Episode 80: The Future of GLP-1 Medications: Quick Pen and Dose Flexibility

In this episode, Dr. Weiner and Zoe discuss the latest advancements in obesity medicine, including the beta launch of their new app Loli, the evolution of GLP-1 medication dosing with the Quick Pen, and insights from recent research on GLP-1 prescribing practices. They also address patient questions on post-bariatric care and the future of medication delivery.

Sign up to be a beta tester for our new app - https://gololi.ai

Transcript

Zoe (00:21)
Hello and welcome back to the Pound of Cure Weight Loss Podcast. This is actually episode number 80. So congratulations, Dr. Weiner, we've made it to episode 80.

Dr W (00:33)
That's pretty good. I'm proud of us for that. We keep at it. We're still doing it. We're here. We're gonna keep making them.

Zoe (00:37)
Yeah, we've stuck to it. I mean, that's true. Yeah, that's

Dr W (00:42)
I'd like to start doing more too. I think that's something we'll ramp up to.

Zoe (00:44)
Yeah, so...

Absolutely. You know, I think it's good that we've been able to continue and like still have these conversations and get the word out there on obesity medicine and of course updates with our practice and patients and all of that. But you know, we it's been a little bit sporadic because we've got a lot going on and we've been working on a lot of other things on the background as well. So we we are certainly still here. We're going to keep doing it, but perhaps a ramp up with some more consistency will be pretty great.

Dr W (01:09)
Yeah

Yeah, for

Zoe (01:21)
speaking of what we've been working on behind the scenes, our new version of the app is basically ready for beta testing. Dr. Weiner, tell us a little bit more about that.

Dr W (01:34)
Yeah, so we are gonna start beta testing in the next week or two and kind of slowly roll it out to a very small group of beta testers and ultimately all of our current members ⁓ within a few weeks after that. But we've really kind of, this app has been revamped from the ground up. It is a completely brand new version. AI from the time I wrote the first app till now has made such a huge transformation.

that it's really allowed us to do kind of all the things I wanted to do in the first app, but wasn't able to because the technology just wasn't there. But we're able to do that now. I mean, we've really gone as far as taking all of our podcasts, really almost all of the videos I put together, the books, Zoe's contributed a ton of content on the nutrition side as well. And we've essentially trained the AI according to our plan.

And what the app will do is it'll kind of walk you through our treatment algorithm, ask you specific questions and learn all about you. And I really tried to model it in the same way that I see patients. So if I see a patient, I have kind of a structured approach to managing them all based on identifying their set point and figuring out what's caused their set point to go up and then creating a.

therapeutic plan to help them lower their set point. And that's what the app does too. It walks you through that exact same process. We've trained it with all of our content ⁓ and it learns about you over time. As you enter information, hey, this dose started to make me feel a little nauseous. It'll start to give you some guidance on that as well. And we've really enhanced the food logging approach as well. So it's all AI powered. So this idea of pointing and searching and finding serving sizes.

that we're not gonna be doing that. You'll just take a picture of your food or not, or just describe it. And actually the AI will measure the plate size and look at portion size and do a lot of really fancy stuff. ⁓ And we've also, think the other really important piece that we've always talked about is we want this to be AI plus human providers. That's always been the model. And so...

on top of the then we're gonna give you a lot more access to Zoe and some of our other support leaders and make that more convenient where you just kind of pop on in the app and can either book an appointment or just pop in line and almost like a walk-in clinic and work with whoever's available at the time and we'll have individual and group options, probably more individual than group. ⁓ And so that's gonna.

that that's gonna enhance the AI. And even some of the providers will be able to see what you've been up to in the AI, what plans you've put together and all that. So this is getting, we're launching this for beta testing soon. We're excited about it. We think it's gonna be a great addition to the program. We're hoping that you'll find it as helpful as we hope it is.

