Ozempic & Other New Weight Loss Medicines

Dr. Theodore Friedman’s Webinar on Ozempic and New Weight Loss Medications
In this enlightening webinar, Dr. Theodore Friedman (The Wiz) discusses the latest developments in weight-loss medications, focusing on Ozempic and other new treatments. This session will guide you through the options available for weight loss and provide insights into their effectiveness and potential risks.

🔍 Key Topics Discussed:
✅ Who Should Use Weight-Loss Medications?: Identifying the patients who could benefit from prescription weight-loss medications
✅ Best Weight-Loss Medications: A breakdown of the most effective medications available, including Ozempic
✅ Side Effects of Weight-Loss Medications: Understanding the potential risks and side effects
✅ How Do Weight-Loss Medications Work with Diet and Exercise?: Exploring how medications complement a healthy lifestyle
✅ Getting Insurance Coverage: Tips on securing insurance coverage for weight-loss medications

This webinar is perfect for anyone considering weight-loss medications or seeking more information on managing weight through medical interventions.

📌 For more information on endocrine topics or to schedule an appointment with Dr. Theodore Friedman, visit:
🔗 GoodHormoneHealth.com

Transcript

SPEAKER_01 0:05

Welcome everybody to the good hormone health webinar today titled OOO OZMPIC a webinar on Ozempic and other weight loss medicines.

SPEAKER_00 0:15

People with type 2 diabetes are excited about the case. In a study with Ozempic, a majority of adults lowered their blood sugar and reached an A1C of less than seven and maintained. Oh under seven. And you may lose weight. In the same one year study, adults lost on average up to 12 pounds. Oh. A two-year study showed that Ozempic does not increase the risk of major cardiovascular events like heart attack, stroke, or death. Oh, no increased risk.

SPEAKER_01 0:44

So those are the three O's. So the outline of today's talk is to focus on health and wellness. Who should go on weight loss medicines? Which weight loss medications are the best. What are the side effects? How do they work with diet and exercise? How do you get insurance coverage? And then I'd like people that have used Ozempic or Majora or Wagovi to share their experience. Um, they can especially do that on Facebook, but I think they can do it on Zoom also. So my focus, my main approach to weight loss is to rule out endocrine problems such as hypothyroidism, cushioning disease, or growth hormone deficiency. These are three conditions I see commonly that lead to weight gain. And simultaneously, I encourage patients to consume a low-calorie diet. I often recommend eating larger amounts of vegetables. I like my vegetable revolution diet. Vegetables are low in calories, a lot of nutrition. And I also encourage my patients to move. A lot of exercise is great. Additionally, I encourage my patients to get a good night's sleep, have good mental health, be out in nature, and avoid stress, or at least don't let stress bother you. Patients tell me they've done all that. Many of the patients already have a healthy diet and exercise. Patients need a jumpstart for the weight loss, and this is where weight loss medicines come into play. And they can also reduce food cravings. A lot of people, especially with endocrine issues, seem to have a lot of food cravings. Um, so I often prescribe weight loss medications after other endocrine conditions are diagnosed or properly treated. Um, in my 2022 Endo Society meeting, I was a fascinating uh talk I went to. It was pointed out that only 2% of patients with obesity are on weight loss medicines. 2%. Imagine if only 2% of patients were diabetes were on diabetes medicines. I think the statistics is like 98% are on diabetes medicines, or 2% of patients with high blood pressure on anti-hypertension medicines. I think 95% or so of patients with hypertension are on hypertension medicines. So the question is why not? Why don't people uh prescribe um obesity medicines more? Why don't doctors use them more? First of all, a lot of doctors don't prescribe them. They don't feel comfortable prescribing them, they don't know how to prescribe them. They have this unrealistic view that if obese patients had more willpower, they could just lose weight. The medicines are often quite expensive. And even more importantly, there's a lack of insurance coverage and difficult pre-authorization requirements, which is actually getting worse. And then this is quite a bothersome for um doctors. Um, it consumes a huge amount of their time. It's getting worse, and there really isn't any checks to prevent this from happening. And then uh the people and doctors are concerned about side effects, rightfully so. So let me talk about the different types of medicines. We're all going to talk about mostly the GLP and receptor agonists, but then we'll talk a little bit about the stimulants. Um the stimulants are related to amphetamine. Uh, so they're further a little bit of upper, uh, give you more energy, make you hyper at times. Um, the one I use the most is called fentramine. Another one I use somewhat frequently is called fendometrazine, tenuate, and there's casema, which is a combination of fentramine and toprmax. Now, the GLP1 receptor, I guess, we're going to talk mostly about today. These are originally medicines for diabetes. The main one we're going to talk about today is Ozempic. We also have rebelsis, wagovi, and manjaro. And we're not going to really talk about lyriclutide and deliglutide, which are called Vectosexenda or Chilicidi, as they have much less weight loss. There's one called Contrave, which is now Trexone plus bupropion. There's one called Orlostat, it's also called over-the-counter, it's