" Overview of Yale Metabolic Weight Management Program " Bubu A Banini (12/15/2021)

December 27, 2021

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00:11OK, so I think we could get started.
00:13Good afternoon everyone.
00:15I will start with the usual announcements
00:17before I introduce our speaker.
00:19First sleep seminar lectures are
00:21available for CME credit as long
00:23as they're viewed in real time and
00:25just text the ID for the lecture,
00:27which is going to show up
00:28in the chat to Yale Cloud.
00:29See me by 3:15.
00:31Recordings of the lecture are
00:32available in approximately 2 weeks
00:34at the site noted in the chat.
00:37CME credit is only available
00:38if you view in real time,
00:39not later and then finally.
00:41If you have questions during the talk,
00:43please just raise your hand and
00:45I can unmute you or otherwise
00:47use the chat and I will.
00:49I will moderate this session so now
00:51it's my pleasure to introduce today's
00:54speaker Doctor Boo Boo Benedi.
00:56Dr Bonini is an assistant professor
00:58of medicine at the section of
01:00jesters diseases here at Yale.
01:02And she's also the translational
01:03research director of the metabolic
01:05health and Weight Management program.
01:07She received her MD and pH D from
01:09Sidney Kimmel Medical College at the
01:11and College of Graduate Studies at
01:13Thomas Jefferson University in Philadelphia,
01:16and she then moved to New York for
01:18her internal medicine internship.
01:19Her residency,
01:20and she also served as chief
01:22residency at Montefiore.
01:23She subsequently completed a
01:25postdoctoral research fellowship
01:26in gastroenterology and Hepatology
01:28at Mayo Clinic,
01:29and this was followed by both a
01:31research fellowship and a clinical.
01:32Fellowship in gastroenterology,
01:34hepatology and nutrition at
01:36Virginia Commonwealth University.
01:38Finally,
01:38she did a fellowship in
01:40transplant hepatology at Virginia
01:42Commonwealth University,
01:43so she came to Yale in 2020 a year ago,
01:45and she is now assistant Professor
01:47of Medicine and the Translational
01:49Research director of the Metabolic
01:51Health and Weight Management Program.
01:53She is currently a principal
01:55investigator of a clinical trial to
01:57assess the feasibility of conducting
01:59future large clinical trials of
02:01digoxin and alcohol mediated.
02:02Immune inflammation of the liver.
02:04She's received multiple honors and
02:06awards for her scientific work and
02:08has been published in Hepatology,
02:09American Journal of Physiology Metabolism,
02:12Journal of Clinical gastroenterology,
02:13Cancer Research, and others.
02:15Additionally,
02:15she has served as a career mentor
02:17for numerous high school,
02:19undergraduate and graduate students
02:21in pursuing careers in medicine
02:23and Biological Sciences,
02:24so we're very pleased to have Doctor
02:26Bernini join us today to discuss
02:28an overview of the Yale Metabolic
02:30Health and Weight Management program.
02:32So welcome.
02:33Thank you, thank you so much
02:34for that introduction. Dr.
02:35Hilbert and thank you for
02:37the honor of addressing you
02:40guys at the seminar today.
02:42So this this is my disclosure.
02:45I served on the Advisory Board
02:48for Boehringer Elgen Ham in
02:51regards to the Nash trials.
02:57So I'm going to give you a little
02:59overview of obesity and then tell
03:01you a little bit about our metabolic
03:04health and weight management program.
03:07And feel free to put questions in
03:10the chart as we go along and I will
03:13leave some time at the end to answer
03:15any questions that you may have.
03:20So obesity as a chronic relaxing
03:25multifactorial neurobehavioural disease.
03:28That sort of starts with increase
03:31in body fat, which leads to adipose
03:35tissue deposition and dysfunction
03:38resulting in physical forces that
03:42cause adverse metabolic biochemical
03:46psychosocial health consequences.
03:49So I think the bottom line is,
03:52everything that sort of interconnects and
03:54goes into this chronic medical condition.
04:02So we use BMI body mass
04:06index for defining obesity.
04:09It is by no means a perfect
04:11measure as it doesn't take into
04:14account several characteristics,
04:15including muscle bones,
04:17but this is a good place to start to get
04:21a sense of how heavy an individual is.
