. History of cardiovascular disease, hyperthyroidism and also MA O I use within the last 14 days. Precautions for this medication would be primary pulmonary hypertension, regurg cardio valvular disease may impair the ability for the patient to engage um in activities, operating machine machinery or driving a motor vehicle, concomitant. Alcohol use may result in an adverse drug reaction. Caution in patients with even mild hypertension we do look at the blood pressure to see if it's controlled or not controlled. Uh and also be careful with use in patients with renal impairment. Common adverse drug reactions can be headache, dizziness, fatigue again due to most likely uh dehydration if they're not getting enough and or not eating enough hypoglycemia, back pain, cough, nausea, dry mouth constipation, and the average weight loss is 7% at one year of continuous use. And then there is no evidence of addiction or withdrawal with this medication as it was previously thought Contrave is a combination of Naltrexone and Bon. Again, we're looking at the same indications with the BM I uh equal to or greater than 30 or uh equal to or greater to um 27 with at least um a comorbidity dosage is 8 mg of naltrexone, 90 mg of, bro. You wanna titrate one tablet every morning for seven days, then one tablet twice a day for seven days, then you're gonna move up to two tablets every morning, one tablet every evening for seven days, then two tablets twice a day. So it does titration mechanism of action. Naltrexone is an opioid antagonist, bro on decreases norepinephrine and dopamine uptake contraindications, pregnancy, uncontrolled hypertension, seizures, opioid use. So, if they're on a narcotic such as Percocet Norco or even traMADol uh anorexia, nervosa bulimia or undergoing abrupt discontinuation of alcohol, benzodiazepine barbiturates and anti medications or within 14 days of an MA O I precautions, suicidal behavior and ideation, uh risk of seizures as it does decrease the seizure threshold. HEPA a toxicity increase in blood pressure and heart rate. In combination with anti diabetic medication may cause hypoglycemia, angle closure, glaucoma as well. Common adverse drug reactions are gonna be headache, dizziness, insomnia, nausea, and about 33% of individuals and dry mouth constipation and diarrhea, weight loss. Uh 5.4% alone. But when you pair it with intensive behavioral therapy, that goes up to 8.1% respectively, the placebo effect was 1.3 and 4.9% weight loss equal to or greater than 5%. Uh and 42% and 57 with that intensive behavioral therapy, I BT place group is um at 17 and respectively, 43% with I BT 10% or more weight loss was 21% alone and 35% with I BT Placebo was 7% alone and 21% with uh I BT Lyric glut tide or Sina. Now, this is a daily injection. Of course, the indications are the same as previous. However, in age 12 years and older with a body weight above 100 and 32 pounds or 60 kg. Uh This can actually be used. The dosage is a titration. So you're gonna start off at the 0.6 mg subcutaneous daily for seven days. Then you're gonna move up to the 1.2 mg for seven days. Then 1.8 mg for seven days, then 2.4 mg for seven days and 3.0 mg for seven days. It's delivered in a 32 gauge subcutaneous needle and the titration is going to be dependent on symptoms. Does the patient have increased nausea? That's not tolerable. Um Are they having vomiting? Are they drinking enough fluids throughout the day trying to at least get in 64 ounces of water or fluids. The mechanism of action is a G LP one agonist and it does um slow down gastric emptying and create satiety fullness, contraindications again as pregnancy also a personal or family history of medullary thyroid cancer or men type two precautions would be acute pancreatitis, acute gallbladder disease, serious hypoglycemia with insulin, sago insulin or sulfon reas a heart rate increase renal impairment due to nausea and vomiting, suicidal behavior and ideation. The common adverse drug reactions are nausea and vomiting dyspepsia, diarrhea, constipation, headache, dizziness and fatigue, hypoglycemia, abdominal pain and uh increase in lipase is possible weight loss. You can expect about 9.2% versus 3.5 in the placebo group. And then at least uh 5% weight loss in 62% of patients versus a placebo of 34%. 10% weight loss is in 34% of patients and the placebo group is 15%. The next medication we go v selu tide. This is also injection except instead of daily, this injection is weekly. So again, you're gonna see the same parameters as the sex sender for the indication. The dosage is also a titration. So you're looking at 0.25 mg subcutaneous weekly for four weeks for a month, then you're gonna go up to 0.5 mg for a month, then it goes to 1 mg for a month, 1.6 mg for a month and then 2.4 mg would be the um highest dose. Again, the dose titrations are going to be dependent on the patient's symptom. Are they having nausea? Are they having vomiting? Are they able to get fluids in? Are they at least eating some form of protein? Um, every four hours are they able to get that in? Those are gonna be the questions that you're gonna be asking as you go up in dose titration. The mechanism of action is the same as the sakina still uses the G LP one agonist. It slows gastric emptying and also creates satiety or fullness. Contraindications are the same as sin with the pregnancy, personal or family history