May 29, 2023

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Hey it’s dr spencer nadalski here again the chief physician for renaissance periodization you’re board certified family physician and obesity specialist and also a specialist in lipidology we’re going to continue our mini series on weight loss medicine and today is part three all about phentermine we already went through the history and what weight loss medicines

Are used for and phentermine is one of the most prescribed medicines for weight loss so let’s get into it what is phentermine anyway well it’s a sympathetic drug and people call it an amphetamine however it’s not actually an amphetamine it has amphetamine-like properties thought to be used due to the norepinephrine in the brain causing an anorectic response

Appetite suppression central in the brain i showed that graphic last week basically we have these neurons in our brain and norepinephrine increase in that area and then also dopamine and some of the other areas of the brain reduces our appetite so centrally acting not a fat burner remember that it was approved in 1959 and um again somewhat of a an interesting

History because they put it together with phenphleramine the fen-phen craze and the phenphlermine part with the serotonin properties had an effect on heart valves so uh phentramine by itself doesn’t have an effect on heart valves by itself we call it monotherapy it’s approved for up to 12 weeks of use many people use it off label including myself i’ve used it

Off label with many patients especially when their insurance wouldn’t pay for the phentermine until pyramid combination which i’m going to be talking about in a second so you see a lot of people on long-term venturing but really the fda only approves it for 12 weeks at a time they should really study it longer term but probably not any money in that anymore due

To patents anyway there are multiple doses of this there’s a newer medicine out there um the brand is is lomaira but uh comes in smaller tablets little eight milligram tablets so you you don’t have to break up the the 15 or the 30 milligram or the 37 milligram tablets and that can be used in case people have side effects from the phenomena which i’ll get into

But uh yeah those are the doses that it comes in again i want to emphasize this because so many people just think oh i’m just going to take this medicine i’m eating 1200 calories already and i’m going to lose weight well again it takes your broken hunger uh satiety part of your brain if you have obesity and hopefully you know stops that hijacking of your your

Wiring in your brain the short circuiting of your brain and gives you a better hunger that’s it just a tool i i will say though i have had many patients who have said they’re eating 1200 calories and they say they’re not hungry and i give them one of these medicines and bam they lose 50 pounds so clearly they were hungry and they just weren’t going to admit it

Or maybe they just didn’t realize so when you consider something like this none of these medicines should be used ever ever ever if pregnant or even considering being pregnant you got to be really careful and this specifically isn’t used for breastfeeding or during breastfeeding i do use phentermine in younger folks i’m very careful with fentanyl we got these

Newer drugs coming out i talked about the glp-1 agonists that in longer studies because people paid for them mind you uh there are actually lower risks of heart attacks and things like that that was during the glp ones with phentermine because it’s a sympathetic um increasing your sympathetic nervous system i’m i’m quite careful in middle uh you know that kind

Of middle older age folks with obesity specifically you know you can screen for cardiovascular disease and things like that but i’m just very careful there’s no studies to say that phentermine increases cardiovascular events but just theoretically i would still want to hold back on that but contraindications still do include heart disease hyperthyroidism you

Know in general if you have hyperthyroidism you’re going to be losing weight anyway so but just obviously you wouldn’t use it regardless with hyperthyroidism uncontrolled hypertension because it’s a sympathetic can rev up your nervous system increase your blood pressure and those with glaucoma pressure in the eyes now uh barring any of those issues i am very

Careful because it’s a sympathetic a lot of patients have anxiety it’s actually very common and i screen for it because if you have anxiety i give you one of these your heart side effects include kind of some palpitations your heart rate goes up a little bit you feel it’s kind of a little bit of an upper uh if you’re already anxious it could put a supercharger

On that so very careful with that and of course if they’re taking any other sympathometic drugs for like anxiety and depression again we’d want to be careful with that anyway so there’s other cautions and that you could look at the labeling but these are when i’m considering looking at a patient right in front of me these are the most common things now venture

Mean by itself is only approved for 12 weeks at a time and yeah you can use it off label i do it all the time and in fact i add in topiramate monotherapy from a generic standpoint and put them together but when you when you have this combination that’s already approved for longer term it’s probably better to use that especially from a medical legal standpoint

You don’t want to get sued for whatever reason or get in trouble by the fda but fenture mean until pyramid extended release which is under the brand name qsemia is approved for longer term use which means you don’t you don’t have a time limit you don’t have to worry about the fda coming down on you now the cool thing about this as i mentioned in the second lecture

I believe talking about future uses of drugs what they’re going to be doing is probably combining lower doses of each thing so you don’t you still get that satiety effect on the neuron or whatever receptor it’s working at centrally in the brain and then you can use multiple pool just like this venture me into a pyramid they work in different parts topiramate

Has has more of this gabanergic activity works in the gaba area of the brain which seems to regulate appetite in a different way than sympathemetics the sympathomimetic amine that phentramine does so you put them together you lower each dose of each medicine and all of a sudden you get fewer side effects and you really increase the efficacy or how well it works

So contraindications meaning you you know similar to uh phentermine where you shouldn’t be using it but they made a big deal about this when it first came out about pregnancy because topiramate uh is known to cause cleft lips uh cleft palates in uh uterus um so yeah obviously if somebody’s pregnant you don’t want to be using weight loss medicines anyway but

Specifically with topiramate you want to be careful if they’re you want to be on multiple birth control methods using condom uh iud all that type of stuff but i got a funny story i have a i had a patient once i kept asking them now you’re on birth control right and they just kept saying i had a tubal don’t you remember yeah so again i’m very careful about asking

Patients about that because obviously don’t want to have any babies with cleft lips and pallets the other thing that they don’t mention in the contraindications but it’s a caution topiramate can increase your risk of having recurrent kidney stones if you had them in the past may be something you want to consider also there are some kidney function things that you

Want to monitor their creatinine levels and also potentially potassium levels and there’s some other uh acid-base stuff that goes on that gets quite complicated with topiramate that you may want to follow as well here’s an interesting part expectations again not a fat burner but i will say that phentermine and specifically fenture mean to a pyramid together is

Probably the strongest of all the weight loss medicines we have my go-to is generally the glp ones because of the the likely decreased risk of cardiovascular events but phentermine topiramate highest likelihood that you’ll reach that five to ten percent of weight loss remember it’s a tool it’s not a fat burner although the topiramate may have some actual increased

Metabolic rate activity but that’s kind of theoretical but it’s just a tool helps you helps you eat fewer calories helps you stick to your plan and if you do not respond this is the beauty of these medicines people are just like oh just if you know people just stay on and it increases the harm because they’re sympathetic uh activity well if you don’t actually

Get the five percent weight loss and their specific labeling here you could do three percent if you’re on the lower dose but it doesn’t matter let’s just say five percent if you don’t get the five percent weight loss uh you you discontinue it because you’re not responding to it and there’s probably more harm than benefit and that’s like any of these medicines they

All have it and i’ll go through the next ones when i talk about the bupropion and naltrexone and the the different glp1 agonists so all right hope you learned everything you need to know about phentermine and the ventra mean to pyramid combination this is what i do with my patients again how i practice and see you next week when i talk about the next weight loss medicine you

Transcribed from video
Phentermine | Guide to Obesity Medication #3 By Renaissance Periodization