04:24So essentially,
04:24BMI is weight in kilograms divided by
04:27square root of the height in meters.
04:30So based on this BMI,
04:31we can classify patients into
04:35different categories with underweight.
04:37Presenting a BMI less than 18.5.
04:40Normal BMI is between 18.5 and 24.9.
04:46Overweight I those with a
04:49BMI between 25 and 29.9.
04:52And by definition, obesity is a BMI over 30.
04:58And within the class agree
05:00of patients with obesity,
05:02we can further sub classify
05:05them based on severity of their
05:08obesity with class one,
05:10which is mild obesity being a BMI
05:13between 30 and 34.9 Class 2 moderate
05:17obesity BMI between 35 to 39.9
05:21and plus three or severe obesity,
05:24essentially being a BMI of 40 and over.
05:28So it is important to recognize
05:31these BMI categories as well as
05:33the overweight range as it impacts
05:36our choice of treatment that
05:38we discuss with the patient.
05:42So it is of no news to you that
05:45the prevalence of both overweight
05:48and obesity has been increasing.
05:51This graphs from a recent systematic review
05:54that looked over 70 looked at over 1700
05:58studies overtime which allowed for the
06:02assessment of prevalence of overweight
06:05and obesity between 1980 and 2012.
06:08So the chart on the left shows
06:11that between this time period,
06:14the prevalence of both overweight and obesity
06:17has been increasing with the blue lines,
06:21the blue dotted lines
06:23standing for male patients.
06:25So the lower one is in developing
06:28countries and the higher blue line
06:31is in developed countries and the
06:34red dotted line representing females
06:36again with the the lower one showing.
06:39The the prevalence and developing
06:41countries and the higher dotted red
06:44lines showing the prevalence in
06:46developed countries and as you can see,
06:48all those are trending up.
06:51Overtime. So on the right,
06:54the chart shows the prevalence
06:57of obesity overtime only.
06:59Obviously again,
07:00the one that left is both obesity
07:02and overweight,
07:03and the one on the right is just obesity.
07:08So looking a little more locally
07:11at the different states,
07:13essentially all the different states
07:15have been showing at trend in the
07:18prevalence of obesity between 1990 and 2018,
07:21and you see the solid black line which is
07:25sorry which is representing Connecticut.
07:27So even locally we have, you know,
07:31uptrend in this condition.
07:35So this is especially worrisome because
07:38we know that obesity is associated
07:41with disease and several other organs.
07:46Looking more specifically at potential
07:48diseases in the different organs,
07:50this is by no means a comprehensive list,
07:52but you can appreciate all the
07:55various health conditions that
07:57have been associated with obesity.
08:04So although BMI is not a
08:06perfect measure of health,
08:07there is very strong evidence that a
08:09higher BMI is associated with higher
08:12mortality as shown in this meta analysis,
08:15the lifespan of patients with BMI between
08:1940 and 45 is decreased by over 6 1/2
08:24years compared to those with normal BMI.
08:27And the decrease or the the the the the
08:32life loss goes off progressively as you.
08:36The BMI increases such that by the
08:41time patients between BMI of 55 and 60.
08:45Their average life years lost
08:47is almost 14 years compared to
08:50someone who has a normal BMI.
08:53So it's very important that patients
08:57appreciate this impact on their life span
09:00because it's not so much the doctor hopping
09:03on getting healthy and losing weight,
09:05but it actually has relevance in
09:07terms of how long they may live,
09:09how much time they spend
09:11with family and friends.
09:12So that is something to
09:14emphasize to the patients.
09:19So one thing we can do as physicians
09:22is to review our patients
09:24medication from time to time.
09:26Certainly there are things that
09:29we can address which you know,
09:31sort of the patient has to
09:33take ownership of that,
09:34but then there are other things that
09:36we can take ownership of as physicians.
09:39For instance, we know that there
09:42are a number of medications that
09:45are associated with obesity.
09:48Data collected between 2013 and
09:502016 showed that almost a quarter of
09:53US adults were all on one or more
09:57weight gain producing medications.
10:00The most common category are
10:02psychotropic medications.
10:03In some cases,
10:04that is the best medication for the
10:06patient and we are unable to change it.
10:09However, in certain cases, for instance.
10:13And in patients on blood pressure
10:16medications,
10:17it is well known that some of them,
10:19like the bitter blockers,
10:20are associated with more weight gain.
