Modern Metabolic Health with Dr. Lindsay Ogle, MD

The Original Weight Loss Meds: Phentermine, Qsymia, and Contrave

• Lindsay Ogle, MD

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GLP-1 medications are everywhere right now, but the “older” obesity medications never stopped helping real patients and they can still be the right tool when matched well. I walk through the three FDA-approved first-generation obesity management options and how I think about using them safely in modern obesity medicine, especially when cost, access, or specific symptoms like cravings are part of the story.

We start with phentermine, the original FDA-approved weight loss medication, and get practical about what it actually does: appetite suppression, typical stimulant-like side effects, morning dosing, expected weight loss, and the key reasons it may be unsafe (like uncontrolled high blood pressure, certain heart conditions, glaucoma, or uncontrolled hyperthyroidism). Then we move into Qsymia, the phentermine plus topiramate combination, including why it tends to produce more weight loss, what to know about pricing, and the topiramate-specific risks like teratogenicity, kidney stones, fatigue, taste changes, and tingling sensations.

Next, we dig into Contrave (bupropion plus naltrexone) and why it can be a great fit when food cravings, emotional eating, mood symptoms, or goals like cutting back on alcohol or smoking are front and center. I also explain the non-negotiable safety rules: no history of seizures, and no opioids of any kind, including products like kratom or 7OH, due to the risk of precipitated withdrawal. We close by talking strategy, including combining these oral options with GLP-1 therapy, using them for maintenance, and an honorable mention of metformin for insulin resistance and metabolic health.

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Welcome And Medical Disclaimer

Dr. Lindsay Ogle, MD

Welcome to the Modern Metabolic Health Podcast with your host, Dr. Lindsay Ogle, Board Certified Family Medicine and Obesity Medicine Physician. Here we learn how we can treat and prevent modern metabolic conditions such as diabetes, PCOS, fatty liver disease, metabolic syndrome, sleep apnea, and more. We focus on optimizing lifestyle while utilizing safe and effective medical treatments. Please remember that while I am a physician, I am not your physician. Everything discussed here is provided as general medical knowledge and not direct medical advice. Please talk to your doctor about what is best for you.

Why Talk First-Gen Weight Meds

Dr. Lindsay Ogle, MD

GLP1 medications are extremely popular and for very good reason. They are extremely effective and overall well tolerated. And I have many, many videos and podcasts about GLP1 medications. But today we're going to talk about the first generation obesity management medications. These were our first options for treating the disease of obesity, and they are still available today and may be a good fit for you. So today we're going to talk about what those three medications are and who they might be good for and when we might want to use them. Before we go into the three first generation obesity management medications, I do want to remind us the purpose of obesity medicine, and that is to treat the excess adiposity to help prevent and treat weight-related conditions. And we can achieve that by achieving at least a 5% total body weight loss. So that's where we start to see real health benefits. So for any obesity management medications, we want a minimum of 5% total body weight loss after at least three months on the max tolerated or max available dose. That's um clinically what we are looking for. But many patients are wanting more than that. And for some for some medical conditions, we do need more weight loss than 5%. We see more benefit with 10 and then even more with 20. And many of our new generation obesity management medications, our GLP1 medications, we do see 15 to 20% total body weight loss.

Phentermine Basics And Safety

Dr. Lindsay Ogle, MD

So the first FDA-approved obesity management medication was fentermine. And this was approved in 1959. This is a stimulant medication, so it's considered a controlled substance, although the abuse potential and misuse potential is very, very low. I always say you don't see people selling fentermine on the streets. It doesn't have a lot of street value. It's also very inexpensive because it's been around for so long. We have it in a generic form. So even without insurance coverage, you can get this for $20 a month or less. The way that this medication helps with weight management is that it helps suppress appetite. And it's technically FDA approved for three months duration, but those of us who work in obesity medicine and many primary care doctors recognize that this really needs to be a long-term treatment because obesity is a chronic condition, and so it is clinically used longer than that. Although I believe in some states it still is legally limited to just three months. You take this medication, it's an oral medication. You take it every morning, and the reason you want to take it in the morning is because it is a stimulant, and if you take it too close to bedtime, it may keep you up at night. The most common side effects are headache, dry mouth, palpitations, or racing heart, um, you know, typical stimulant, um caffeine-like effects. Some people feel a little bit anxious, um, maybe a little bit of irritability, but most people tolerate it pretty well. If you are having side effects, it's important to know that there are slightly different versions of ventermine. You can take a lower strength, or you can transition to another medication, diethylproprion, which is often tolerated better and can be dosed actually three times a day. So you can take it with each meal because it's shorter acting or shorter lasting. Um, so that medication, diethylproprion, is also available. You do not want to use this medication if you have uncontrolled high blood pressure, a history of cardiac disease, like a history of a stroke or a heart failure or aphib. You do not want to use this medication if you have glaucoma or uncontrolled hyperthyroidism. Average weight loss with this medication is somewhere between 5 and 10%.