available as OLI, doesn't work too well and has a lot of side effects. And there is one called Belvix or Lor Cursart, Lor Lorcasserin, which was removed in the market in 2020 due to increased risk of rates of cancer. Fentamine, I do use it a fair amount. And um, it's even good if you want to take a holiday from the Ozepic type of medicines. You can go in fentamine. It's also called adepex P or Suprenza. It was part of the fenfen with the fenfluoramine, the fen with a F was removed from the market due to heart and lung problems in around 2000. The fentamine itself, the with the pH, has been in use for 50 years and is safe. Uh, this comes in 1530 and 37.5 milligram tablets or capsules. It's about $40 a month for the 37.5 milligram dose. So about a penny a pill, uh about a dollar a month, a dollar a day, excuse me, not too expensive. It's approved for short-term use, sort of in a two to four month range. It decreases the appetite and may have some increased uh effects on increased metabolism. It's in the category of amphetamine-like drugs, has common side effects, including uh hyper, jittery, rapid heartbeat, increased blood pressure, trouble sleeping, and possibly urinary retention. Works pretty well at a low cost. I usually give a half a pill of the fentamine before lunch and dinner, and that's when people eat the most. If someone gets an insomnia, I move it earlier in the day. Um, there's always the caveat, the long-term use is not established. Um, it does seem to wear off with time, as do some of the other medicines. And I usually give this for a period of two to three, two to six months. Fendometrazine is also called bontrol. It comes in the immediate release, 35 milligrams, the slow release, 105 milligrams. Um it's $32 for 90 capsules of the 35 milligrams, so pretty inexpensive. The SR is also about a dollar a pill. Um, it decreases appetite and may have some effects on metabolism. It's also in the family of amphetamine-like drugs. Side effects include dizziness, dry mouth, difficulty sleeping, is irritability, nauseousness, vomiting, upset stomach, and diarrhea. The immediate release form is labeled as PDM in reference to the active ingredient, fendometrazine. The 37, the 35 milligram tablet is usually prescribed two to three times a day to be taken 30 to 60 minutes before each meal. This stain release is taken as a single dose of 105 milligrams once a day, usually 30 to 60 minutes before the morning meal. I use it in patients who have failed pentomine. Um, also, again, you could use this as a holiday for people on um the GLP1 receptor agonist. And sometimes, but not always, it's hard to find. Just make sure everybody's still muted. So Tiffany, do you make sure everybody's muted on Facebook? It sounds like we have a little bit of background, but uh yes, everyone is. Okay, great. Um then the next one is called Casema. It's fentamine plus Topamax. It comes in these different doses, including the higher dose of 15 milligrams of fentamine plus 92.92 milligrams of Topamax. You can see the dose of fentramine is much less than the dose of fentramine by itself. It's $629 a month, so it's a fortune. It's a mixture of fentramine, but fentamine is much less expensive. Um, and which fentamine lowers your apple height and topamax, which is used to treat seizures or migraines. Um, the idea is it's supposed to make you feel hungry, less hungry, or fuller sooner. Side effects include constipation, dizziness, dry mouth, taste changes, especially with carbonated beverages, tingling of your hands and feet, trouble sleeping, and people feel stupid on it. So it's effectually called stupamax. Um, and I don't use this drug at all, basically. I don't see any advantages over the fentramine. So let's go on to the main topic today. It's called GLP1 receptor agonist. These are drugs that are called increotins. I'll explain what that means in a second. That's because they've done experiments that when about 50 years ago, they gave oral glucose and raised people's insulin more than IV glucose. So it was thought there was a factor in the intestine that secretes insulin. Years went by, and this factor, there's two of them found. One was called glucagon-like peptide one or GLP1, and one is called gastrointestinal peptide one or GIP1. And um, these have been the, as the years go by, and I'll explain a little bit about the history of this, uh, these have been the basis of the GLP1 receptor drugs. And they were found to have, uh, there's been found to have GLP1 receptors in the brain that control appetite. So a lot of the reason why they work is they are they're intestinal peptides, but when they're given to the body, they bind to the GLP1 receptors in the brain and cause satiety. So this is an interesting history. I used some of this before, but there was an article in the Wall Street Journal at the end of June about this. I thought this was really fascinating. So in 1980, researchers at Mass General Hospital wanted to use new technology to find the gene call encoding a hormone called glucagon. Glucagon is a hormone that kicks in when you have low blood sugar. And um, they studied the angular fish. The angular fish is shown at the top left there, it's sort of ugly fish. They have a special orgasm that makes the hormone, which made it easier to gatherify and purify the uh the tissues. They eventually determined the genetic sequence of glucagon and learned that it was the same gene that encodes related hormones known as peptides. The peptide it encoded, and I was a little bit involved in some of this research in my years at the NIH, my years at Cetrocyanite. I studied the enzymes that broke down the um the pro-glucagon molecule to glucagon-like peptide one as well as glucagon. The glucone-like peptide one is