Semaglutide: Misconceptions and How To Use

Foreign. Talk to you about semaglutide and some misconceptions and even maybe different ways we can approach this drug, the use of this drug to make it maybe more cost effective and even manage some of the shortages of their, their bends. So in summary, semaglutide is a, it's pronounced different ways. That's how I've been pronouncing a semaglutide. Ozempic and Wegovy are the brand names. Ozempic is a diabetes formula and WeGovy, the weight loss formula. Both have been approved, FDA approved in the United States will go away for weight loss under certain circumstances. And Semaglutide as ozempic for type 2 diabetes. And they're called GLP1 agonists, glucagon, like peptide 1 agonist, which means they turn on this GLP1. It was discovered almost a decade ago as part of the pathway that a drug called metformin activates. Metformin raises GLP1 levels up and this semaglutide pushes GLP1 forward, which has effects in the brain and the pancreas, areas in the gastrointestinal tract. So we respond better with insulin sensitivity. And it decreases cravings for food, especially junk food. And interesting, it decreases cravings and habits of other sort of less drinking, less compulsive behaviors. It also has other effects like it seems to help autoimmune diseases. And since it came out, there's been a regular shortage. There's people that are, have. Most people don't have insurance coverage for WeGovy. So they're using Ozempic, which is FDA approved for diabetes, and they're getting their insurance companies to pay for the Ozempic, which could potentially be a problem with, you know, insurance fraud if you don't have weight loss coverage, you know, diabetes. That's something that I don't think we've sorted out yet. But because this is, these drugs have been this drug and other obviously classes have been on the drug shortage list by the fda. They can be compounded and they're compounded in under with Both what's called 503A and B laboratories in Mass. And these compounders are catching up with demand that winds up being a lot less expensive. So we're talking about some of the misconceptions about Ozempic and wegovy semaglutide and how we've been using it in our practice successfully the past couple of years. So again, FDA approved for weight loss for a couple of years, I think three Years now, wildly popular. So popular there's been regular shortages and then the compounded versions have come into play. So there's different forms of compounding and there's been a lot of attempts to discredit compounders because they're using a different form of semaglutide, perhaps salts. But now they're pretty much all using semaglutide base. They sometimes will add B12 or carnitine to it, I think to reduce some of the side effects of nausea. They're allowed to do that and also gives them maybe some intellectual property protection. So I'm not going to really discuss the compounding of it, but that's. We're seeing commonly used as compounding compounded semaglutide because it's far less expensive. The WeGovy's over $1,000 a month. So we look at the studies, people saw between 15 and 17% weight loss over a year period. A little over a year period. And we look at that weight loss, most of it occurred or the highest percentage of weight loss occurred in the first 13 or so weeks. First few months weight loss really dropped weight come down really fast and then sort of slowed down and about 48 weeks it trailed off and then the weight stayed stable in some cases went up a little bit. So we see the weight loss not continu. But people are thinking they have to take this drug forever. That's what they're told by big pharma. Here's a summary of some of these studies and I'm going to talk about things like the muscle mass, some of the dose escalation issues, and what we're seeing in successful our practice that reduces costs substantially. So first off, they showed that this caused weight loss. And for a big pharma company, they want you to be at it forever. And the bid is to call obesity and disease that way. Your insurance could be potentially forced to pay for it. Because most insurance that don't pay for right now, Medicare certainly doesn't. And if we did have coverage for supper glutide mandated, it'd be, you know, three quarters of the population would be on it. And at $20,000 a year, that health care insurance is immediately, you know, bankrupt. Make Medicare insolvent. So we got to manage this cost thing somehow. So they did in the study, they start people off at 0.25 milligrams and every four weeks they increase it until they get 2.4 milligrams. So actually the starting dose where you lose most of the weight at is 1/10 as, as the maintenance dose. That is because you rapidly get tolerant to the semaglutide. In fact, when you started out, if you start up in a high dose and make you very sick to your stomach, has a lot of side effects or gastrointestinal. That's mainly just gastrointestinal, but they're very manageable at these low doses. And as time goes by, your body gets sort of immune or just used to this semaglutide, and you have to escalate the dose to get additional weight loss. So the starting dose is 0.25mg and the finishing dose is 2.4mg, 10 times as much. And on the maintenance dose, you're not typically losing more weight. You're losing weight on these starting doses because your body rapidly gets tolerant to it. But there's another thing