10:22For instance, compared to the the carbs.
10:26So those are things that we can do and
10:29are within our our power to do such things.
10:36So. We know that in patients with obesity,
10:44utilization of pharmacotherapy
10:45is very low in these patients.
10:49So the study you show that that is shown
10:52here shows patients with obesity on
10:56the left side compared to those with
10:59type 2 diabetes on the right side.
11:01So over 90% of patients who have
11:04a diagnosis of type 2 diabetes
11:07are treated with medications as
11:10opposed to the case with obesity,
11:13where less than 5% of these patients
11:16who actually have treatment
11:18indicated on medication.
11:19So there's a lot of room to go.
11:22There's a lot of improvement
11:23that can go in this area.
11:29So further looking at prescription of
11:32medications for patients with obesity
11:34on the left side with the bar graphs,
11:37you get a sense of which patients
11:39are being prescribed with last
11:41medications by their physicians.
11:43So as you go progressively up and wait,
11:45which is not a surprise,
11:46there is slightly increased.
11:50Prescription of medications,
11:52but still even in patients who have
11:56a BMI over 40 only about 3 1/2% on
11:59appropriate anti obesity medications.
12:02Actually on anti obesity medications period.
12:05So again there's a lot of room to
12:07improve in this area and looking
12:09at the medications that are
12:12actually being prescribed.
12:13On the right side, the blue,
12:15the solid blue line shows Phantom
12:18and so overall over 75% of
12:21medications that were prescribed
12:23in in this study up to 2015,
12:27where for fentiman.
12:30So again a lot of education is needed
12:32is a lot of room to improve here.
12:39So the mission of the Yale Metabolic
12:41Health and Weight Management program
12:43is to provide all weight management
12:46options in one place utilizing a
12:49comprehensive and multidisciplinary
12:51approach for all patients who are
12:54above a healthy weight. Sorry.
12:58So here you see the list of
13:03providers that we have in the group.
13:05We have medical providers.
13:08Currently there are three MD's
13:11and a nurse practitioner,
13:13and we advise patients and guide
13:17them through lifestyle changes.
13:19We offer a meal replacement program
13:22which our dietitian is in charge of and
13:25we prescribe anti obesity medications.
13:27We also recently hired.
13:28A psychologist who is in the process
13:30of being credentialed at this point,
13:32so that will be that's a great
13:35addition to the group.
13:37We have an endoscopist who offers
13:40endoscopic weight loss methods and
13:42we work very closely with bariatric
13:45surgery and we refer patients
13:47back and forth between our teams.
13:54So just quickly getting a
13:55sense of higher numbers.
13:56I would say that this program has
13:58been in place for about 6 years now,
14:01and as you can see,
14:02there's a steady increase in the
14:05number of encounters such that in
14:07the last fiscal year 2021 we have,
14:10we had over 8000 encounters
14:13among the providers.
14:20So when we see patients in clinic,
14:22we screen for other for
14:25weight related complications.
14:26As I mentioned in my earlier slide,
14:29obesity is a multifactorial disease
14:32and increases their risk of
14:34disease and several other organs,
14:36and the hope is that we will
14:39catch other comorbidities and
14:41other complications of obesity
14:44in these patients and refer them
14:47to the appropriate provider.
14:49Such that those diseases can
14:52also be attended to.
14:58So our treatment at the metabolic
15:01health and weight Management Center is
15:04a stepwise and combinatorial approach,
15:07so we typically start with self
15:10directed lifestyle changes.
15:11Educating the patient on the impact
15:15of their disease and how they can
15:18modify their lifestyle such that the
15:21the risk of disease progression is
15:24mitigated and things are reversed.
15:29And we also offer professional guided
15:31lifestyle change in terms of referring to the
15:35dietitian and referrals to psychologists.
15:38Patients are then offer pharmacotherapy
15:41so so one thing to say is that a lot of
15:44times by the time the patient has seen us,
15:47they've gone through several cycles
15:48and iterations of the self directed
15:51lifestyle change and the professional
15:53guided lifestyle change.
15:54So sometimes you just have to jump
15:56into the pharmacotherapy because by
15:58that time the patient is frustrated
16:00and nothing they've done has worked.