nicknamed GLP1. Scientists in Massachusetts and Europe learned that it encourages glucose insulin release and lowers blood sugar. So they hoped this could be used to treat diabetes. There was also some thought that patients with diabetes had high levels of GLP1, but then the more later studies showed they have low levels of GLP1. So it was sort of thought that this could be a good target for diabetes. And they uh felt that the GLP1 makes people feel fuller, slows down the empty fluid from the stomach. But there's a problem. The GLP1 vanishes from the body as fast as it is secreted. It's just uh digested by enzymes. The main one is called DPP4. There's a drug that blocks the enzyme also, um, called genuvia. Um, and then it gets diswashed away in the kidneys in minutes. So there was little chance of developing this peptide into a drug. However, as the years go by, scientists turn to a the Gila monster, which is shown in the lower left, sort of an ugly uh creature, although I think it's sort of cute. These are uh animals that are found in the mostly in the southwest United States, mostly in Arizona. I think there's even a city called Gila or Gillam, Arizona. And the Gila monster only eats maybe four times a year. I heard twice a year, but this article said four times a year. And they don't get high blood sugar or low blood sugar. It keeps them full for these um, you know, every three months when they eat. And they eat about maybe eat a rabbit or a rat or a mouse or something like that. And they're able to keep their blood sugar pretty constant because they have an endogenous GLP1. They live most of their lives below the ground, they slowly digest energy stored in their tails. So two people studied the Gila monster venom. They ordered from the Miami Serpentarium, whose owner survived 172 snake bites over the years as they produced venom for the research. One of the doctors, Dr. Eng, isolated a small peptide that was called extendant four. It was very similar to GLP1, so it was very exciting. However, the advantage of the extendant 4 is it doesn't get broken down by those uh enzymes. Um, it's they gave it to diabetic mice and they found that it reduced blood sugar and it did so for hours. It lasted a long time. The mice and eventually the people got side effects. A famous researcher, David Nathan, was a Massachusetts general physician scientist who led the 1991 study. He still remembers what happened when they increased the dose to humans. One person leaned over the side of his chair and threw up on my shoes. However, um, this led people to use this drug from the HELAMUNS or the chemical sequence of that to make a peptide. And that peptide was called extendin. And its um brand name was called Bietta or by durion. And um the UFDA approved this in 2005. And I remember when it came out, it was sort of exciting. I used a fair amount of it in my patients at the beginning. Um, it didn't work too well either. It was taught twice at a shot, and it gave people sort of welts where they got their injection. Um, but you know, it was okay, and people lost a little bit of weight on it. Um eventually Nova Nordris got into this business, Lily got into this business, um, and they made um new drugs that were related to the Xendon and modified the peptide so it lasts even longer. So the drug called Lyriglutide would get FDA approval in 2010. And that was a drug, again, GLP1 receptor agonist lasted a longer time, once-a day drug, um worked reasonably well. However, as the years go by, people tweak the molecule more. And seven years later, which is in the, let's see, so this was in 2010. So in 2016 or 2017, um, the drug semaglutide was approved that became Ozempic. And first it was um used, and I think it's a game-changing medicine, basically. I think this is we think about the advances in our medical society. I think this is nearly near one of the top uh game-changing medicines. Um in 2021, it was too so 2017 it was used to treat diabetes. In 2021, uh the great drug called Wagovi came out and was used to treat obesity. So you have Ozempic for diabetes, Wagovi for obesity. So, what how do these GLPM receptors work? Um, in hyperglycemic states, when the glucose is high, these GLP1 agonists stimulate insulin secretion and they delay gastric emptying. So, this is the so-called increotin effect, the effect in the intestine, and it slowers down your emptying, so your food stays your stomach longer, you feel fuller. Um, it gives you more insulin, so that helps with diabetes. In um in euglycemic states, um, it suppresses your glucagon, so you don't get this counter-regulatory effect, and your glucagon doesn't go up. And most importantly, it decreases your appetite, and that all those things result in reduced body weight. There's a little schema of it here. The um the GLP1 is secreted upon ingestion of food from your intestine, unless you take it as a pill, increases the beta cell in your pancreas to make more insulin. So it enhances glucose-dependent insulin secretion. It decreases, it promotes satiety, reduces appetite in the brain. It's one of the key things. The alpha cells are the cells in the beta in the eyelid of the pancreas. It decreases postprandial glucagon secretion in the liver, it decreases uh hepatic glucose output. So you have glucose coming from your from your liver. And most importantly, or equally importantly, it helps reduce gastric empty in and that slows down your intestine and makes you feel full. All these work to both treat diabetes and treat obesity. So, semaglutide, or also called osempic, is a diabetes medicine that leads to profound and sustained weight loss. It is not an amphetamine-like drug, so patients will have side effects on something like fentramine or fendometrazine, can often tolerate