Episode 64: GLP-1s Without the Side Effects? This Might Be the Answer

In this episode of the Pound of Pure Weight Loss Podcast, hosts Zoë and Dr. Matthew Weiner discuss the evolving landscape of weight loss medications, particularly focusing on GLP-1 medications and the implications of recent changes in compounding laws. They explore the concept of microdosing these medications, highlighting its potential benefits and the importance of personalized patient care. The conversation emphasizes the need for innovative dosing strategies and the future of weight loss treatments in conjunction with nutrition and lifestyle changes.

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Transcript

Zoë (00:21)
Welcome back to the Pound of Cure Weight Loss Podcast. We hope you're having a great day so far. We're excited to be here and actually Dr. Weiner and I have a couple articles to go over with you. We haven't done an article review in a little bit so we're excited to do this.

Matthew Weiner, MD (00:37)
Yeah. No, I mean, there's really been so much movement in this space. mean, it's, it really is crazy to me. We try to keep up as a practice and we're just a small practice. mean, we're, we are really a small operation ⁓ and keeping up with this stuff, keeping up with the availability of different drugs that we're getting it from Canada. We're now starting to source it from Israel for some patients and you know, then the self pay and we've got our creative dosing strategies using the U S products and then the compounding markets and.

all of the changes, keeping up with all of the data, and we're not even really tackling all the new drugs in the pipeline. And we'll start to talk about those fairly soon because we will have some new products coming out in the next year or so. But honestly, I could never see another patient and be busy 40 hours a week, kind of keeping tabs on this and putting new content together and everything like that. So ⁓ yeah, we're gonna talk about two things today.

The first is really kind of the, I think this is probably gonna be one of the last times we really address this as a present topic. think every time we refer to compounded GLP-1 meds going forward, it's going to be more like retrospectively. Like remember when there were compounded GLP-1s out. ⁓ And what has happened is there's been a lot of court cases that compounding pharmacies have really pushed.

to try to preserve their right to manufacture a medication that they don't hold a patent to. And as much as I'm not necessarily a huge fan of the pharma industry, I am a fan of following the law and the patent law is clear. These companies hold the patents, the compounding pharmacies do not, and therefore you can't manufacture a product that someone else holds a patent for.

And I've talked in the past about how unfair patent laws are, and that's a whole other story, but those are the laws. And so what we've seen is that we've had in the past an official ruling on terzepatide. So terzepatide, monjaro, Zepbond came off the shortage list first, and therefore it was banned from being produced because compounding pharmacies were only allowed to produce these medications.

because there was a shortage. They were on the FDA shortage list. They have since come off, terzepotide came off sooner. I've always talked about how I thought terzepotide was probably easier to make because it was just more readily available from the start, or at least Eli Lilly had an easier time making it. But there is now an official ruling that the small compounders, 503A Compounding Pharmacies, have to stop making it on April 22nd.

the big compounding pharmacies have to make it on May 22nd. We're filming this on April 25th. So the small compounding pharmacies have already had to stop and the large ones are gonna have to stop in less than 30 days. so, big takeaway on this for patients, because these things are still out there. I'm still kind of hearing about it. And technically you can sell semaglutide for another 30 days.

But it's really important to understand the providence of these medications. They're not coming from Eli Lilly or Novo Nordis. They're coming from some other country's manufacturing plant, which is definitely gonna be overseas. ⁓ And some other drugs come from them too. A lot of our drugs are manufactured overseas and that's fine. But these drugs are coming from ⁓ a place we don't know about. And at this point, if you are a legit business person who

cares about risk and who cares about patient safety, you're out of this business. You're out. You don't want anything to do with it. I can tell you, if somebody came to me and said, here's some compounding meds, you can sell them if you want. I'll give them to you for free. You're going to make a ton of money. I would be like, no way. That is just not worth it. Totally. I'm a fairly risk averse guy. I don't like risk.

Zoë (04:46)
Keep it away.

Matthew Weiner, MD (04:52)
I just, doesn't sit with me. I don't gamble. I've been to Las Vegas like five or six times in the last probably 10 or 15 years and I've not gambled a single cent. Not like a dollar in the slot machine, not like $5 on a blackjack hand, not a single dime. To me, it's just, I don't get it. And that's why I bariatric surgery, because there's quite honestly so little risk. So, you know, that's how I approach the world. I try to avoid risk as much as possible.