that happens is that tolerance rapidly gets extinguished. It goes away when you're off of it. In fact, if you're off of the medicine, let's say you're in a maintenance dose of 2.4 milligrams, you stop it for a month. You can't go back to 2.4. Generally, it will cause too much GI distress. You got to start over at the lower dose again. So we have this ability to look at tolerance and extinction of tolerance. We also can see that most of the weight loss occurred in the first, say, three months. That's where the most rapid weight loss occurred. More than half of the weight loss occurred at that point. And we have a drug that's expensive, in shortage, so how can we use less of it? And we know that the maintenance dose, which doesn't cause weight loss is 10 times higher than the starting dose. So what can we do? We also know that metformin increases GLP1 levels and can be used synergistically with it. We typically don't start metformin in some glutath at the same time because they both have GI upset as a side effect. And if you were to get that, you wouldn't know which drug is causing it. But they can be taken together. So we've done in our practice, and I've written about this before, wrote a white paper on it, is we put a group of people, they're in our South Carolina office and wanted to lose weight that were overweight or obese on 13 weeks of semaglutide, mimicking the clinical study trial. So they escalated the dose, but they just did 13 weeks. And then they stopped it for two months. And went on metformin, and then they had the opportunity to go on the semaglutide at the starting dose again if they wanted to, if they wanted to lose more weight or if they wanted to sort of keep it off. And we found after a year was that people lost an average 14 of their body weight in the first 12 weeks, much faster than they did in a clinical trial. But this wasn't a placebo controlled trial. They knew they were getting the real drugs. They probably made some additional efforts. Plus they work together, so there's some social interaction. Maybe eat a little healthier. We buy lunch for our staff, so they eat more Mediterranean food. So they could kind of work on their weight loss. Yeah, but they lost 14% of their body weight on average, and then they kept it off for a year. Some of them lost much more than that, but nobody gained the weight back. And what we saw was that some of them went on additional intermittent dosing of semaglutide. Some of them intermittently used metformin. Some really didn't need anything to keep it off. But the additional dosing or, or rounds of semaglutide did allow additional weight loss. And when we look at, again, the clinical study, the weight loss occurs very fast and then really tapers off when you go on the second round. You don't lose weight as fast again because you're again, you're at that already at that 14. And in the study participants, they had maybe up to 20% weight loss. So it does not. It's not as strong the second time around, but it does allow additional weight weight loss. And this combination of semaglutide with holidays off the drug and taking the metformin and then starting again really allows you to cut down on the total amount of medication you're using. Plus you're using the much lower dose, which is far less expensive. Okay, so if you use commercial system and you're on it for a year, you're looking at over $15,000. Whereas using the system of intermittently using the semaglutide, you know, maybe less than $2,000. So it's far less expensive. And then you're not taking as much medication. Now, in the clinical study, another clinical study that the manufacturer did, they said, well, if the drug, you get the weight back, therefore you need to be at it forever. So they had one arm where they ran people out for 68 weeks, a little over a year and a half almost. And they saw this weight loss, about 16% body weight. And then they continued one group of people on this high dose, 2.4 milligrams a day, I'm sorry, a week of semaglutide. And another group, they said, okay, we're going to take you out of this study and see what happens. Well, here's what happened in the study. They didn't just give them a shot. They gave him a shot of drug or placebo. They didn't just do that. They also said, we want you to exercise 150 minutes a week, so 30 minutes a day, five days a week, and we want you to cut your calories by 500 calories a day. Okay, so diet and exercise. Well, in the placebo group, they lost a couple percent of body fat. I'm sorry about body weight, which could be expected. So if you were, you know, 200 pounds, you might lose, you know, four or five pounds. And the people that were 200 pounds were on the drug, they might lose more like, you know, like 30 pounds. And when they got to the 68 weeks, some people had lost 5%, some people lost 10%, some people 15, some people 20, some people over 20%. And they took a group of people, they said, well, stop the drug and stop exercising and go back to your old diet. Now, this keeping mind as a drug company is doing this because they want to show you that you have to take their drug. Heaven forbid you continue to manage your lifestyle. Well, in that study, the people that had lost very little weight, they got it all back. But the people that lost over 20% of their body weight, they gained very little weight back because they did not abandon their new lifestyle. They did not abandon it. So