the osempic quite well. The main side effect of the osempic is nauseousness and feeling full. Those happen in a good portion of the people. So you need to go gradually on the dose of osempic. We'll talk about that in the next slide. But basically, I have people start at 0.25 milligrams weekly for a month. And then we usually do 0.5 milligrams weekly for six weeks. And then we go up to one milligram weekly, and then you can go up to two milligram dose, as it's fairly been recently been improved, and you can get some additional weight loss and diabetes effects. Um, some people do fine on the lower dose, they don't need to go up, you know. So I think you should ride out the lower dose for the most part if you're losing weight and you feel full on it. Um, and then when you that subsides, you can go up to the higher dose. Um, if you start on the, if you go from the one milligram to two milligram dose, I recommend the first two doses of the two milligram dose every 10 days instead of every week. If you do get nauseousness, and I'll talk about a little more about clicks on the next slide, but you can go down to 0.25 milligrams a week if you're on the 0.5, for example. If you're on the one milligram dose, you can go down to the 0.5 milligram dose. And we can also give you the zofrine, which goes under your tongue, and that helps with nauseousness. Now, my good colleague Ann Peters at USC taught me about the clicks. And I think the clicks are really a cool thing to do. It's only available in Ozempic. When Google Maduro don't have clicks, only Ozempic does. 18 clicks is 0.25 milligrams. So if you develop um nauseousness on the 0.25 milligrams, that's 18 clicks. You could go down till the you could stop at the nauseousness resolve and start at five clicks or eight clicks, and then you go up by five clicks every two weeks as tolerated until you're up back to the 18 clicks or the 0.25 milligrams. In general, the weight loss is higher, it's greater at higher doses, but the side effects include vomiting, diarrhea, constipation, feeling full, nauseousness. They're also higher at the higher doses. Um, the ozempica lowers your hemoglobin A1C, your average blood sugar, but it doesn't give you hypoglycemia. So if your A1C is already low, you know, you don't have to worry about getting hypoglycemia on it. Um, it just basically works basically if the A1C is high. It has very importantly has cardioprotective effects. It helps prevent heart attacks, which is a very important people with diabetes. It has renal protective effects, which is also important with people of diabetes, helps protect your kidneys, improves polycystic ovarian syndrome and helps with fatty liver disease. Usually doesn't give low blood sugars. The side effects include uh nauseousness, feeling full, vomiting, feeling like food stuck in your chest, abdominal pain, loss of appetite, diarrhea, and constipation. So there's three different cartridges here. There's the red cartridge, which is the it's considered a silly game. It's called the 0.25 or the 0.5 milligram dose. There's two milligrams per three mils in the cartridge here. You start at this dose here for four weeks, the 0.25 milligrams. You can stay on the same cartridge and go up to the 0.5 milligrams. And usually I have people take that for six weeks, and that uses up two cartridges. So we'll order the two of the 0.25 or the 0.5 milligram cartridge, two milligrams per three mils, and that's the red label pen. Take the 0.25 milligrams for four weeks and then go to the 0.5 milligrams for six weeks. This will use up two of the pens, uh the two milligrams for three mil pens and last about two and a half months. Then you can go to the one milligram dose. The one milligram dose is a blue pen. So you can see here it's blue, it has um a blue label, and it says one milligram on it. Well, usually order three of the one milligram doses. These each one, uh each cartridge lasts a month. So this will last weekly for three months. Um, I usually have people schedule an appointment after three months or so. We can sort of get them up to this one milligram dose and to see how they're doing on and see about side effects and things like that. After being on the three milligram dose for um a month, I'm sorry, the one milligram dose for a month, you can go up to the two milligram dose, which is the brown label pin. You can see it over here, it's sort of a brownish label. And that will last about three months if we order three of those as well. So the two milligram dose has the higher dose per milligram, eight milligrams per three mils. The clicks would be half the amount of clicks. So instead of 18 clicks for 0.25 milligrams, it's 18 clicks for it's 18 clicks for 0.5 milligrams. Um, and um, so the you can people can stay on the two milligram maintenance dose. Um, it can be used with or without meals. You inject once a week, usually the same day of the week. Um, you often people do it on Sundays. It's not the same as insulin. Doesn't cause low blood sugar, it can reduce weight, it reduces the risk of heart, liver, and kidney disease. Um, basically, I encourage people to inject it under in their abdomen, although you can also do it thigh and upper arm. Don't inject it into muscle or vein. You can change the rotation, change or rotate the size of your injection. If you're having side effects, don't increase your dose and notify your provider. Um, you should store these in the refrigerator also. They come usually in a cool pack, keep them in the refrigerator, although if they're out of the refrigerator, it's not that important. Um, it's an expensive medicine. Um, so the first important thing people should do is check with their insurance and see what's covered. OZEP is the one used for diabetes, and Wagovi