And so the people who are going to be selling these things are going to be people who have no problems taking risks. They're taking a risk of being sued by Eli Lilly and Novo Nordisk who've made it very clear that they're gonna shut this down. They're at risk for being prosecuted by the FDA. And so if they're willing to take these risks, how much attention are they putting into the safety of the product that they're selling?

Zoë (05:50)
and they're willing to take big risk with patients' health and safety.

Matthew Weiner, MD (05:54)
Yeah, yeah, if they're taking the risk with their own business and their own livelihood, they're gonna take it with your life too and the safety of your life. And the legit players are out of this space. And you're only going to, you're gonna see two groups of people still doing it. The kind of gray market, black market risk takers. And we'll see these things I think continue to be sold under the table in shopping malls and strip malls and you know, all kinds of places in very shady ways.

And then you're gonna see the hims and hers and the row and all of these bigger companies that were making a crazy amount of money that have a lot of like venture capital and kind of big corporate money. And they've sheltered everything and they've pulled out everything they can and they've protected themselves. So when Eli Lilly comes, the thing just folds like a house of cards, like, oh, sorry, we're bankrupt, bye bye. And fly off in their private jet with the money they extracted out of that and then work on their next little scheme.

And I think we'll see that too. ⁓ that, you know, so that'll happen also, but I just don't see legitimate centers selling these products anymore. Yeah.

Zoë (07:05)
Yeah, and

so with this like hard stop on compounding, because like you mentioned before, it's like before the internet was invented and after the internet was invested, this is going to be, you know, while we were compounding and the times after compounding and now we're in the times after compounding. But you know, that means that getting creative with your not only the dosing strategies, but also your sourcing strategies, things that we do in our platinum program.

Matthew Weiner, MD (07:14)
Bye.

Zoë (07:34)
But knowing that utilizing the real medications in just maybe again, more creative ways can still help patients get their hands on these medications for cheaper, with so much, like I don't want to say all, but so much of that risk is eliminated.

Matthew Weiner, MD (07:45)
Yeah.

Yeah, yeah, no, I mean, and so we're sourcing these medications overseas. There are different products, different dispensing methods that are for sale outside of the United States that make our creative dosing strategies actually quite easy. We've kind of our creative dosing strategies sometimes require a little bit of medical expertise. And I've been amazed at our patients and how creative they've gotten with this process. And quite frankly, I kind of learned everything from them. ⁓ But this

the new products that are available in Canada and now we're also sourcing from Israel, make it really simple and straightforward. And this really kind of dovetails into our next article, which, and I've been looking for evidence like this, and this came out, this is actually quite an old article, believe it or not. ⁓ And it goes all the way back to 2018.

Let me double check that because this seems...

Zoë (08:53)
Yeah, 2018 it looks like.

Matthew Weiner, MD (08:55)
Yeah. Okay.

So this goes all the way back to 2018. And I think, you know, this is something else that's really interesting is we've kind of known about this for a while. ⁓ I'm actually, I'm kind of embarrassed that it took me kind of a while to figure this out. But this is, it's an article from Lancet and it talks about micro dosing for using GLP-1 meds. And this is something you see on social media. You hear people talking about it, but the data is very clear. So they looked at just shy of a thousand people.

And this was a quality study. was a double-blinded placebo controlled trial. And they looked at using very low doses of semaglutide, Ozempic. Now Ozempic starts at 0.25 milligrams. The next dose is 0.5. The highest dose is 2.4. So they looked at 0.05 milligrams. They looked at 0.1 milligrams. They looked at 0.2, 0.3, 0.4 milligrams.

And they compared it to placebo. They also compared it to Lira Glutide, Victoza. I won't go into the details of that. But what they showed was that the placebo group lost 2.3 % of the weight. And I always look at the placebo group, Zoe, because that tells me, did they just give them the drug?

Zoë (10:11)
Mm-hmm.

Matthew Weiner, MD (10:15)
or did they do some other stuff too and help them lose weight and have them meet with a dietitian? And so the placebo group lost 2 % and so that shows me they probably did something. These people were actually trying to lose weight. They weren't just taking the pill and moving along. And then when we look at the other groups, the .05 milligrams, I'll tell you .05 milligrams is like a whiff. It is like nothing.

Zoë (10:29)
Mm-hmm.