Qsymia Benefits And Topiramate Risks

Dr. Lindsay Ogle, MD

Next generation we have cucimia. And cucimia was FDA approved in 2012. Cusimia is a combination of ventramine with topirmate. So it has all of the same effects as ventramine, but then it has toirmate added to it. And what they found was that it has an additive benefit. And so on average, qsimia is more effective than ventramine alone, and people may lose 12 to even 15% of their total body weight on cucumia. It similarly works at the brain level to control appetite. Um, just it seems to be a little bit more effective with that combination treatment. It is still considered a controlled substance like ventramine, although the FDA approved long-term use of cucimia, and so there are no limitations for prescribing in any state. The name brand for cucemia can still be pretty expensive. There is no generic at this time, but there are some programs where you can get cucemia delivered to you, and you can get it for $89 for a 30-day supply or a 90-day supply for $210, which would be $70 a month, and it gets delivered to you, which is very convenient. Sometimes physicians will also prescribe the individual components of Qsimia, so they'll prescribe ventramine and topiramate. The doses are slightly different, but it can be a lot less expensive that way, and so that's an alternative option that you can talk to your doctor about. In addition to all of the contraindications and reasons why you should not take fentramine, um, there are a couple additional reasons why you should not take kusimia because of the topiramate that's in it. The number one, most important, is that topiramate is known to be teratogenic, meaning that it can lead to birth effects, specifically clef lip and clef palate. And so if you have any potential of becoming pregnant, then you should not take topiramate. You should be on effective birth control if you had the potential for pregnancy to prevent that complication. Topiramate can also increase risk of kidney stones, and so you want to make sure you're staying very well hydrated. Um, at high doses, it can cause fatigue, um, it can make people a little bit sleepy. Um, and sometimes people get an abnormal taste, um, which um interestingly can be more prominent with carbonated shrink. So it can be very helpful for people who are looking to cut back on their soda intake. And then some people um get abnormal sensations, um, often in their fingers or toes. That's reversible when you stop a medication if that does happen

Contrave For Cravings And Mood

Dr. Lindsay Ogle, MD

to you. Next, we have Contrave. Contrave was FDA approved in 2014, um, so 12 years ago now. And Contrave is a combination of um buproprion, which the brand name is Wellbutrin, and Naltrexone. And this is another oral medication, um, a combo medication, and it can really help mostly for food cravings and emotional eating. And so it can help break up the food reward pathway. Uh, buproprion or well butrin is often used to treat depression, sometimes anxiety or ADHD symptoms. It also helps people cut back on cigarette smoking. And then naltrexone is an anti-opioid, it blocks the opioid receptors, and it's most commonly prescribed to decrease cravings for alcohol. And so, if you are struggling with mood or wanting to cut back on cigarette smoking or alcohol intake, then Contrave could be a really good option for you because it's gonna have that dual benefit. Um, you cannot take this medication if you have a history of seizures. Preproprion can lower the seizure threshold. So if you've ever had a seizure before, please do not take this medication. And you cannot take it along with opioids. That will make you very sick to take the naltrexone along with opioids. And I will also make a plug on that the over-the-counter Kratom or 70H products, those are opioid products. You cannot combine these two medications. It will make you um have precipitated withdrawals and really bad flu-like symptoms. Contrave also is still under brand name only. Um, to get the lower cost if you do not have insurance coverage, there is a program where you can get it for $99 delivered to your home. And then similarly, the individual components are generic and your doctor can prescribe those to you to take together. And again, the doses are a little bit different than what is in the brand name Contrave, but it could be a much more affordable option. Common side effects may be nausea when you first start the medication, potentially headache or palpitations. Um, viproprion can be a little bit stimulating. So some people, if you take it too late in the day, could keep you up at night. Um, some people feel a little bit of restlessness or anxiety, again, mostly in the beginning. But overall, it's pretty well tolerated medication.

Where These Fit Next To GLP-1s

Dr. Lindsay Ogle, MD

So those are the three FDA-approved first generation obesity management medications. They're all our oral options, and if you noticed, it took from 1959 to 2014 to get these three medications approved. That is not that many options over the course of many decades. Compare that to the last decade, where we've now had many GLP1 medications approved. We have Saxina, which is the daily injectable GLP1, which is not commonly used because of you know convenience, um, and it's not as effective as our newer GLP1 medications. We have Wikulvi, we have Zipbound, we have Oral Weakov now, we have high-dose Weak OV, and we have um Fondeo. And coming up very soon, we're gonna have Cargy Semma and Reditrutide and many more medications. And so it's a very exciting time in the field of obesity medicine. We have many options for patients, but I don't want us to forget our tried and true first generation options because there are many people out there who do very well on those medications. And oftentimes we may do a combination because they work in different ways. You can take a someone who is on the highest dose of their GLP one and they've done great, but they haven't reached their you know complete health goals. You may decide to add on one of the first generation medications, and that's okay to take those together. There could be other instances when cost may be a factor and somebody can not, they can't afford to take a GLP1 medication long term. Maybe we start with that treatment, wean off, and then maintain with one of our first generation obesity management medications. There could be reasons, um, maybe if there's a medication shortage again, we have to utilize these other medications. Um, it's good to know that there are many tools in the toolbox to treat this multifactorial chronic condition obesity.

Metformin Mention And Closing Questions

Dr. Lindsay Ogle, MD

I also want to give an honorable mention to metformin. Metformin can again be used alone or in combination. Metformin does not control appetite, it does not control food noise, it does not impact fullness, but it does treat underlying insulin resistance that many, if not all, people who struggle with their weight have, and it can definitely improve metabolic health. Metformin is generic, it's very inexpensive, we've been using it for decades, it can be a great adjunct to treatment of obesity. So it's not technically an obesity management medication, but it is honorable mentioned, and I do use it quite a bit in my practice. So, what are your thoughts? Have you tried any of our first generation obesity management medications? Is this something that you would consider adding on to your GLP1? Let me know. I'd love to hear your thoughts, and I'll see you next week. Thank you for listening and loving how you can improve your metabolic health in this modern world. If you found this information helpful, please share with a friend, family member, or colleague. We need to do all we can to combat the dangerous misinformation that is out there. Please subscribe and write a review. This will help others find the podcast so they may also improve their metabolic health. I look forward to our conversation next week.