is the one used for weight loss, and see what the approval process is. Insurance companies vary in the coverage and they're getting more strict about the coverage because it's an expensive medicine and they try not to cover it. Other insurances cover it okay. Some of them, this is a new trick they're playing, is they want you to go on a less expensive GLP1 receptor agonist like Trulicity or Vectosa before LZMPC. Um, and then they, if you have to fail them. So this is another way they try to save money on that. I try um sometimes we do that, and sometimes we just try to argue with them a little bit. Uh, we'll do one pre-off for these medicines, but you know, we can't really afford to battle these insurance companies. Um, it just takes too much time. And um, you know, usually they have their rules. And if you don't follow the rules, you don't basically don't get it. Um, another option is um at to get it from Canadian pharmacies. Um, so I think a Canadian pharmacy might be 300 a month. The non-insurance cost is at least a thousand a month in the United States. Um, there is some pharmacies that I've heard of, I haven't used any yet, that compound it, uh compounding pharmacies, but I'm not really too experienced with how they are. So I really don't recommend that right now. But um I'll look into that as the time goes by. Now, the most important question is what about long term side effects? It's really unknown. These drugs have not been out that long, but you know, as the years go by, at least the Ozempic's been out since I think 2016 or 2017. So it's a little Well known. There's um a history of weight loss medicines were found to have long-term side effects and pulled from the market. The fen with FEN as part of Fen Fen was pulled. Locarsin and another one called Slobutrimi were all found to have side effects and pulled from the market. I don't think this is going to happen with Ozempic, but I'm not 100% sure. Um, in rats, it causes a rare type of thyroid cancer called medullary thyroid cancer. So there's a warning on the label. Don't give it to people with medullary thyroid cancer. Those people are super, super rare. It's a rare disease. Um, 99.9% of thyroid cancer is not medullary. So this is usually not a relevant issue. However, there's a few studies and they're coming out now that are called meta-analysis. They pull other studies together, and there might be a slight increase in the guarded variety of papillary thyroid cancer increase. Um, I don't think this is a concern. I don't recommend getting ultrasounds or monitoring it to prevent it. Um, but you know, they're just it's it's a caveat that there might be some concern with this medicine. So I really recommend only taking Ozempic if you need it. So semiglutide is also called Wagovi. This is a little tricky. Wagovi and Ozempic are the same drugs, but they have a different cartridge. And the Wagovi is approved for weight loss, the Ozempic is approved for diabetes. The Wagovi comes in 0.25, 0.5, 1 milligram, 1.7 milligrams, and 2.4 milligram pens. It does not allow partial dosing or clicks. You give it all or none. You should stay on the same dose for at least a month and then only go up if you're not experiencing side effect. Um, there's a shortage of these medications, um, including different doses at different times. For a while there was a shortage of the starting dose, and then I think now most many doses are shortage, but many pharmacies have it. So you need to call around to different pharmacies, check with your mail order pharmacy, check with your local pharmacy, check with some smaller pharmacies, and see if you have it. Um, its side effects are similar to that of Ozempic. There's another one called Rebelsis, and they're also the same medicine. It's also semi-glutide. Rebelsis is an oral pill, it comes in seven and 14 milligrams. It's approved for diabetes, and it gives less weight loss, almost some weight loss than Ozempic. Um, you know, I think originally people were concerned that people wouldn't want to give themselves a shot, but the shot's really easy. It's a small needle. Most people don't mind the shot. Um, so I know there's not that much of a role for the rebelsis. Um, you should scan stay on the same dose for a month and only go if you're not experiencing side effects. Side effects are like Ozempic, and I rarely prescribe it. Now, the new one on the market that's been around for a little more than a year is a very exciting drug. It's probably going to be the biggest selling drug of all time. It could be. Um, it's made by Illalili and it's called Monjaro. The uh generic name is terzipatide. Um, it's called a dual increptin. It has the GLP1 and the GIP. And we talked about both of those are hormones made by the in the intestine that do slow down your um gastric emptiness, give you some satiety, and um uh lower your appetite and give you improve your diabetes. Uh, so the two of them work together, and it's even thought that we thought, I thought at least the GLP1 would be the main one. It seems like the GIP one has a very important role in this uh the effects of this medicine. It is not approved for weight loss, and it also hasn't been found to have cardioprotective effects, such as the uh Ozempic does. But it probably will end up doing that. I'm pretty convinced it will, and I think it probably will be approved for weight loss also. It has very impressive weight loss properties, more so even, I'll show you on the next slide, than the Ozempic. On the highest dose, people can lose up to 25 pounds. It's given once a week, like Ozempic, has similar side effects, including nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, and abdominal pain. I think it has about the same amount of side effects as Ozempic, not really