of medullary thyroid cancer I and type two precautions, acute pancreatitis gallbladder disease, serious hypoglycemia and a heart increase renal impairment and and with an insulin secreto, common adverse reactions are the same as the SINA which is the nausea, vomiting, dyspepsia, diarrhea, constipation, headache, dizziness and fatigue, hypoglycemia, abdominal pain and increased lipase potential as well. Weight loss. So weight loss, you can expect about a 14.9% versus the 2.4% in the placebo group. If you're looking at a equal to or greater than 5% weight loss, 83.5% of individuals did experience this with the placebo group at a 31.1%. Now, 10% or higher um was in 66.1% of individuals and the placebo group was at 12%. This next one is not considered a medication, but it is considered a medical device and how it works. The name of it is plenty or gas is 100. The indication is a little bit different than the other one. So BN I is equal to or greater than 25 to 40 kg. The age group is 18 and older dosage is three capsules with 16 ounces of fluid, 20 to 30 minutes prior to lunch and dinner. So it's twice a day that you would take the three capsules when you take it right before lunch and dinner. It expands to occupy the volume in the stomach and the small intestine create a sensation of satiety or fullness. Contraindications would be pregnancy or allergy to the ingredients, precautions. It could interfere with absorption of other medications. Uh You want to avoid using this in patients with esophageal, an atomic abnormalities. Um One of the things to be aware of is that there has not been any data in use of this medical device after bariatric surgery. So would not want to use this in those patients as there has not been any data on that caution with suspected strictures. Uh, patients with Crohn's disease using caution with patients with um, gastroesophageal reflux disease, ulcers, heartburn, history of G I complications that may alter uh motility. Common adverse drug reactions can be abdominal pain, constipation, gas infrequent bowel movements, abdominal distention, diarrhea, and nausea, weight loss effects. 59% had um a greater than 5% weight loss, 26% had a greater uh weight loss of 10%. Um And the average cost of this is $98 a month or $250 for a three month supply. So it, it typically is not covered by insurance. Some insurances may um but that might be a little pricey for some of our patients conditions. Considerations to keep in mind when you're ordering anti-obesity medications is, could you order a medication that can potentially already help a condition that the patient may already have? So, if a patient already has migraines or seizures, would they benefit also from topiramate? Uh that can help with weight loss assistance. Diabetes is another condition where you can use, um, Metformin G LP, one agonist um to help with weight loss, uh things like um Ozempic, uh Ter Zett are a couple of G LP ones to name a few. The Terzi is a G LP one and also a G IP binge eating is another condition that, uh, you may possibly use a medication to also help with weight loss, which would be by Vance, uh, topiramate as well. Depression, Wellbutrin, uh, or bon you can use for the depression to also help with weight loss. It's, uh, been studied with the Contrave that the combination of the NALTREXONE and the Wellbutrin work better together than just Naltrexone or the Wellbutrin separately. Uh nighttime eating disorder. Um several medications there that you can use for that as well. So looking at what the patient already has as a medical condition and may be pairing an anti obesity medication that can work for both of those things. Medications used off label for obesity, sym patho medics. If you're using those greater than 12 weeks, then that is considered um off label. You would want to make sure to do some documentation on that as well. Metformin um has a 2% weight loss. It can definitely help with insulin resistance that's typically used off label for uh assistance with weight loss. Topamax is another one that's used off label. It can also be utilized um for Binge Eating Disorder, which is FDA approved uh generic combination of the Naltrexone and the Wellbutrin. A lot of times patients can't afford contrive on its own. So sometimes uh providers will order these separately. Um in order to do that, you need to make sure that you try to stick as closely to the titration of the Contrave as possible. And so bro on sustain released 100 mg tablets plus Naltrexone half a tablet of the 50 mg which is 25 mg and these would be taken for a week. Uh That would be appropriate on sustain release 100 mg once in the morning and once in the evening and half of a 50 mg Naltrexone tablet once in the morning and once in the evening, then the third week, you could order the bro on uh suspended release 200 mg in the morning, 100 mg in the evening along with half a tablet of the 50 mg Naltrexone in the morning. And in the evening for a week, the fourth week, you could do the bro on 200 mg um in the morning, 200 mg in the evening along with Naltrexone, half of a 50 mg tablet in the morning and the evening as well. This will give you the final dose of Buproban sustained release 400 mg daily and a total of 50 mg now trone daily, which are still well within the safety limits of these medications. And this is the closest to the final dose of Contrave which