16:04So I mentioned earlier on to pay
16:07attention to the different BMI categories
16:09because that impacted the choices that
16:12may be available for the patient.
16:14Weight loss surgery is next on
16:16this permit and that is indicated
16:19for those who have severe obesity.
16:21So by definition BMI of 40 and over
16:24those patients will be candidates
16:27for weight loss surgery.
16:29You know whether insurance actually covers
16:31it or whether after they are very expensive.
16:34Evaluation they are found to be
16:36candidates is a different issue but
16:39but but just theoretically,
16:40those who are candidates for
16:42weight loss surgery.
16:44Those with a BMI of 40 and over.
16:47Or a BMI between 35 and 40,
16:51plus complications of being heavy.
16:53So diabetes, high blood pressure,
16:56high cholesterol, fatty liver.
16:57Those are some of the common
16:59complications of being heavy,
17:00so if a patient has a BMI between 35
17:03and 40 plus any of those complications,
17:05they also would be a candidate
17:08for weight loss surgery.
17:11By definition,
17:12candidates for obesity
17:14pharmacotherapy are those with BMI
17:18over 30 or BMI between 27 and 30,
17:22plus any of those weight
17:26related complications.
17:27So again, going back to this parameter again,
17:31sometimes.
17:31Unfortunately patients regain
17:34weight after surgery and so a lot
17:38of times we also see those patients
17:40to help guide us to what we can
17:43do to sort of lose weight after
17:46surgery and also manage any surgical
17:48complications that they may have.
17:55So we know that there are a host
17:57of diets and this slide actually
17:59doesn't mention all of them.
18:01Sometimes patients ask Doctor Vinny
18:04what diet would you recommend?
18:06What is the best diet for me?
18:07I think at the end of the day it
18:10depends on what other comorbidities
18:11they have and you can see on the
18:14right side the health effects,
18:15potential health effects
18:17of these different diets.
18:20For instance,
18:20the dash diet is good for
18:22decreasing blood pressure,
18:24so if this is something that the.
18:25Patient has had issues with that.
18:27Maybe a diet that they want to try.
18:31But at the end of the day,
18:32I tell the patient look the diet
18:35that is best for losing weight is 1.
18:37That is low calorie and you
18:39can sustain for a long time.
18:42That is, that is it.
18:43So any of these diet potentially
18:45is OK for you as long as it
18:49creates a calorie deficit.
18:50And it's not something that you
18:52get off off in a month or two,
18:55because this is going to be
18:58a lifestyle lifetime change.
18:59So you need to pick something
19:01that is reasonable and that you
19:02can sustain for the long term.
19:04Now it's different if you're
19:06doing a diet for a special diet
19:08for a couple of months,
19:10jumpstart your weight loss journey.
19:11That's a different.
19:12Issue,
19:13but if you're looking for something
19:15that you want to adopt for your
19:17lifestyle and for lifetime,
19:18potentially any of these may work,
19:20as long as it is low calorie
19:22and you can stick with it.
19:26So in terms of the knee replacement
19:29program that we offer through the
19:32program, it is called optifast.
19:34Optifast is a medically monitored.
19:38Supervised diet that occurs over
19:41the course of 18 weeks actually.
19:45So that is an error.
19:46It's it's a 18 week period of time with
19:49the 1st 12 weeks being the active or
19:52the intensive phase where everything
19:54that patients are eating is provided
19:56through up to fast so they have soups,
19:59shakes, and bars that patients order
20:01through up the fast and get delivered
20:04directly to their home and then the
20:06remaining six weeks of the 18 weeks.
20:08Is a hybrid phase where patients are
20:11starting to add in self prepared meals.
20:14Of course, with guidance for the program as
20:16to what it is that they should be eating.
20:19It's a low calorie program and the the
20:21the intent is to help patients jumpstart
20:24their weight loss program and also
20:27to get some comprehensive lifestyle
20:30education to help them be successful
20:32in keeping the weight off long term.
20:35So throughout the Optifast program,
20:37weekly classes are offered and now
20:39those are being held virtually and so
20:42patients have a chance to meet with a
20:44dietitian and also with other patients
20:47on optifast in the group setting.
20:49There are a number of handouts and
20:51a number of educational materials
20:53that they get,
20:54and some of these are shown
20:56here on this slide.