Matthew Weiner, MD (10:42)
that they lost 6 % of their total body weight. And at .1 milligrams, again, tiny amount, 8.6%, and then at .2 and .3 and .4, it was somewhere in the 11 to even 14%. Now, this doesn't quite jibe with what we see in the We Go V trial where they lost about 16 % at 2.4 milligrams. But I think this also really gets to a very important point. I've talked about this before.

and we saw this in the surmount trial for trisepatite, which is that the majority of the weight loss occurs at the lowest doses.

And that's something that when we work with patients on our creative dosing strategies, we're really leveraging that. ⁓ And there's so many advantages to working at lower doses with these medications. And Zoe, I think you have just so much experience doing this with our patients. Tell us what you're seeing when you're working on people's nutrition at these lower doses.

Zoë (11:45)
Yeah, well, it really does reinforce that we want to ride out that lower, like we don't want to increase it. If you're losing weight and you're not experiencing very many negative side effects, which so many people tend to come to me, we know we're working on nutrition and I'm asking them how they're feeling, know, if they are having any of those negative side effects and they're like, I feel great. I just not thinking about food as much and I'm just not.

is hungry and they're getting all these really positive benefits, but they're not feeling like that nausea. They're not feeling kind of all of these yucky side effects that once you get at the higher doses, some people experience, you of course, not everybody falls into that category. But I'd say the majority of people who can ride out these lower doses, and that's where we can really hone in those nutritional changes, because most people

Matthew Weiner, MD (12:17)
Right.

Zoë (12:41)
You know, most people who've tried to lose weight for a while, it's not that they're not trying. It's just that they need that little extra oomph. And this microdosing strategy and really utilizing that lower dose to quiet some of that food noise, maybe decrease a little bit of that food volume and hunger and that sort of thing, then we can really soar with those nutritional and lifestyle changes.

Getting that positive reinforcement of seeing that scale finally go down after probably years of doing everything right and not seeing that scale budge. But then if we can get that little extra oomph, that little extra nudge in the right direction, that provides that motivation to continue that motivation to continue that positive momentum forward.

Matthew Weiner, MD (13:13)
Yeah, that's it.

Zoë (13:35)
And guess what? It's a whole heck of a lot easier to continue working on your nutrition changes and the lifestyle habits that you're working on when you're seeing that scale moving when you're feeling successful.

Matthew Weiner, MD (13:45)
Yeah. I mean, I think that what you just said is exactly that is the very essence of how micro dosing works. And, and, know, the number of times I'm sure that you've been working with patients and man, are they trying and they are doing everything right, everything. And the scale is not moving that it, and it's just so frustrating. And eventually they're like, why am I trying so hard? Why am I doing this?

doesn't make a difference. And so then they kind of go back to old habits. But if you just hit them with the tiniest amount of this drug, then all of the sudden, all of those efforts work so much better. And it really takes advantage and allows those nutritional changes to be effective. And just like you said, it drives that motivation because results are very motivating.

Zoë (14:26)
Mm-hmm.

Success is

the biggest motivator.

Matthew Weiner, MD (14:47)
Totally and so you know this to me when I look at nutrition What's nutrition look like in the future or in the near future? I think it's low dose meds plus a great nutritional program and that Addresses so many of the issues that our patients are seeing ⁓ You know number one people like I don't want to be on a med. It's not natural Okay, well zero milligrams is not natural is point one milligrams unnatural like

Yes, but just by a tiny amount if you can go to 2.4 milligrams and we're giving you point two milligrams or point two five milligrams One-tenth of that amount you're just being a tiny bit unnatural and let's be honest all of us are a tiny bit unnatural at times Yeah

Zoë (15:19)
Thank

Yeah.

And

if the, you know, I know that they're working on potentially coming out with a non shot version. if it's just, you know, in a supplement added to the supplement stack that most people are taking a ton of different supplements anyway, something else I wanted to mention that I think that this micro dosing. So, you know, a lot of people are doing a lot of the like doing feeling like they're doing everything right.

Matthew Weiner, MD (15:45)
Yeah.

Right.

Zoë (16:04)
I do think that we talked about this a little bit ago on a previous episode, but I do think that, you know, I think it was on the recap of our predictions episode, but I'm getting to the point of alcohol and how we see people feeling that decreased desire to drink and how we know that alcohol is such a sneaky source of empty calories and a really

Matthew Weiner, MD (16:30)
yeah.