Zoe (04:33)
Yeah, absolutely. And something else I wanted to add in the food logging system, for those of you listeners who are patients of ours or maybe you've been using the old Pound of Cure app, you're familiar with Caloratio, where we're tracking the quality of the calories rather than telling you how many calories you should be eating, which I just absolutely love. But in this new version of the app, we have...

like you mentioned, Dr. Weiner, not only really enhanced the tracking, but we've also simplified it on you, the user facing part, where instead of having a Caloratio score, which is a percentage, which in the old version of the app is basically your percent compliance with the metabolic reset diet, we've turned it into letter grades. So it's much easier to identify

you know, where you're at score wise. And then what I love is the feature where you can ask, how can I improve this? And then it goes ahead and gives you some recommendations and talks you through how you can actually make a better choice to get a closer to that A plus score.

Dr W (05:47)
Yeah, yeah, no, we're excited. We're excited for you guys to use it and we're hoping you find it helpful. We actually have changed the name of the app. It's not going to be the Pound of Cure app. We actually named it Loli, which is my wife's childhood nickname. So I've kind of named the app after my wife. ⁓ So we were kind of bouncing a bunch of ideas around and we wanted something a little bit more modern and that kind of just popped into it was actually my idea popped into my.

And I kind of ran up on my wife and she liked it. And so here we are. The app's name is Loli. ⁓ And we actually have the website up. You can see a few screenshots, very, very early stuff, but it's gololi.ai is the website for it.

Zoe (06:30)
And I'll have that link in the show notes as well. And I love the name. I think it's great. It's catchy, it's memorable, and I love that it's a personal touch too.

Dr W (06:40)
Yeah, for sure. Well, what do we have for today's show?

Zoe (06:45)
Yes, well, you know, something that's big that has been a shift that we need to talk a bit more about is the introduction of the Quick Pen and how dilution is kind of on the outs.

Dr W (07:00)
Yeah, so I mean, we've been in our practice and this has all been kind of off label stuff and you know, I'm a little bit of a, as I tell Zoe and the rest of our team all the time, I'll bend the crap out of a rule but we're not gonna break it. And so we've kind of worked through this with our patients because it's so hard for people to get these medications. I think the biggest issue with these meds is cost and side effects. And our dilution approach, we've always thought was,

a better way to address both by diluting the medication. If you're at a lower dose, it reduces the cost substantially by a third or sixth of the traditional cost. And then that was our original intent when we did it. But what we found was that we were able to move people from, say, if we're looking at Zep-bound from 2.5 to five, instead of that big jump, which causes a lot of side effects. And people walk around nauseous for a month or two from that transition.

We go from 2.5 to 3 to 3.5, and there's essentially no side effects. So it's a far more comfortable approach. And a huge percentage of our patients are doctors, nurses, medical people. And so we've always found this technique to be appropriate. And that was actually, they kind of brought it to me and then we worked through it together. And so that's always worked out well, but it's a little awkward kind of.

manipulating these medications in this way. We think it's very safe, but it is certainly something that's not for the fainted heart. ⁓ But the Quick Pen really brings this to everyone. And we had experience with this back because we used to prescribe a lot through Canada, and the Quick Pen's been available in Canada for a while. ⁓ So what the Quick Pen is, and it's actually very similar to Ozempic. So Ozempic is the only US product up until recently with ZepBound.

that uses a quick pen. So the difference between the single injector pens and the quick pen is a single injector pen has a certain dose in it. You push the button, it delivers the entire dose. There's no ability for you to modify that dose in any way, shape, or form. And so that way, if your doctor changes your dose from 2.5 to five, well, you get the five. You can't get three or four. With the quick pen, you turn the dial.

all the way to the end and push the button. And that's how it's intended to be used. That's the FDA approved method. However, if when you turn it, it clicks, click, click, click, click, click. And it turns out that each pen has a set number of clicks to a full dose. If you know the total number of clicks and you, say, let's say it's a 15 milligram pen, if you, let's say it's 60 clicks to the end.