21:03So in terms of anti obesity
21:06medications I mentioned previously,
21:08the criteria which is a BMI over 27
21:11plus comorbidities that are associated
21:13with being heavy or in the absence
21:17of those comorbidities than anti
21:19obesity medications are indicated.
21:22For patients with a BMI over 3.
21:30So just going through some of these
21:33medications that are typically
21:35used fentiman is one of the
21:38oldest medications that has been
21:41around for weight management.
21:43It is involved in catecholamine
21:45release from the hypothalamus,
21:48and suppresses appetite.
21:49It was approved by the FDA in 1959.
21:54Definitely at that time the amount
21:58of data and knowledge available
22:01currently regarding obesity
22:02was not available at that time.
22:05So fentiman in 1959 was approved
22:07by the FDA to use for a maximum
22:11duration of three months,
22:13and we know that that is not enough time
22:16to get a handle on someone who is heavy,
22:21so we don't stick to the
22:23three month rule anymore.
22:24I still see some providers who do that,
22:27but in general practice that is not the case.
22:31We essentially use it for as long
22:33as the patient can tolerate as
22:35long as there are no side effects,
22:37the patient just stays on contentment
22:39because what happens when they
22:41stop fentiman is that they're
22:42going to gain the weight back.
22:44So the average weight loss for Phantom
22:48in over one year period is lost 6%.
22:51But again that is average and I've
22:53seen definitely seen patients as so
22:55patient recently who lost about 15% of
22:57her baseline weight on phentramin which
22:59she's been kicking for about six months now.
23:02We typically those between 8:00
23:05and 37.5 milligrams daily,
23:07and the common side effects are palpitations,
23:11increased blood pressure.
23:13Sometimes it interferes with their.
23:15Also, they may get constipated.
23:18A few patients complain of dizziness,
23:21dry mouth, insomnia,
23:23and irritability.
23:25So for something like the GI side effects,
23:28that can be very well addressed by putting
23:30the patient on something like miralax
23:32or stool softener to help with that.
23:35So sort of depends on what other side
23:38effects or complications you may be
23:39having in regards to whether to continue
23:42it or to look for something else.
23:47So in terms of contradictions and
23:51warnings here you see listed on the
23:53left side with patients who have
23:56underlying cardiovascular disease,
23:57you want to be a little more cautious
24:00in terms of putting them on fentiman.
24:03If their blood pressure is uncontrolled,
24:05you don't want to put them on huntemann,
24:06because like I said, one of the
24:08side effects is high blood pressure.
24:10If they already agitated and anxious,
24:13phantom is going to make them more jittery,
24:15so you don't want to do that.
24:17Possible history of drug use.
24:19I would say that it's a
24:20relative contract kacian.
24:21If the patient had drug use,
24:23you know long time ago and they've been
24:25off the drugs and they are doing well.
24:28Sentiment could still be used in that
24:31setting and then you see that the
24:34other contraindications listed here.
24:36And then on the right side some
24:38things for monitoring and and I
24:41pretty much mentioned those already.
24:45So Fentiman can also be combined with
24:49topiramate. I think I'm missing a slide.
24:54Sorry for answering,
24:55could be combined with so permit
24:57and that is sold as a QC Mia that
25:00was approved in 2012 so we talked
25:04about fentanyl progressively,
25:05which is, uh,
25:08not releasing agent and topiramate
25:11is a double receptor modulator so in
25:15combination with topiramate you can get
25:18away with using lower doses of fentanyl.
25:22So, uh,
25:23in the trials with fundamental permit
25:26combination and also in real life,
25:29the combination gives you a a
25:31bit more weight loss than if you
25:33were to use a huntemann alone.
25:35So you're going up from an average of
25:37about 6% weight loss to more in the
25:41order of eight to 10% weight loss.
25:45When we start to see Mia or the
25:47fundamental premier combination,
25:49we start at the lower dose and go
25:51up with time in order to minimize
25:54the side effects.
25:56So we typically start with the
25:583.75 slash 23 milligrams daily
26:01for the first two weeks.
26:04If no adverse side effects, then you can.
26:07You can use a double of that dose
26:10again once a day if a patient
26:13is losing significant weight.
26:15Sorry with that that up titration
26:18to some .5 and 46 you can just
26:21have them continue on that dose.