is 360 mg of Buproban sustained release and 32 mg of Naltrexone sustained release Contrave. Um Company definitely does state that all the data research has been done on the combination through their um, name brand Con Grave and not done separately. So considered off label, if you do it that way, generic combination of phentermine and topiramate, we see this quite a bit as well. Um, used off label. Her zite is for type two diabetes, but they did come out with a coupon for commercial insurance. And so this was utilized um for some providers for weight loss as well and then medications, we're gonna switch gears with a potential of weight gain. When you see a patient, you wanna see what medications they're already on and see if some of those medications can be changed, that could potentially cause weight gain and try a different medication that would be more helpful with weight loss or at least, um, not cause weight gain. So some of those could be glucocorticoids, uh, hypno hypnotics, anti seizure medication. Gabapentin is one that I see quite a bit. Um, if the patient needs it and there isn't an alternative. Um, just know that it is a potential for weight gain cardiovascular medications. Um, some of the beta blockers, Atenolol metoprolol, a lot of patients are on those as well. Diabetes, medications, insulins can definitely, um, have a potential for weight gains, the onora, um, and then medications that can cause potential weight gain mood stabilizers. Again, you'll see the gabapentin in there, lithium. Um, the whole list there that can definitely cause potential weight gain, migraine medications gabapentin listed again. Um, some of the beta blockers. Again, antidepressants are also listed. TraZODone is even among those antipsychotics. Um, risperiDONE. So, a lot of these medications are used quite commonly. So even checking with, um, their psychiatrist that might be ordering the medications if there's, um, a better weight neutral medication that the patient can, um, go to safely. And that works for them. A summary of the anti-obesity medications. So, here's a summary of the anti-obesity medications. Phentermine, the 15 mg or 30 mg capsules, you can do 37.5 tablet or capsule and the 8 mg dose of lame. Those are some of the choices for the phentermine. Again, uh it can cause anxiety, agitation, palpitations, dry mouth, um actions, it does decrease the appetite and food intake in return. Uh wanna watch and make sure that they're able to fall asleep at night and that it's not keeping them up. Um Finot topiramate the Kimia doses are listed there and again, the side effects, numbness and tingling in the hands and in the feet. So, paresthesia and then carbonated uh beverages may uh taste bad. This may not be a bad thing for patients trying to stop um drinking soda actions, it decreases appetite and food intake and there are some taste changes. Uh Contrave the dosages are also recapped there. Uh side effects again, nausea, anxiety, increased blood pressure. Um You don't wanna use this with opioids or with traZODone. Um it can decrease the appetite. Uh and it can also lower the reward center part of the brain. So they don't have that impulsivity to go for cravings. So this medication is used more. So for patients that do have cravings for sweet salty savory. Um Lide Cinda, again, this is a daily injection side effects with this nausea, heartburn, diarrhea, constipation. And you don't wanna use this if there's any history of Mendu thyroid cancer and you wanna be careful Um with pancreatitis too, don't want to use it in patients that have had pancreatitis. The actions for this is reduced food intake, increased feeling of fullness, improved blood sugar and metabolism, semaglutide or we go v um again, same side effects as the Cina uh constipation is one that can frequently occur. So making sure that patients understand before they even start the medication that they could experience constipation, diarrhea. And if they do experience constipation, give them alternatives of what they can use even over the counter to help with this. Whether it be clase, maybe a little bit of Miralax to help with that. There's um smooth move tea out there that a lot of patients are starting to use to help with bowel movements. The actions of this is reduced food intake, increased feeling of fullness and improve blood sugars and also metabolism as well. Medications that are coming down the pipeline. These pipeline medications can treat rare genetic diseases which can cause obesity. They can help manage diabetes while also helping with weight loss and can also help with weight loss alone. So, am 833 is in the very early stages of development. It's also a weekly injection and it works by causing patients to eat fewer calories by mimicking the hormone called amylin amy and slows the movement of food from the stomach to the intestines. And this can cause constipation. It also enhances the feeling of fullness. Early data shows that this medication um cause people in research studies to lose almost 11% of their weight. And side effects of this medication may include nausea and vomiting. Uh and I'll add on their constipation as well. Set myon tide repairs, genetic diseases like Barad Beetles syndrome and also Ahm syndrome. Uh and a few others. These disorders typically cause early childhood weight gain, diabetes, uncontrollable hunger and I'll add in