If you only turn it 30 clicks, you'll get half the dose or 7.5. And if you do that, the pen will last twice as long, which cuts the cost in half. So this gives you a very simple way to adjust the dose ⁓ to very, very small increments. If there's 60 clicks in a pen, essentially there's 60 different doses.

and you can save a huge amount of money. Now there's a lot of rules and things we work through in our program to kind of get around this stuff that can make it work for everybody. But my hope is that this quick pen represents an acknowledgement by Eli Lilly that this 2.5, five, 7.5 kind of this large step incremental dosing where the patient has no ability to adjust or change the dose on their own.

is not the future of GLP-1s. And as we've kind of done that, we find that patients over time kind of adjust their dosing ⁓ according to their lifestyle, which is better. It's so much better. You wanna go on vacation for a week and maybe eat a little and not walk around feeling nauseous. You deserve to be able to do that. And with the power of these medications, you can do that, lose weight. That's what...

Naturally thin people do they go on vacation they eat a little bit more they come back and they kind of mind themselves and lose the weight ⁓ And so with the GLP ones it gives you the power to do that and make those adjustments Which I think is a great enhancement and people are gonna stay on these medications as long as they like them At some point if you don't like it, you're gonna stop it and and really because of all the benefits Long-term use is better and I'm hoping Lily rec rec recognizes. Hey

If we can make this more comfortable for patients, we're gonna get better compliance. We're gonna get less people stopping these meds. So I really, I'm excited about this QuickPen. Cost savings, dose flexibility, simple, safe, a lot of great things about it.

Zoe (11:53)
Mm-hmm. Yeah, it's gonna be a game changer for sure. And that actually goes right into an article that we're going to review a little bit. It is in Medscape from Dr. Taylor Cantor. The name of the article is, we prescribing GLP-1s wrong? And, you know, ultimately this article mirrors what you were just talking about and our practice philosophy, which is,

letting the patient's response and side effects really dictate those dose adjustments rather than following the protocols given by the pharmacological companies. So that's one piece of it. Minimizing the side effects and also just giving a meal plan or just handing out a nutrition handout is not support. And that was something that was really emphasized in this article.

that the patients who did well and actually lost that upwards of 22 % of total body weight over their 68 week trial, their success was so much more enhanced by that support that they were receiving through Dr. Cantor's practice and their philosophy. you

we're really working on bridging that gap between just having the medication as that quick fix and providing nutrition support in an accessible and realistic way. Because I've been with the practice, Dr. Weiner, for almost five years and we've been putting in a lot of energy and effort.

into that nutrition support because we see the value of it. But it's also been a lot of trial and error and we have been doing a lot of iterations to try to get this support to our patients and then with the launch of lowly, you know, beyond just our patients in a way that

meets the patient where they're at because that's what matters more than a perfect nutrition program is actually getting the buy-in and people showing up for themselves, but not by how we dictate it to be, but by how they can actually implement it into their life. So it was just great to see this article really exemplifying what we are working towards and see to be true in our practice as well.

Dr W (14:25)
Yeah, so this, you know, I thought this article was, it was a couple things about this article. First of all, this is a guy who owns a telemed company, sold compounded medications, so this was all compounded semaglutide. ⁓ It wasn't peer reviewed in the traditional way, so I mean, there's a lot of things that would fail in terms of this being a high brow scientific article. Certainly, if you wanna compare it to, say, the Stampede trial where,

where that it got FDA approval for ZepBound. This isn't that quality of a study by any means. But I think it's really interesting too, because it just, in medicine, there's a real dichotomy between kind of the literature and the ivory tower, the academic institutions, where if the patient is seen by the medical student, then the resident comes in and then the attending walks in for three minutes and sees the patient and they kind of.

They almost practice medicine out of a book instead of at the bedside seeing the patient compared to say our practice, we're private practice and I see the patients from the very beginning, aside from a nurse kind of weighing you, your visits with me. ⁓ And so this is a very different model of care. And so you start to see things change and over time, I've been doing this a while, you kind of adjust the way you see patients to optimize it for them. ⁓

In academics, because they practice by a book, they're limited to the research studies. And the problem with the research studies is they are not optimized for you. The research study was funded by Novo Nordisk or Eli Lilly or whatever drug company, because that's where most of the big studies are funded. It was funded by them. So who do you think they're optimizing it for? They're optimizing it for their corporate.