26:24However,
26:25if the the weight loss is not as
26:29expected and I'll go through what
26:31we expect in the minute or if at
26:33some point they start to plateau,
26:35then you may want to go up to
26:38the next level of dosing.
26:41And then further up to the front doors,
26:43depending on whether more
26:44weight loss effect is needed.
26:47So typically when we start
26:48a weight loss medication,
26:50the UM,
26:51the goal is 5% or more.
26:57Body weight loss in three months.
27:01So you're starting a patient
27:04on QC Mia for instance,
27:06and they're weighing 200 pounds at baseline,
27:10so we want to see them in three months,
27:13and in those three months,
27:14the recommendation is that they would
27:16lose 1010 pounds of £200 at baseline.
27:19You want them to lose £10 or more
27:22within the next three months.
27:24Now if you see them in three months
27:26and they've lost, you know £8.00.
27:29You know 7-8 pounds,
27:30they're closer to 5%.
27:32Alright, let's continue the same and give
27:34us some more time and see how things go.
27:36But if they've only lost one
27:38or 2% in those three months,
27:40in the absence of anything else that
27:42they can still put their finger on,
27:43then maybe that medication is
27:45not working for them and you may
27:48want to look at other options.
27:50Come on side effects of the
27:52combination are listed here.
27:53As you can see,
27:55including headaches, paresthesias,
27:57dizziness and others.
28:01Now you want to make sure that the patient
28:04is not pregnant and is not breastfeeding.
28:08As you know to permit is actually
28:11something that is a is a threat to.
28:14It's a teratogen.
28:15So you want to make sure that
28:17the patient who's been put on
28:20topiramate is on birth control.
28:22So the guidelines recommend
28:23that you test for you.
28:25Do a pregnancy test before you
28:28prescribe topiramate and then
28:29the patient has to be doing.
28:31Home pregnancy test.
28:32Once a month for the duration
28:35of treatment with two pyramid.
28:37So that's something that you really
28:39wanted to emphasize for the patient
28:41and also actually in regards the
28:43other weight loss medications as well.
28:45You wanna tell them that.
28:46So so in general you just don't
28:47want to be getting pregnant on any
28:49of these weight loss medications,
28:50so only one that we use off
28:53label for weight loss.
28:54Metformin that one the
28:56patient can get pregnant on,
28:58but anything else you want to make
29:00sure that they are on birth control.
29:06So the other weight loss medication
29:09that's approved is Contrave, which is a
29:11combination of naltrexone and will pro P.
29:13And we know that we use bupropion for
29:17depression and also for smoking cessation,
29:21so this is actually a good choice for
29:24patients who may have those comorbidities
29:26in addition to being being heavy.
29:29So now Trackson is an opioid antagonist,
29:33so you don't want to put a
29:35patient who is on chronic.
29:36Opioids are now check some because
29:38they're going to go into withdrawal.
29:41And the Pro plan is a document and
29:44and no preference reuptake inhibitor.
29:47The average weight loss is about four
29:50to five or 6% on these patients,
29:53just like you.
29:55See me a you want to titrate,
29:57can't rave from the low start,
30:00start them on the lowest dose and
30:02titrate up if no adverse side effects.
30:04So typically 1 tablet daily in the
30:06morning for the first week and then one
30:09tablet twice a day for the second week.
30:12And then you keep going up
30:13until the maximum dose again.
30:15In the absence of any side effects,
30:17if they were to experience some side
30:20effects during this up titration depends
30:22on the severity of the side effect
30:24and what what the side effect it is,
30:26because you may either have to stop it,
30:28or you may have the patient go back
30:31down to those they were on which
30:33did not produce a side effects.
30:36So sort of individual individualized to
30:38the patient, and what else is going on,
30:41and you see the common side effects.
30:43One thing you would notice with most of
30:45these weight loss medications is that
30:46one one side effect that runs through
30:48pretty much all of them is a GI side effects,
30:51nausea,
30:51sometimes vomiting,
30:52and I tell the patient that this may
30:55not necessarily be a bad thing for
30:56weight loss because if you're taking the
30:59medication and you're feeling nauseous,
31:01it's going to dissuade you from eating.
31:03So again,
31:04it depends on how severe it is.
31:06'cause sometimes it's so severe
31:08that they can't continue,
31:09but if it's a mild nausha,
31:10maybe that's not necessarily a bad thing.