people that were effective at losing weight, they didn't really need to take it forever. So I think that was very much a misleading. Typically, if you're going to do a lifestyle change and a drug's helping you out, you should continue the lifestyle change. If you stop the drug, hopefully that's what you would do. If you're going on a Mediterranean diet, starting to exercise, let's continue that. So that's one flaw in the study is that they told us stop exercising and dieting, which we typically, as doctors, would not tell you to do. That's part one. And there's some people obviously would like to take a drug and not worry about their lifestyle, but that's maybe not a practical solution for us as Americans. So in our grouping, we've asked people to continue to the lifestyle. We're not instructing people to exercise. We're giving them some advice. You should try and Do a Mediterranean diet. We want you to take extra virgin olive oil every day, at least a tablespoon. That helps with weight loss too. Mediterranean diet is the most effective. That's a lifestyle change. It can lead to long term weight loss and health. That's one part I want to make clear. You don't have to take this drug forever. You can continue, can lose the weight and then get a little help with either metformin or intermittent semaglutide and maintain lifestyle again. Our first group being in South Carolina, most of them didn't do a whole nother round of semaglutide. They just did a little like a few weeks dose to keep the weight off. So it'd be an option for you to have a bottle in your fridge. You know, this compounded 503B lab that that makes it for us. They say the bottle's good for a year and once it's pierced it's good for 28 days. Well, it's probably good much longer than that, but that's kind of the official word. But you can keep this on hand and use it when you need to. So that's version one. The second thing I've been hearing some from very famous podcasters and some people, Semalukide causes lean muscle mass and that's where most of the weight loss occurs, is in lean muscle mass. One very famous podcaster has actually said it's making people fatter and he claims there's no studies showing preservation lean muscle mass. Well, that's false. I don't know why these, these misinformation is coming out of people that are seemingly are experts. I mean, they obviously have the ability to read the same literature that I do. These are published, peer reviewed and I cannot find any evidence to support this nonsense that's making people fatter. And I find plenty of evidence that is creating more lean body mass as a percentage of body mass. Now when you are somebody who goes through a major weight loss, let's say they did bariatric surgery, that's where you do a stomach stapling and they lose a hundred pounds. They do lose some muscle mass, there's no doubt about that. Because it takes less of a musculoskeletal system to carry around 150 pound person than to carry a 300 pound person. That's just a fact of life. So somebody that is obese has got very thick bones and thick muscles that carry that frame around. And if you lose weight, the muscle mass does decline, but mostly you're losing fat so this is something that happens. We look at people that go through bariatric surgery or go through weight loss. Typically we look at lean muscle mass as a percentage of their overall weight. So if their lean muscle mass was at 50% of their overall weight, which is actually kind of high, and they lose weight and they're still 50% of their overall weight, that means they preserve muscle mass even though they might have lost a pound or two of muscle. So clinical studies looking at the use of semaglutide in people that are not actually training, they're just using the drug, they've shown improvement of lean muscle mass, not worsening, as suggested by these famous podcasters, which I don't know where they're getting this information, others saying that they see it in their own practice. We're not seeing this, it's not been published. And there's three peer reviewed articles, I have them on my other screen showing preservation of lean muscle mass. So preservation lean muscle mass would imply that lean muscle mass as a percentage of your weight stays the same or gets better, and it stays the same or gets better. So it's nonsense. That you're going to lose muscle mass is unfounded. If you lose £100, you're going to lose some muscle mass because you don't need so many muscles carrying you around because you have 100 pounds less weight to locomotive around. So this is something that is very misleading, trying to scare the public off of something that's very safe. There's been studies showing that semaglutide is, I mean, we know that it reduces some autoimmune conditions, it reduces certain addictions, particularly food addictions, it reduces cardiovascular events. In fact, there's a recent paper showing that in diabetics who have a high risk of cardiovascular events, it likely adds 1.7 years onto their cardiovascular life. What's that worth? 