That's why they did it. They're optimizing it for FDA approval. They want to get through the FDA process as fast as possible. And I get it because if you said, hey, we gave them a quick pen and we let them dose whatever they wanted, that's not a good trial. That's just not going to be a good study. You're not going to get good results. It's going to be challenged. So I'm not criticizing their trial design by any means. It was exactly the right thing to do. The wrong thing to do, though, is to look at that trial.

Zoe (16:32)
you

Dr W (16:47)
and then say, well, this is what I'm gonna do with my patients. And we've seen that in two ways. Number one, we've seen a lot of providers out there being like, it's 2.5, the patient comes in at the end of the month and they're like, I'm puking three times a day. Well, the trials say you go to five, and then we're shocked when they quit taking the drug. And so, we've seen it that way where these providers kind of say, well, the trial is the trial, we practice evidence-based medicine.

and therefore this is the right way to do it. But even more, and most of those providers, they caught on because it was stupid in a lot of, it was just, you know, didn't take, it didn't take a rocket scientist to figure out that that was a bad way to do it. The more damaging place that we saw was with the insurance companies, where we would submit a second month prescription for 2.5 milligrams and it'd get denied because we were obligated to

do the five milligrams. And thankfully we've had our dilution techniques. So would have that patient, I'd teach them how to dilute it. They squirt the drug into a vial and dilute it and take out the medication. And we would work with them on that. just, cause it was no other way for them to do it. And you just, you know, our system is so screwy. If you're not kind of doing stuff like that, it's not gonna work out for you. ⁓ So I think this was an interesting study in that they also kind of shared that they did not follow these.

these academic rigorous studies. We need more things in the literature that show that a patient-driven dose advancement strategy is more comfortable, less side effects. The quick pen is a sign we're moving in that direction. We've been doing this for a while. So, to us, this is not news. We understand this. I know it because I see the patients and I spend all the time with them. So anyway, ⁓ yeah, interesting study, certainly not

Now this doesn't mean, this is the new way of doing it, but at least it's a sign we're starting to move in that direction.

Zoe (18:52)
Well, you know, I thought it would be a good opportunity for us to pop over to some comments and questions that we've gotten on over on YouTube, because if you.

Haven't yet heard or you forgot you you missed last episode. We did get hacked on social media So we are no longer active on social media I don't even think our we don't even have any accounts or anything up So, you know youtube is where you can submit your questions So if you have questions and you want to jump in on the conversation definitely put a question comment a question right there on our video on youtube But I did want to go ahead and start with a question that we have from at christina gonzalez 23

She says, I've already had the gastric bypass, so now what are my options? They said I have a hernia and I'm getting severe pain and my stomach dry heaves, so what should I do?

Dr W (19:45)
Well, mean, go see a bariatric surgeon. I mean, I think that's the very, very first thing that you should do. know, gastric bypass is a great surgery, ⁓ but certainly, know, there's a couple of, the first thing is there's rules to a gastric bypass, and I go over this with my patients all the time. Number one, you cannot smoke after a gastric bypass.

Absolutely positively, no tobacco use. Number two, no NSAID use, no Advil, Levibuprofen, Aspirin, anything like that, Tylenol only for pain. Number three, little to no alcohol, ideally none. We've covered that ad nauseum on this podcast. We'll probably talk about it again though because it's really, really important, but very, very little alcohol use.