more, not really less. And some people can have side effects on injurial non-osempic, and some people the other way around. The doses are 2.5, 5, 7.5, 10, 12.5, and 15 milligram doses. You should stay on the same dose as for four weeks and only go up to the higher dose if there's no side effects present. And again, some patients do fine on the lower dose, even more so, I think, than the Zempic. Some people can stay on the 2.5 milligrams. I was just in contact with a patient who had did well and lost a lot of weight on the 2.5, had some side effects on the five, a lot of side effects on the 7.5. So I put her back on the 2.5 milligram dose. She was doing well on that, losing weight. Um, some patients, uh, many patients do find a lower dose. There is a coupon, but the coupon is less beneficial than it used to be. It used to be like you didn't have to check with your insurance, it was just paid the coupon. Now you have to check with your insurance. There's different coverage rates depending on what your insurance covers. Um, but it could be quite helpful. It can be as low as $25 or three months, but it's usually not quite so low. So check on the um on Jero.com. So tersopatite is a twin crinin, twin ancrinin. It is a dual GLP1, GIP1 and GLP1 receptor agonist that is used for treating diabetes. It lowers your blood sugar. And this is uh a paper we don't have to go over that much in depth, but you can see over here in B the weight loss. You have the first one, the open circle, those dark circles here of semaglutide, one milligram dose. The patients lost 6.2 kilograms, which is about you know 15 pounds or so, 6.7%. Then the next one over here is the Manjuro at 5 milligrams, then you have Manjuro at 10 milligrams, and then you have Monjuro at 15 milligrams, the maximum dose. At the maximum dose, they lost 20, 12.4 mil kilograms, which is um about uh 30 pounds, 13% of their body weight. It's quite impressive. The people that lost 5% of their weight, let's say that was your target with the 15 milligram dose, 80% lost at least their target of, let's say, uh 5% loss, 10% loss was 57% with the highest dose of manuro. All these seem to be better with manjural compared to Ozempic. Their triglycerides got better on the um on the highest dose, their cholesterol got better, the HDL, the LDL, their VLDL, their HDL actually improved, their LDL got worse. All these uh I'm sorry, the LDL got better and the HDL got got got uh um lower and got higher and high is actually good. The LDL got lower and lower is actually good. So this had very beneficial effects on people's lipids as well. So the important question I think is um in this day of insurance, um ruling the medicine, you got to call up your insurance company to see if they um uh to cover these. Some don't cover them at all, some have criteria, some of you have to have diabetes, some you don't have to have diabetes, some of you have to do a form. Well, all of them you have to do a form, basically. Um, some of the form just says, you know, do you is this worthwhile? Some of them have to say, um, you know, what different criteria? We'll try our best to complete these forms for you, but um, it's it's sometimes it's hard to do it. I think most of the time we we get them covered, but not all the time. Um, you know, I don't really recommend face-to-face appeals, um, uh appeals. It's usually unlikely to be um beneficial. So, how long do you stay on these medications until you get side effects, until you're at your ideal weight? You know, so somebody's 200 pounds, they want to get to 140, they get to 140, they can stay there and go in a lower dose. Um, for fentramine, um, it could stop working in three to six months. You could take a holiday. Most weight loss medicines, you have some rebound when you stop the medicine, the same with these uh Zepic and Manjuro. Some studies suggest that people, when they stop it completely, gain about half their weight back. So at least they still lose half their weight, but they lose, they gain it back some half of it. Um, so um, you know, these medicines are often need to be given long term. They're expensive. Long term, we're concerned more about their side effects. What do you do if when an exemplif stops working? I think one thing you do is push the diet and exercise, take a break for a month and restart it, go on fentramine for a month and then go back on the uh Zempic, or see if your insurance cover is menural. These work with uh diet and exercise. In general, these weight loss medicines curb your appetite. So you put less toxic foods in your body. I think people eat a lot of toxic foods. Uh, food is expensive. Um, it's time consuming to eat it, it's time consuming to shop for it. So if you can eat less foods, you'll do better. It allows you to jumpstart your diet, it decreases cravings, decreases insulin resistance. Usually people feel better on these medicines. Um, their energy goes up, even some of the weight loss, but in general, there's less inflammation, it's easier for them to exercise, probably changes their microbiome and their intestines, give them better gut health. So, all these are sort of beneficial things of the medicine. Um, what is the Ozempic diet? I saw this also in the Wall Street Journal. I'm among other places. Ozempic can result in loss of muscle mass. So consume a fair amount of protein, try to reduce your carbs and go on a low-carb diet. Take advantage of this decrease in food cravings because I think a lot of people crave carbs when they don't have those food cravings, they eat less of the carbs. Really try to eat clean. Okay, so um that concludes the main part of the talk. Uh, we will have people all uh people can go in the chat or unmute themselves and unmute themselves and ask some questions or