Zoë (16:31)
Even if they're doing everything right with nutrition and exercise, if they're drinking regularly or having a drink or two a night or a couple times a week or whatever it is, that can potentially be a difference maker too. And so then if this maybe microdose not only gets that push going in the right direction on all these other things, if it's decreasing that desire to partake...

then that could potentially be another really great benefit of working everything together to really start seeing that weight loss.

Matthew Weiner, MD (17:04)
Yeah, no, absolutely. mean, I think that another piece that people are worried about is like, what's going to happen in 20 years with these meds? And I think I've addressed that because all medication...

considerations are risks and benefits and we're seeing so many benefits the risks would have to be pretty pretty rough but the one thing we know about side effects and long-term use of medications and if anybody's ever taken calculus out there they'll kind of understand this concept of the area under the curve and what that really amounts to when it comes to taking medications is what is the dose you are taking and how long have you been taking it?

So if you're on this med for 40 years, then, but you're on the tiniest amount.

you just don't have that high, large area under the curve. So you're less likely. We see this with smoking too. Smoking is measured as pack years. So if you smoke a pack a day for 10 years, that's 10 pack years. Half a pack a day for 20 years, that's still 10 pack years. And so, you know, that we can all understand if you smoke one cigarette a day versus a pack a day, that's gonna have a very different impact on your likelihood of developing cancer and heart disease in the future. And I think we're gonna see if there is something down the road and we don't see any.

anything right now, but you we don't know what we don't know, that by taking a low dose, you're hedging your bets and you're reducing your risk of suffering any of the consequences of that.

Zoë (18:33)
Yeah, and along the lines of this point, ⁓ I have heard several patients who this drug has been so incredibly life changing for, and they've gotten so much of their life back. I've heard many people say, don't really care if there's a negative effect 20 years down the line. I'm getting all this life back now, and I get to live a life that I'm.

Matthew Weiner, MD (18:58)
Thank

Yeah.

Zoë (19:03)
happy to live and if I mean you know of course that's not everybody that has that sentiment however you know it's kind of aligned with what what we're talking about.

Matthew Weiner, MD (19:13)
Yeah,

yeah, I think, you know, if you use these things smart, and I think the same, you know, we've learned the same thing about bariatric surgery. If you do bariatric surgery on the right patient with the right amount of preparation.

that you get great results and you really don't have these long-term risks that everybody's worried about are quite minimal and the rewards are very substantial. And I think we're going to see, know, if, we're probably gonna find out something bad about these things at some point, but I think it's gonna be a tiny, tiny bit bad and we're gonna be seeing so much good, it's really still gonna be negligible and we're gonna continue to dose them. It'll make the headlines and it'll generate probably a thousand portal messages to us,

Zoë (19:55)
Right.

Matthew Weiner, MD (19:56)
But we'll deal with that when it comes. I think the other thing that this microdosing idea ⁓ addresses is cost, right? Because again, using our creative dosing strategies, and we're so limited in the US because, you can't get 0.25 of Ozempic and we go V.

⁓ But the highest, the lowest dose of terzepatide is 2.5 milligrams. I was talking to a patient today who took 2.5 milligrams and he was like, I was miserable. I couldn't handle it. And so, you know, we were using some creative dosing strategies and we brought the dose down and he was doing so much better. He was like on one milligram. And I see that. And so there's some people who just do really well on much lower doses. And so I think that we need that flexibility to do that.

We don't get that from the US product, but we do get it from the overseas product.

Zoë (20:50)
Mm-hmm.

And that just reinforces, you know, that the whole point here is patient driven care. We're here to do what's best for our patients and to help them get the best results and to help them actually be able to afford the medication and, you know, having that individual massaging of the journey. That's not exactly how I want to phrase it, but, you know, having that individualization.

Matthew Weiner, MD (21:14)
Yeah.

Zoë (21:19)
the journey is so critical because everybody is different. like, yes, we have our overall nutrition protocol and plan that we want to be working towards, but everybody's going to require a little bit of different implementation because your life is different than their life, it's different than their life. So how can we make this work for you? And that's a really great example of that, Dr. Weiner.

Matthew Weiner, MD (21:34)
Yeah.

Yeah, the-

I've met with at this point thousands of people taking these medications and what I've found is everybody's story is different. And there's definitely a group, the super responder group.