Number four, you must take a bariatric vitamin with iron and get your iron checked and your labs checked regularly after a gastric bypass. And number five, you cannot eat garbage. If you eat fast food and you vomit or gag or heave after a gastric bypass, the problem is not the gastric bypass, it is the fast food. And so I think the first thing that you gotta do with these patients is, and if you're out there listening,

If you're violating any those rules, you gotta fix it because those symptoms may be a direct consequence of you violating those rules. ⁓ The next thing is a hernia. What kind of hernia is it? There's different types. There's umbilical, there's incisional, there's ventral, inguinal. Hiatal hernias are something we've also talked about where the stomach slides through the diaphragm up into the chest. And a small hiatal hernia after a gastric bypass is typically irrelevant.

it very infrequently causes any substantial side effects. ⁓ And so that alone to me wouldn't be like, this needs to be fixed. In fact, someone comes to me with a small hyaluronate after a gastric bypass and says, I'm vomiting, I'm gonna say it's probably not from the hyaluronia, you know, look for other things. The next test is an endoscopy. ⁓ And to look and make sure you don't have an ulcer, to make sure you don't have a chronic stricture. ⁓

If the bypass was four to six weeks ago, this very well could be an acute stricture, which is actually a very simple fix. An endoscopy and you go home and you're eating fine that evening, or you just kind of stretch it. It's like a band of scar forms across the connection and you just have to break it open with the endoscope and you just kind of pop it open and then it opens up and then you can eat literally right afterward. And so if that's the situation, that's a simple fix, but you know.

this person needs to be evaluated by a surgeon. What's the diet? If someone comes to you and says, I'm really having food intolerances after a bypass, I'm having a lot of issues, what are you gonna do with them diet-wise? What are some specific adjustments you're gonna make? Where's dairy fall into this and other things like that?

Zoe (22:51)
Yeah, know, obviously for a starting place, getting a sense of what they're actually eating so we can identify those specific targets for that person. But if we're thinking about broad recommendations, if somebody like this is presented to me and we're trying to identify what we can fix, having those small frequent meals so that you are able to be more

Something that I do find to be an issue with a lot of people is that mindless eating whether it's eating too quickly, eating while driving, eating while watching TV or the screen or something like that. And when your attention is off of how your body is responding to your food, you're more likely to not tap into those cues and your body telling you. remember from last episode when we talking with Taylor about how she is so present in her body and listening to her body's new cues.

that's definitely something to start with. And when you are having smaller meals, you can be more attuned to those cues because that's a part of learning your new body, right? So that's about the behavior of eating and some of the tweaks we might wanna make with that. But...

going back to our golden standard of whole, real, unprocessed foods as much as possible. You know, if you can have more than 80 % of your diet being from those whole, real, unprocessed foods, then you're gonna be in pretty good shape. Of course we wanna get protein in, but are you getting protein in through fatty cuts of meat and processed foods and a bunch of protein bars and protein shakes and all of these things that maybe you're not tolerating versus

prioritizing again those whole food, plant-based sources, lean animal sources of protein to make sure you're getting your protein needs met, but in a way that you're also getting other nutrients in. And then of course also the fiber piece, the produce piece. I do find a lot of people who've had bariatric surgery have been trained to be so protein focused. And of course during the honeymoon period that is important because that's when

when you're losing the majority of your weight. That's when weight loss is quick and we need to preserve your muscle tissue and when you are in maintenance mode, we do still need to make sure you're getting baseline enough protein in, but what's more important at that point is filling your plate and filling your body with produce fiber rich plants so that you are getting.

that volume you're getting that fiber that you need and your body really does respond better to that because that's what keeps your set point at its new low point.

Dr W (25:40)
for sure. I think that the bottom line for this patient, if you met with a bariatric surgeon, there's experience, you met with a bariatric dietician who can kind of log, go through your food logs and come up with some suggestions for you, this is a solvable problem. ⁓ 90 % of the time at least, we're going to be able to help this patient and kind of get them back to normal again. There's an obvious cause of this. So I think, you know,

This seemed like there was a lot of frustration and fear in this person's question. And I would say this ⁓ is a solvable problem. This is not a problem where I'm like, boy, that's tough. This is something that I think you can figure out.

Zoe (26:13)
Mm-hmm.

