Endocrine Problems and Their Relation to Unwanted Weight
Dr. Friedman’s main approach to weight loss is to rule out any endocrine problems, such as hypothyroidism, Cushing syndrome, or growth hormone deficiency, that may lead to weight gain. This is then followed by encouraging the patient to consume a low-calorie diet, and he often recommends eating a large quantity of vegetables, as they are low in calories with a large amount of nutrition, as well as to increase exercise.
He recommends using an app like Lose It! or MyFitnessPal to track calories. However, many patients need a jumpstart for the weight loss, and this is where weight loss medicine comes into play. Dr. Friedman often prescribes weight loss medications after other endocrine conditions are diagnosed/treated.
At Dr. Friedman’s most recent Endocrine Society meeting, it was pointed out that only 2% of patients with obesity are on weight loss medications. Imagine if only 2% or patients with diabetes were on diabetes medicines or 2% of patients with high blood pressure were on anti-hypertensive medications.
Available Weight Loss Medications
The table below lists available weight loss medicines. Dr. Friedman’s favorite medicines are phentermine, phendimetrazine and Ozempic, which is a diabetes medicine and its cousin Wegovy which is a weight loss medication. There is a promising new diabetes medication called Mounjaro (tirzepatide) which can give weight loss up to 25 pounds at the highest dose. Phentermine and phendimetrazine are low cost and can be used even without insurance coverage. All the other medicines (including Ozempic, Wegovy and Mounjaro) are very expensive and patient needs to check with their insurance on coverage. Some will be covered while others may not be covered and some may be covered only if the patient has diabetes. Some of them have coupons on their website that may reduce the cost.
Phentermine (brand names Adipex-P, Lomaira (8 mg) and Suprenza 15, 30, 37.5 mg) has been around for over 50 years is FDA approved for short-term but not for long-term weight loss. Phentermine was part of the Fen-Phen combination that was quite popular about 20 years ago. Fenfluramine, the drug that is abbreviated Fen, was pulled from the market in 1997 due to valve and lung problems. However, the Phentermine, which is the Phen drug, has remained in use and is actually a quite-effective weight loss medicine.
How Does It Work?
Phentermine works by decreasing appetite and also may have some effects on increased metabolism and is in the family of amphetamine-like drugs. Therefore, the side effects of Phentermine include feeling hyper or jittery, rapid heart beat, increased blood pressure, and trouble sleeping, so it should not be given at night. The drug works quite well short-term in reducing food intake and can often be given before lunch and dinner. The tablets are 37.5 mg in dose and therefore, Dr. Friedman often gives 1/2 tablet before lunch and dinner. In some patients, this keeps them awake at night and therefore, Dr. Friedman may give them a full pill to take in the morning. However, as the drug is only FDA approved for short-term use, Dr. Friedman usually gives this for a period of 2 to 6 months.
Phendimetrazine tartrate is a sympathomimetic amine, which is similar to an amphetamine, used as a short-term supplement to diet and exercise in the treatment ofobesity. Phendimetrazine is available in tablets and capsules. The standard immediate-release form is labeled as PDM, a reference to the active ingredient phendimetrazine. It is a 35 mg tablet most often prescribed for use two to three times per day, to be taken orally 30-60 minutes before each meal. The sustained- release formula (Bontril SR) is taken as a single dose of one 105 mg tablet taken 30-60 minutes before the morning meal each day. Both are good choices, especially in patients who was on phentermine and then it stopped working.
Semaglutide (Ozempic) is a diabetes medicine that leads to profound and sustained weight loss. It is not an amphetamine like drug so patients who have side effects on Phentermine or Phendimetrazine are likely to tolerate Ozempic. To avoid side effects including nausea (which is common) and feeling full, it is recommended to go up gradually on the dose of Ozempic (0.25 mg weekly for 1 month, then 0.5 mg weekly for 1 month, then 1 mg weekly).
The 2 mg dose has recently been approved and patients can go right from the 1 mg dose to the 2 mg and get an additional weight loss effect. If you get mild nausea, go down to a lower dose (go to 0.25 mg a week, if on 0.5.mg). If the nausea is severe, stop the Ozempic until the nausea resolves, then restart at 8 clicks and go up by 5 clicks every 2 weeks as tolerated. 18 clicks is 0.25 mg. The weight loss is greater at higher doses. Other side effects include vomiting, diarrhea and constipation. Ozempic lowers HbA1c (only modestly if already low), has cardioprotective effects and improves PCOS and fatty liver disease. It usually doesn’t give low blood sugars.
Ozempic is an expensive medicine, so patients should check with their insurance to see if they cover Ozempic (used for diabetes) or Wegovy (used for weight loss) and what is the approval process. There is a coupon on https://www.ozempic.com/savings-and-resources/save-on- ozempic.html that offers a 3-month supply of Ozempic for a $25 co-pay and doesn’t need insurance approval, but often it only covers co-pays. The final option is it is available at a lower cost from Canadian pharmacies.
Semaglutide (Wegovy) Wegovy and Ozempic are the same drug, but Wegovy is approved for weight loss. It comes in 0.25 mg, 0.5 mg, 1 mg, 1.7 mg and 2.4 mg delivery pens and does not allow partial dosing (clicks). Patients should stay on each dose for 1 month and only go up if they are not experiencing side effects. There is a shortage of the medication at mail-order pharmacies but is often available at retail pharmacies. Its side effects are similar to Ozempic.
Mounjaro (tirzepatide) Mounjaro is a new diabetes drug that is called a dual incretin. It has very impressive weight loss properties with patients on the highest dose losing up to 25 pounds. It is given once a week like Ozempic and has similar side effects as Ozempic including nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, and abdominal pain. The doses are 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg per 0.5 mL in single-dose pen and a patient should stay on the same dose for 4 weeks and only go up the higher dose if no side effects are present. There is a coupon that may reduce the costs (however the coupon for $25/month is no longer available) at https://www.mounjaro.com/savings-resources.
Qsymia Another FDA approved drug is called Qsymia, which contains Phentermine plus extended-release Topiramate. The Phentermine in the drug is actually a lower dose than in Phentermine itself and is usually given as either 15 mg or 7.5 mg of Phentermine compared to the 37.5 mg which is available as Phentermine alone. Topamax is a drug that was originally developed as a seizure drug that was found to have weight loss properties; however, this drug has a lot of side effects and is actually nicknamed “Stupamax” as it often makes people have decreased memory. Qsymia came out in 2012 and has only recently been used. It is available, but there is some difficulty getting it and it is about $160/month, with only about 1 out of 5 prescriptions covered by insurance. Dr. Friedman does not see any advantage of this drug over Phentermine itself. Therefore, Dr. Friedman does not use Qsymia in his patients.
Belviq (lorcaserin) was removed from the market in 2020 due to increased rates of cancer. The FDA does not recommend any special type of cancer screening in those who took Belviq.