sight issues as well. Uh Side effects may include darkening of the skin medications coming down the pipeline. RM 853 is an oral medication that is meant to block the hormone called ghrelin. So, ghrelin in the stomach, um you can think of it as the hunger hormone send signals to our brain um that make us feel hungry. Um So ghrelin can cause us to feel uncontrollable hunger and overeat. It can also cause diabetes and other genetic disorders known as Prader Willi Syndrome. Uh that does cause childhood obesity. It's meant to prevent and fix all of these diseases. It is still in the early stages of development. So we don't know all the side effects of this. My lept uh replaces leptin. So, leptin is a hormone that's actually secreted by the adipose tissue in our body. And so the adipose tissue is considered its own organ. Leptin is a hormone that tells our brain that we're full when it is absent. Uh we overeat and gain weight. Eight. This medication is intended for those who have a genetic disease which causes leptin to be absent. Mylet will consist of a daily injection. It's approved for all ages. Some side effects, uh include infections, diabetes and a cancer known as uh lymphoma. Her appetite. I know this has gained a lot of uh traction with a lot of patients. Um, as I said before, there was a coupon out for it with patients with a commercial insurance. They were supposed to have a type two diabetes in order to be on this medication. Um, this medication, it's a weekly injection. Um, the other name of it, by the way, is called Mount gyro and it causes weight loss by imitating two hormones in our body that our body naturally produces from the small bowel and the large bowel. So one of those hormones is G LP one, which is Glucon like peptide one and also the other um that's added into it. What sets this apart from the Wi gobi and the Cinda is, it includes a G IP which is a glucose dependent insula tropic uh polypeptide, it turns sugar, we eat into energy. Our muscles can use instead of storing it as fat, it slows down the emptying of our stomach. Um that can cause constipation. So our food stays in longer. So we're actually fuller for a longer period of time. And in return, we end up eating much less to zet or mal gyro decreases the feeling of hunger that a brain sends to us when we eat. It also increases the number of calories you burn while you're doing daily uh activities. And research studies found that patient lost about 12 pounds over 12 weeks. Side effects may include nausea, vomiting and diet area. Um There is studies that will be released out, I believe, may 17th on this. It's already with the FDA to be approved for weight loss. In particular, we should be seeing that coming out uh within the year 2023. So it will be coming out soon for weight loss. Um With this medication, a lot of the anti-obesity medications insurance does tend to be a factor in whether medications are covered as well. And I'll go into that in a bit. Um A newer medication by mamma is a human monoclonal antibody that binds to an active type two receptor and it prevents the action of natural ligands that negatively regulate skeletal muscle growth, uh growth. And then the, the ac tr two blockage also promoted actions outside of the skeletal muscles and includes effects on brown adipose tissue, uh differentiation and activity. So, basically, it affects brown adipose tissue and it can preserve lean muscle mass. So, by preserving that lean muscle mass and helping burn that adipose tissue. This is how the medication works. It is a single IV dose. Um and it's given once a month, it helps improve insulin sensitivity and it has shown uh less total weight loss overall. Uh, that helps preserve the lean muscle mass. So I am seeing some research studies appearing this with pos uh with we govi. So then you've got, we GOVI that helps with um, the weight loss. And then you've got the Mima orab that can help preserve the lean muscle mass and also help burn that adipose tissue as well. I've got my contact information here for, uh, questions and answers. I will leave on a note as, um, insurance does tend to be the biggest factor when it comes to the anti-obesity medications. A lot of times insurance companies that will cover we go va lot of times we'll have a patient trial or have a contraindication to the other medications that were listed above. So maybe the patient has to trial and fail phentermine. Um, the Contrave Kimia orad, a lot of patients are not excited to try that medication with the side effects of the oily bowel movements and possible fecal incontinence. And then, um, there's some insurance companies that will not cover the anti-obesity medications at all. So when it comes to the anti-obesity medications, um, specifically the injections like, uh, the, we go V and also the Mal Jro, um, those medications tend to be quite expensive, even the SINA. So it can range anywhere from 1000 1200 a month all the way up to $1600 a month. And as we know, most of our patients, um, cannot afford that cost. So we're hoping to see insurance companies start to include some of these medications now that we have medications that are definitely have higher percentages of weight loss. Moyra or to appetite is, um, at about a 22% total body weight loss. The we go be, um, is about a 15 to 17% total body weight loss. And um, so insurance companies is, is really the hardest