Yeah, for sure. Now we, in a previous episode, talked about the introduction of the GLP-1 pill. And so we do have some questions, lot of chatter on YouTube about using the pill for maintenance. We have some people who've lost weight.

whether it's from bariatric surgery and then introducing GLP-1 injections, having that kind of increase and decrease of weight, but ultimately wanting to know can they use the GLP-1 pill for a small maintenance dose.

Dr W (27:02)
I think that remains to be seen. ⁓ I'll tell you my observation of people on these drugs. ⁓ Your relationship with the GLP-1, it becomes intensely personal, much more so than other drugs. And so, you know, where if you're saying taking a blood pressure medicine or even another diabetes medicine that doesn't kind of impact your appetite, your weight loss, the way GLP-1s do.

and the doc says, hey, I wanna switch you over to this. It's like, oh, okay, whatever, it's a transaction. What's the best thing for my health? What's the cost of this? What are the side effects? Okay, when you use a GLP-1, because it really impacts the way you feel on a minute by minute basis, and there's a difference from say semaglutide to Zep-Bound, there's gonna be a difference between the injectables and the pills that.

In the end, I believe it's going to be how these medications make people feel and how well they work that dictates what formulation, what maintenance looks like, what you're gonna do for injections, all of that. ⁓ And so that's gonna be, in my mind, what determines it. So could you use a pill? Some people can and will be able to. Some people will say the pill causes a lot more side effects, and so.

I don't like these side effects, so I'd rather do the injections. They work better and I feel better on them. So I think in the end, it's gonna be efficacy, not route ⁓ or formulation that matters. But we'll see. I mean, this is something we're actively working through and I can tell you, I've got a dozen or so patients we're kind of working on this with and seeing what we can figure out. And it's gonna be different for everybody. ⁓

I think where you gotta work with someone who is comfortable and familiar with these medications and who isn't biased and says, oh, I work for a company and this is, I think there's a couple of telehealth companies and essentially they're drug sales companies. They're not healthcare companies. And so, you wanna work with someone independent. It's like my financial advisor. I made sure when I chose a financial advisor, he doesn't sell insurance, he doesn't sell other products, he just.

Zoe (29:14)
Mm-hmm.

Dr W (29:26)
gives me his advice and I pay him money for his advice and he doesn't make any other money except from the money I give him for that. And I think that when you're talking to your doctor, unfortunately, you have to recognize, you know, is this person working for a company where the company profits from drug sales? And if that's the case, guess what you're going to get? You're going to get the drugs. And if that's what you want, that's fine, but just understand you're not gonna get, we'll switch to the pill. If something new comes out,

they might not switch you over if there's not a profit ⁓ mechanism for that. ⁓ So, you know, it'll be interesting to see where this goes. The idea that everybody's gonna switch to the pill and everybody's gonna be on the pill, I don't see it. I don't buy it.

Zoe (30:08)
last comment we have here is not so much a question, but just a great comment that I want to share. And this is from Nikki Smith, 84 47, who says that she cannot wait to share our link with a friend on Reddit who is having issues with sadness and mourning her old self. Excellent post. So we we really appreciate that. And, you know, just kind of tying in back to our old conversation about ideally kind of moving into the Reddit

space. I love to hear that you're already going to start that for us. That's great.

Dr W (30:37)
Yeah.

And we are on TikTok still, right Zoe? Yeah, we're still on TikTok. So it's really just Instagram and Facebook that we're not on anymore. ⁓ you know, honestly, that company's kind of rotting our children's minds and they don't really care about it. And I'm okay not being part of that. So.

Zoe (30:42)
huh, yes we are.

Mm-hmm. Yeah. ⁓

Yeah,

I think it's a good shift. anyway, that pretty much wraps up our show today, little combo, and we'll have some more patient interviews coming up for you soon. So we're very excited about that. But let us know in the comments, what are you working on? What has worked for you for your weight loss? Are you struggling with anything in particular that we can help chat through? We'd love to tap into the community and we just really appreciate you being here with us.

Dr W (31:29)
Yeah, on the website, go lowly.ai if you are interested in being a beta tester, there's a form you can fill out and we'll put you on the beta testing

See you next time.