Tirzepatide For Weight Loss

Foreign. Talk about Tirzepatide, which is known as Zep bound as a weight loss drug or Manjurno as a diabetes drug. Now I've talked a lot about semaglutide which comes in the forms of Ozempic and wegovy. And just to kind of clarify these terms of Wegovy and Ozempic for the semaglutide and the Zeppelin and Mangernal for the Tirzepatide, when these drug companies make these drugs, they have certain indications and one of the indications would be for diabetes and that would be in the case of semaglutide, I.e. the ozempic. In the case of Tirzepatide it is mongernal. The weight loss indication is a different indication, but the exact same drug, exact same dosing, but they had to give it a different name. So when doctors are writing the prescriptions, it would determine if your health insurance is paying for it or not based on do you have health insurance coverage for weight loss or diabetes? Most people don't have weight loss health insurance coverage. So that's really the reason they give it two different names. That's not uncommon. When a drug has one medical use that is an in medical necessity use and one use that's medical, but it's not a medical assessing that covered by insurance. So tirzepatide, how does it compare to semaglutide? Well, we don't really have a very good answer on that because there haven't been studies to my knowledge, comparing them head to head. But you can look at them a different window and say, okay, what did the study show on semaglutide and would the stomach show on tirzepatide? Both of them are called GLP1 agonists. Glucagon, like peptide agonists, they stimulate that pathway you're talking about in the pancreas, the brain and the gut and the adult tissue. And tirzepatide has an additional action of what's called gip, that's glucose dependent insulin, tropic polypeptide. So that's a long word, but it's another pathway that's found in the brain and the adipose tissue and helps regulate blood sugar. So both of these drugs, tirzepatide and semaglutide, are effective for weight loss. Now just at a casual glance, if you read the New England Journal of Medicine studies that the companies did for weight loss, you would say, well, it looks like the tirzepatide led to more weight loss than the semaglutide drug, well, they weren't comparison, they weren't in the same realm. So in tirzepatide the weight loss was dependent on the amount of milligrams the person got to. So if there was was three different arms in the tirzepatide in addition to Vegas, four with a placebo control, one was a 5 milligram maximum dose, one was a 10, one was a 15 milligram maximum dose, and the 5 milligram maximum dose, they lost about 15% of their body weight, which was similar to 2.4 milligrams of semaglutide. So pretty similar. But in the 10 and 15 milligrams they got closer to 20% body weight loss, which we didn't see that much weight loss in semaglutide. In both cases, however, they were very effective for weight loss, much better than placebo. The higher dose led to more weight loss, but of course more side effects. Both of them had to be ramped up. In other words, you started a relatively small dose. In the case of semaglutide, the maintenance dose is 10 times higher than the starting dose. And a tirzepatide is really not quite that much as about five to ten times as much, five to seven times as much dose for the maintenance than there is for the starting dose. But in both cases, most of the weight loss occurs at the lower dose, not at the maintenance dose. And we're seeing this pattern with both of these drugs and we're also seeing a rapid tolerance to these drugs where your body stops losing weight, you get to a steady state and stop losing weight. So then the drug companies set it up, so now you're on this drug for the rest of your life to keep it off because they showed if you withdrew the drug, many people would gain the weight back slowly. So how can we mitigate that yet not take this drug long term? Expose yourself to potentially side effects of long term drug. You still want to take more than you need to, but still have the benefit of the drug. Now the drugs in case semaglutide has been studied very well, showing decreased cardiovascular disease, probably decreased kidney and liver disease. Decrease weight. And there's a lot of talk about losing muscle mass. That's actually been another podcast and that's very, very misleading. Your percentage of lean body mass actually goes up relative to your weight, even though you do lose some muscle mass when you're losing fat. That happens with any kind of weight loss. So very misleading. We're not seeing major Risks other than long term use. Seeing some what's called gastroparesis and gastric issues. So in our practice we've been doing this for a couple years, we treated thousands of patients and we're seeing that just do it by doing this periodically, going on the drug for a period of time, say three months, losing weight, then coming off the medication, going