one, to try to um, get these medications covered. Thanks so much. I appreciate it. Great. Thank you Michelle. Um, there is a question, uh, what's the longest you let patients continue in termine if they are getting, uh, ok, if they're getting good weight loss results have no side effects and blood pressure, heart rate remain well controlled. Absolutely. So when it becomes off label, um, you definitely can have the patient even sign a form that states that they understand that they're continuing the medication off label. You wanna cover all your bases with documentation. Um Sometimes you can have the patients on it for three months. And then if they're having really good results, maybe let them take a two week break and then continue on it. The most important thing is documentation of the patient's weight loss and that is, is continuing to help them and that the patient is aware that you're using this for an off label reason. And then there's a second part to that question. Have you seen any data on famine use greater than one year? Um So the latest study out was long term for up to one year. So they do need to have more research studies that goes beyond a year. Some patients are good responders to it and continue to respond to it. Other patients, uh they have a tolerance to it and it no longer works and then you have to try something else. Ok. Um Second question, are you combining weight loss medication if one doesn't work? And which combinations do you use? Absolutely. So you can take these medications that are in different classes and use them simultaneously, you know, as long as they're not coming up against any other contra indications for medications that they're already on or medical history because it works in different parts of the brain. So you've got the Topamax and the phentermine, you've got phentermine, that's a stimulant. Topamax is separate, working on the Gaba receptors and then um you can pair it with another medication. So for example, Naltrexone works on the frontal lobe with coming down that reward center for the cravings. Um, there's not a lot of research with combining the medications, but I have combined them just for the best results. And as long as they're in separate classes of medications and you're not doubling up in the same class, you can do that. Also. Another condition that wasn't mentioned in here is autoimmune. So things like hashimoto's fibromyalgia, there is new research emerging that Naltrexone and micro doses has been helpful for those. And as you know, Naltrexone also helps with that reward or the craving part. Um Unfortunately, they haven't done research in the higher doses such as the 25 mg and the 50 mg that we'll use for weight loss. But that's something to keep in the back of your mind. OK. And then one more uh how much does Manero cost if ordered in Canada? And likewise, we we'll go. Yes. Um So Canada, as of about a month ago, they um had stopped even letting us get Ozempic. Um We're not getting Munro from them. Uh Ozempic is actually Mark's landing was the pharmacy from Canada. And so uh there's such a shortage that as of now, I don't believe they are selling that the concern with the price of these medications, there is a lot of pop up and I wouldn't even say pop up. They're in chiropractic centers and places like that that actually sell Ozempic Mount Jarro we go be at $35 a week, $70 a week, sometimes $70 a month. These medications are coming in vials, uh, have received a lot of emails from the actual, uh, um, home company that state. This is not something that they're selling in vials. It comes in the pen. So I'm not sure, um, where these providers are getting this medication from if you're using a compounding pharmacy that is not FDA regulated. So you can't really guarantee what they are giving you. Ok. That was it for, to, for today. And if you all have any other questions that you know, maybe come up later on. Oh, wait, is there one, have you done NALTREXONE? 4.5 mg for autoimmune disease? Uh Yes. So in primary care, I see that quite a bit. Um It's a microdose and it's used in the hashimoto's fibromyalgia, autoimmune diseases. Now, at a 4.5 mg dose, you're not really gonna see the weight loss effects. It needs to be closer to the 25 to 50 mg dose. And of course, um you know, it's off label if you're only using that. Um because Contrave is the combination of the Naltrexone with the wellbutrin where the research studies has shown that it helps with weight loss. Ok? If you guys have any further questions, you can always um go ahead and you can email me and I will get those to Michelle and she will get those back to you. This is a pretty hot topic because patients come into primary care and, um, you know, whether it's trying to lose weight because they want to or if the provider gently ask them, you know, for weight loss to reduce risk, heart disease, risk of cancer. And so there's just almost not enough providers to go around to help out on the weight loss side of things. So it's almost done in primary care as well. The biggest takeaway I would say in primary care, even though you're prescribing a medication, it really is helpful to have that intensive behavioral therapy along with it because it definitely changes the percentage of patients that will be successful with it. Great. Well, thank you so much. I appreciate your time. Welcome. Thank you. Yeah, thanks.