We saw this in bariatric surgery. Quite honestly, if you're a super responder and I tell you, here's the rules, don't drink, don't smoke, you know, don't eat a bunch of garbage and you're a reasonable person, you're like, okay, he said it, I'm not gonna really do it. I'll do it a little bit, but maybe not the smoking, but you know, the other stuff I'll do a little bit and you know, I'll be okay. And if they're a super responder, they can kind of be like, thanks for the surgery, Dr. Wine, I'll catch you on the flip side and disappear and they'll do amazingly well and have a great experience.

Zoë (22:21)
Yeah. ⁓

Matthew Weiner, MD (22:26)
DNA was very favorable. We see the same with the GLP-1s. There's that group of people where you put them on the intro dose and as long as you keep their prescription active, they're gonna do just fine. everybody else has a much harder road to hoe and their nutrition.

and their dosing and their side effect management and all of the things that go into figuring this out is much more complicated. And so that's really, think, where people need that ⁓ extra assistance. I'm so excited for our app to come out because I feel like our app solves that. So many times people have been like, I wish it was all in one place and I wish it did this and I really feel like it is. Yes.

Zoë (23:11)
Like, just wait!

Matthew Weiner, MD (23:13)
May 9th, we're beta testing. So if you are in our nutrition program, you will be automatically be offered a beta testing spot. ⁓ And so we will have that out. May 9th, we'll be starting our beta testing process. And so again, if you're in our nutrition program, you're going to get an email, we're going to enter you into our system, and you'll be able to log in with your

with that same email you use for our nutrition program and start using our app and beta testing it. And I can't promise you it's going to work perfectly because that's what a beta test is about, but it's actually working pretty well these days. But we'll keep smoothing out the wrinkles. ⁓ So yeah, we're really excited about that too.

Zoë (23:58)
Yeah,

lots of good stuff in the pipeline.

Matthew Weiner, MD (24:00)
For sure, for sure. But yeah, this article I thought was interesting. We're gonna see more and more talk about microdosing. I think the US dosing pens that we see with Wegovia and Zepa, I think it's wrong. I think that's the wrong way to do it. This product, the quick pen in...

Canada or Israel or most other countries quite frankly, is a far superior way to use this medication. It helps patients reduce side effects. I think it enhances comfort and because comfort equals weight loss with these meds. If you aren't comfortable, you're not gonna get the long-term weight loss because you're gonna quit. And I won't blame you a second because none of us want to continue to inject something into our body that makes us feel like crap. We're doing this because we want to feel better about our body.

Zoë (24:42)
Mm-hmm.

Matthew Weiner, MD (24:48)
not worse. And so when you have access to these in-between doses, lower doses, it gives you a lot more opportunities to be comfortable and therefore to sustain the use of the medicine. And I think that Novo Nordis and Eli Lilly are gonna figure this out and start offering this product in the US. I think they're just so focused on their profits.

rather than their comfort. And I think what we're seeing, I'll tell you something I'm seeing, I'm seeing a lot more people coming around looking at surgery. And they're looking at surgery because they're not having the experience with the meds that they'd hoped they'd have. And I think some of that is from them not being able to dose it at the right amount.

Zoë (25:21)
Mm-hmm.

Matthew Weiner, MD (25:35)
and being very limited. It's also the financial component too is a huge, huge cause. And so, you know, I hope that the drug companies recognize that the long run for them and their patent lasts a long, mean, 2032, I think for semiglutide and trisapatides late 2030s, they've got a lot more years of selling this thing and they're gonna have a lot of competition. And if they don't figure out how to make it more comfortable for people, I think it's gonna cost them on the sales front.

Zoë (25:53)
Bye.

Alright, well I think that pretty much wraps up our show today. Dr. Weiner, you have anything else you'd like to add?

Matthew Weiner, MD (26:09)
No, I I think, you know, I'm glad we're kind of back at doing the podcast. And, and I think these were two really great conversations as I'm doing more and more med work and combining meds with surgery. I'm really starting to kind of figure out a lot of the nuanced components of this. And, and I think it really just kind of solidifies this idea of, you know, lifestyle and nutrition as the foundation of any weight loss program with the meds and then the surgery.

Zoë (26:14)
Yes.

Matthew Weiner, MD (26:39)
at the very top and kind of how we put that together. We're just seeing more more evidence of the importance of nutrition, but it works so much better when combined with the meds or the surgery. ⁓ And so I'm glad we're continuing this conversation and I think we're gonna keep cranking out the episodes.

Zoë (26:57)
Absolutely, so we'll see you on the next one.

Matthew Weiner, MD (27:00)
See you next time.