give their experience. Um I think a lot of my patients that are on the calls and on the Facebook today have been on Lozempic. So people can now chime in with uh either questions or their experience with it. Questions or comments or experience? So Sarah asks, what could be the reason behind manuro not causing any weight, even with higher doses? So these medicines don't work on everybody. Some people, just whatever it is, their chemistry, they don't work that well, you know. Um, in general, I think the manuro can work a little bit better than the Ozempic in some people, but some people they just don't work. Some people may do better on a medicine like fenchamine than um than um manjo or wagove. Um, you know, some people have a lot of people have the side effects they can't tire with the higher dose. But you know, the studies are showing that most people do lose weight on these. Uh Janet asks, what's the target A1C? So I think the general the target A1C for most people is like seven or a little less. If you're older and have a lot of other medical problems, it might be a little bit higher. If you're younger, it might be a little lower. But I think less than seven is good, maybe even less than 6.5. Warren asks, is there any credibility to berberine as a natural effective Ozempic alternative? Uh, berberine gives much less weight loss than Ozempic does. It does lower your blood sugars for people with mild elevated blood sugars, but not nearly as much as Ozempic. Um, I like berberine for um a lot of my patients, um, but it's not Ozempic. Preston asks, are any thoughts on the prescription dose or lost? So orlostat, I didn't conclude in my talk here. I did do my last year's talk. But orlostat is an oral medicine that basically gets you to secrete fat in your stool. People get like oily stool from it, smells bad. It usually doesn't, people don't like it too much. Um, the prescription dose, I think, is 1 something, three times the dose of the regular, the regular dose, the oral, the over-the-counter dose is 36. The prescription dose, I think, is about 116 or so. It works a little bit. I wouldn't have that as my top choice. Um, Nicole asks, is it safe to stay on maintenance dose of avoid weight regain? I think so. So I think that's what I recommend is people go on a lower dose for weight maintenance and you need to stay on that forever, it seems like. Um, otherwise, most people gain their weight back. Sarah asks, is it true that if you have Christianity's disease weight loss medicines, it won't work? I don't think so. That's true at all. I find these patients work very well in my Christian patients. I use it in conjunction with giving people medicine like ketoconazole or uh esteresa, but I find that Christian's patients probably do better on these medicines than you might expect. And my guess is it probably lowers your cortisol sum, but I haven't done any studies on that. Um, Janet asks, why do these medicines help with PCOS? So they help with insulin resistance. A lot of insulin resistance is key, uh part and parcel of PCOS. Um, they seem to lower your testosterone a little bit, um, um, improve, but improving the insulin resistance is the key. How do these drugs affect hypothyroid treatment with uterid? In general, they don't affect it. The only thing is if somebody loses a lot of weight, they can be, they may need a little less thyroid medicine because the thyroid medicine is usually dose based on your body weight. Tammy asks, I use casema for over a year. The highest dose is not affected at all. I just began azempic to lower um the weight loss and to lower A1C will be more effective. I think it will. I think again, these medicines are better than the um pentamine type of drugs or the topamax type of drugs. And can it be used with low dose naltrexone? It can. Um, I don't think low dose of naltrexone gives you much weight loss either, um, but you can use them together, certainly. Uh, Mark asks, why do endocrine disorders cause intense food cravings? That's a great question. So, some of it has to do with brain hormones. And um, you know, just like these medicines may decrease your GLP1 receptor binding, GLP1 binding to the GLP1 receptors of the brain. Some people, maybe with endocrine issues like cushions, may have more binding of that. There's other satiety hormones that there might be less in endocrine conditions and more uh hormones that cause you to eat more in diseases like cushions or hypothyroidism untreated. Jamie asks, I've read that osempic helps with curving compulsive behaviors like biting your nails behind food. Have your patients reported any behavioral changes? I probably noticed so myself. So there's a lot of interest in using um osempic type of medicines for addictions, um, including smoking cessation, um, um, gambling. I think there's some studies on um, it's a very promising area, probably uh, you know, methamphetamine and opium addiction, it seems to be promising. Um, so I think that's an area key word. And I do some of my research in that area also. We're probably going to try to investigate some of that. Um, so I think that is very promising. Is glucagon an endocrine hormone? Yes. So glucagon is not under the control of the pituitary, it's made in the alpha cells of the pancreas. It usually kicks in when you have low blood sugar levels and it causes you to raise up your blood sugar, which can be detrimental. There are these, what's called a tri. So uh Monjuro is a dual enclocotin. It has GLP1 and GIP1. There's about 38 drugs on the in investigation that are similar to these medicines, all with some variation on them. Some of them have glucagon in them. So someone has a tri-incretin that includes glucagon. To me, that seems like it would be worse because glucagon raises your