1.7 years later to get a heart attack than you would otherwise. That's, that's really kind of valuable. So semaglutide is cardioprotective in diabetics or non diabetics being studied for cardiovascular benefit and non diabetics now. And it's been shown to be positive, it appears to extend cardiovascular life or life overall. All cause mortality, causes fat loss. Predominantly there's some muscle mass loss, but preservation of lean muscle mass as a percentage of your body weight, that's really how we should be looking at muscle mass. So again, somebody goes from £300 down to £150, they're going to have less Muscle, their bones won't be as heavy because it's not carrying around as much weight. That's just nature. So the idea that you have to eat a lot of protein or do this mass amount of exercise while taking some gluten is nonsense. You can eat your Mediterranean diet that doesn't have a whole lot of protein in it and probably should do some exercise. We should be doing that anyways if you're trying to get weight off. But the, the idea that you're going to lose predominantly muscle mass and I've heard it said there's, there's a doctor advertising his plant paradox book saying that you predominantly lose musc muscle mass. That's just false. So that, that is absolutely false. We can't just make this stuff up and you know, tell as these are doctors saying this stuff that are promoting their own products. They're very misleading. I don't like seeing that. So let's do a summary and recap. So semaglutide was designed to take for the rest of your life, even after you lost weight, no longer obese. That's what the company wants. And they've got a drug that's very expensive, is 15, $20,000 a year. And it's just unattainable. This imagine like living with that kind of expense rate. If your insurance company's covering it, your insurance rates are gonna go up and your employee's gon have, your employer is going to have some, some issues with paying for that. So can we look at different ways? Well, metformin is synergistic. Synergistic meaning it aids semaglutide that can be used together. Metformin raises GLP1 levels, it slows down the breakdown of GLP1. And semaglutide acts on the GLP1 pathway. So they are synergistic. We can use semaglutide in a short period within the lower dose, which is 1 to 12 or 13 weeks. Way less expensive. And getting up to that high dose, which is 10 times higher than the weight loss dose, and then take a break and go on metformin to maintain that weight off, maintain that suppression of appetite. Metformin myself does help with weight loss. And then if you need additional semaglutide you could take it periodically at the lower dose or do another round. If you want to lose an additional percentage of body weight, you can take another whole 12 weeks round. That'd be plausible to do. Also be practical for you to be able to get injection periodically when you need it. We find that people start losing the weight at about week four. It doesn't happen so much at week one and two, but week in one and two, the habits start getting better, the appetite starts going down, and the craving for junk food does go down. So that's a theoretical thing that can be done is that you're, you know, you're going on a trip and you don't want to eat a bunch of junk food. You can take a semi lutide shot and suppress your appetite. It does not cause loss of lean muscle mass as a percentage of body weight. That's just false. There's been some talk about the semi luti face where people, you know, their face deflates. Well, I mean, if you're heavy, your face is full of fat. When you lose weight, you're gonna lose it out of your face and everywhere else. And in some cases, being a little heavy makes your face look potentially a little younger. And we do have ways to solve that. We use fillers that make up, you know, we do the magic lift, which basically takes up the space where the fat's gone. So that's really easy to handle. So I would use that as a reason to dissuade you from being healthier because we know that when weight's lower, we're healthier, we're gonna live longer. In this case, semaglutide, 1.7 years just based on a short term use of it. So semaglutide, not something to be afraid of. It is a shot. There is a pill form that does cause weight loss, but the FDA approved dose is up to 14 milligrams and the weight loss dose is 50 milligrams. They only make a 50 milligram pill. So that's something that we might see out in the future. Was just published at Lancet very recently this year. But it's a dose, you know, really about 10 times higher than the oral dose of the, of the oral form of semaglutide. That's, that's not out yet. There might be something down the road. Right now it's an injectable. It's done once a week. Again, we do 12 or 13 weeks. Typically one bottle lasts about 13 weeks of the compound of semaglutide and we switch over to metformin, usually 850mg at night. Less GI distress when you take metformin at night. Somebody who get upset stomach with or no diarrhea, something doesn't happen at nighttime. The extend the release form and then if you need additional weight, wait about, you know, six or eight weeks, you go back on it at this low dose, escalating up the weight loss won't be as fast the second time as the first time. Usually we're seeing about 14% body weight the first time, but you will typically lose a little bit more weight and then it off long term, probably be on continuous whatever lifestyle habits you picked up that are beneficial going on Metformin long term, that's safe. Metformin is actually being studied as an anti aging drug. It appears to make people live longer and might be periodically using semaglutide or periodically doing cycles of semaglutide rather than taking it continuously to save on cost. So thank you very much.