something like metformin or barmarine, which increases GLP1 receptors, so increases receptors and then going back on the drug periodically if you need to, to lose additional weight or to keep the weight off. So in our practice we're not seeing the need for long term use of these drugs. Although it might be perfectly fine and safe to do that. It's quite expensive. So tirzepatide has two different pathways and we've mostly been using in people that had struggles with losing weight on the semaglutide dosing, which is not very often. But about 5% of people that we're seeing aren't getting good. Most people are and they want to try something different. Some people want to jump right into tirzepatide. Tirzepatide because they assume it's better. Don't really know. Again, the studies weren't comparing themselves to each other. They both had significant weight loss, both had similar safety profile, side effect profile. So for tirzepatide, if you have interest in it, the dosing is different. So the milligrams are not at all the same. When you're drawing it up in a syringe, the CCs don't really translate into milligrams. We're really talking about milligram or weight of drug because the drug is a outer crystal that gets reconstituted with saline and then you inject it. You can put any amount of saline in it. So if you have interest in going on tirzepatide, I'm not going to say that it's better than semaglutide. It's just different. If you've had struggles with semaglutide not working for you, it's worthwhile to try Tirzepatide. It is more expensive right now, it may change in the future. And it's just like semaglutide. It is on the drug shortage list. So it is able to be compounded either by a manufacturing pharmacy or a compounding pharmacy, which are identical to the commercially available ones. The main difference is the commercially available one is only made by manufacturer and there's a special pen so that when you give yourself a shot, it's automatic where in the case of this compounded versions of GLP1 agonists, you have to draw it out of a vial yourself and give yourself a shot. So tirzepatide dosing, if you choose to go on it, the dosing schedule is different than the semaglutide. You get different instructions for it. But otherwise, in terms of what we're recommending for lifestyle intervention and you know, we recommend a Mediterranean diet consuming extra virgin olive oil sourced from one country and this helps potentiate weight loss and potentially taking a probiotic called Akkermansia. There's one pendulum brand that we like because they seem to have the most likely to have the highest quality. Akkermansia and metformin can be taken with it. However, we generally don't start at the same time because Both drugs, the GLP1 agonist and metformin have risk of GI distress. So if you had that problem, you wouldn't know what drug is from, but you can add that in later on. Metformin in and of itself is effective for weight loss, not as effective as GLP1 drugs, but is effective, very safe and is even being studied as a longevity drug. We don't know the answer on that as of yet. So the Tirzepatide is an alternative to semaglutide. It is available in a more inexpensive compounded version version. The lifestyle intervention should be the same in each case. You should be making some attempts to lose weight. That way when you do get your weight down, you can eventually come off the medication, maybe with a little help with metformin or something else, but not necessarily be dependent on it long term. And really just a note that if you are on this medication long term and you are at risk of heart disease or diabetes, it still gives you long term health benefit. Likely reduces mortality, I'll cause mortality, but we know it statistically reduces cardiovascular mortality from that standpoint. If you're overweight and you need this drug long term, that's just fine. We're seeing it's going work really well doing it on a pulsatile basis where you go on three months off for a couple months on three months. Because when you come off the drug for even a little, a few weeks, your tolerance of drug drops off. When you start it up again, you have the ability to lose weight again. So kind of like stair stepping it down, even stair stepping it to lose weight or doing periodic dosing with a holiday where you're off of it in between to lose the tolerance to the drug and get the long term benefits of these medications. So tirzepatide is a alternative to semaglutide. There's no direct evidence that it is better. Better. The higher dosing of tirzepatide, the study showed more weight loss than we saw with the semaglutide at the highest dosing, but it wasn't significant. But it was, it was different. And it does have additional pathways working on both GLP1 agonists and another pathway called GIP, another glucose signaling pathway. So it's a good alternative for people who want to try something a little bit different. So thank you very much and good luck.