blood sugar. But some, there's other things about it that seems to be helpful, including some of the weight loss properties. It's not under control of the pituitary. Denise asks, well, Zemper major be better for some who has gastro diabetes and also has gastropresisis. No. So if you have gastroparesis, you don't want to take these medicines. Gastropreesis is when your test, your stomach's slow emptying, and these medicines make that worse. So I would say that's one of the contraindications, along with, you know, maybe recurrent pancreatitis, gallbladder disease, where you don't want to take these medicines. What tips can I give my PCP to get my insurance to cover it? So he your PCP, your he or she just has to order the um do the pre-authorization, and you have to check with your insurance. What is the pre-authorization needed for this? It varies with the insurance companies. Um, Betsy asks, couldn't tolerate major at 2.5 milligrams, had nauseousness, severe abdominal pain, burning esophagus headache, and had to stay in bed all day, couldn't eat at all, itchy white spots appear on my legs. Does this sound like an allergy? It sounds like a side effect from it. Um, you might want to try the Ozempic at like five clicks a week. Um I probably wouldn't go back on the Majora though. Um, and there's a possibility that you're not going to tolerate the Ozempic if you did so poorly on the Manuro. Amy asks, do these drugs contradict with other medicines? Um probably not. I think they're probably okay with other medications. I haven't heard of any major problems. Um you know, one of the things is if you're on a diabetes medicine, you may have to cut down on your other diabetes medicines because you don't, or at least you don't, you may not need them anymore. Let's put it that way. I think you may still you could still take it, but you may not need your other medicines as you drop your weight. You may not need your blood pressure pills. Why? What if I can't tolerate zofrine to deal with the nauseousness? Um, you probably need to go down on your dose. You know, the zophrin works pretty well. Um, but um, you know, if you don't tolerate the zoophrine, probably you need a lower dose. I've had uh success with um Lagovi, then I had to then had to switch to a Zempic. Haven't lost any since uh switching to a Zempic. I'm sure it doesn't cover major. Would it be beneficial to add fentamine daily, or is that not recommended? Um, you know, in general, most of the time people don't add fentamine to uh weight loss medicine. They uh GLP1 receptor agonist. But I think in theory you could, or you can either do that, like alternate one month of fentamine and one month of uh of you know wagovey or zempic type of medicine. My daughter is 16 years old and had a patriot tumor. She's currently on Wagovi, although the low dose is out of stock and she hasn't been on it for a few months. We use it for her because it helps her feeling full, not overeating. She did a sexenda previously, but we didn't see the best results with that. Is there Zempic approved for children? I think it has just been approved for children. Um, I think I can think it's 18 or less. Um, I'm not 100% sure. I don't treat that many kids. Um, it is a better drug than um than sixenda, probably, though. So she might do better on it. Um go back up a little bit. I think we skipped Abby's. She's on 2.5 buckets of manure. Notice that I'm more sleepy than the first two days, the first two days after the injection. Is that likely to side? Yes, it's likely to side. Most of the side effects get better with time because I write it out, it's better. Um, and again, the manjuro, unfortunately, you can't um do clicks. Um, you can try to spread it out a little bit, maybe 10 days, but it seems like it's right after the dose. Um, so um I think you'll just have to write that out. Uh Lisa asks, for those of us without adrenals, do you recommend increasing hydrocortisone dose? Probably not. I think you might even um, I think you probably will be okay. I did mention that it might decry your cortisol, but I don't think it affects your when you take isogenous cortisol. Um, but you have to watch out, you know, the side effect is nauseousness, which is the same side effect as adrenal insufficiency. Jenny says, I prescribe a go to your patient. Have you prescribe a go to your patient with hypothalamic hyperphagia ucranial phenomenon? Um, yeah, I think we have. Um I think that works well, it works well in them. Um, you know, we there's a paper by um one of my patients who used um naltrexone, high dose naltrexone plus um uh oxytocin. And that seemed to help uh a lot of the hyper uh hyperphagia from obesity. Um but I think osempic would be a good choice. With PCOS and A1C that is healthy, how much weight loss should be expected with a major beginning with PCO, you could still lose a lot of weight on either for A1C or you have PCOS, you could still lose a lot of weight on it. Um, I think, especially as you go up on the dose, people could lose up to maybe 30 pounds or so. Can people without a gallbladder take turse apatite or zempic? I think they could, but I would probably start um slowly and really watch out for the nauseousness. Deborah asks, is there a certain amount of being overweight? The call is one to be on these medicines. Yes. So the insurance companies vary with this. Um, you know, some of them may give you, may say you have to be in a certain BMI and certainly don't say that. Um you have to just check with your insurance company. You can email us at um mailgoodhormonehealth.com for an appointment in general. Um, you know, I as I said, I'd like to exclude anger conditions first before giving this, but I can I'm happy to consider this in patients with uh who would benefit from it.