31:15And again, contraindications
31:16to the use of Contrave.
31:19As you can see here,
31:20listed pregnancy and breastfeeding
31:22again listed uncontrolled high blood
31:25pressure and other contraindications
31:26you don't want to use them with the
31:29last point in the contraindication.
31:31You really don't want to put patient someone
31:33who has seizures on this combination,
31:36especially because we Propecia
31:38lowest the seizure threshold.
31:41So you want to be careful about that.
31:47So the next medication is always
31:49start and I'll say this is one of the
31:52least used weight loss medications
31:54Orlistat has been around for a while.
31:56It is a light peace inhibitor and it gives
32:00you an average weight loss of about 3%.
32:03So you know, I think the side
32:06effects is usually unbearable
32:08for most patients you know,
32:12have diarrhea and a lot of
32:15bloating and incontinence,
32:17so a lot of patients find
32:19that they cannot tolerate it.
32:21It's available over the counter
32:23in a lower dose of 60 milligram,
32:26three times a day,
32:28which the patient will take before meals
32:30in the prescription dose it's available.
32:33Is 120 milligrams three times
32:36a day again before meals?
32:42Pregnancy breastfeeding against the
32:44contradiction of safety concern you may
32:46not want to use this medication if the
32:49patient already has malabsorption syndrome,
32:51because all of that again,
32:53as I said, it's a life is inhibitor,
32:55and it will worsen their malabsorption.
32:58It is associated with calcium
33:02oxalate nephrolithiasis,
33:03so you want to avoid in patients who
33:07have had kidney stones in the past.
33:10Again, on the right side with the
33:12monitoring you want to monitor
33:14for kidney stones for gallstones.
33:21So GLP one agonist, liraglutide,
33:26is one of the newer kids on the
33:28block and actually even more new with
33:30some appetite which is going to be
33:32my next few slides so they travel.
33:35Tide is available for weight loss at
33:38Saxenda and it was approved in 2014.
33:41It gives an average weight loss
33:44of about 6% in these patients.
33:47Again, you want to titrate up from
33:49the lowest dose of zero point.
33:51Text, milligram subcutaneous once a day,
33:54so this is a once a day injection
33:57and after every week you can go
34:00up on the dose to a maximum dose
34:04of three milligram daily,
34:06again watching for any side
34:09effects or adverse events that may
34:12occur during this up titration.
34:14The most common side effect is known Shivam.
34:16Eating it can interfere with the bowel,
34:19so some patients get diarrhea
34:21and others get Constipation.
34:22I tell them when I'm prescribing it.
34:24I don't know what you're gonna get.
34:25I don't know whether you're gonna be
34:27constipated or you have diarrhea,
34:28so we will start it and see how things go.
34:30And depending on which side effect you get,
34:33we will deal with it.
34:36In very rare cases it can
34:38cause increased heart rate,
34:39but this is not very common at all,
34:42but this is good for the patient
34:45to know and and if they have it,
34:47typically it goes away
34:49after the first few doses.
34:54Again, contraindications pregnancy has
34:56always been there and it's still there.
34:59You don't want to use it in patients
35:02who have a personal or family
35:05history of medullary thyroid cancer.
35:07In the MEN 2 syndrome,
35:09so you specifically want to ask the
35:11patient if they have heard of this
35:14term or if they know anybody in their
35:17family that has Missouri thyroid cancer.
35:19You also want to avoid it in pancreatitis
35:22because it increases the risk of
35:25pancreatitis slightly so so weight loss,
35:27just weight loss by itself
35:29increases the risk of pancreatitis.
35:30And then when you add on a job you want,
35:32I'm gonna say the the the the risk
35:35goes up by about one or two percentage.
35:37Points, so that's something that
35:38the patient should be aware of.
35:40Now if they had hundred titles several
35:42decades ago, and they know the culprit,
35:45maybe they were drinking at that time,
35:47or they had a gallstone.
35:48And since then, they've stopped drinking,
35:51or they've had a closest ectomy,
35:52then you may want, you know,
35:54you might go ahead and and and
35:56put them on liraglutide.
35:58But if it's like a recurrence,
35:59bronchitis and it was recent,
36:01you really don't want to
36:03put the patient on GLP.
36:04One not going to.
36:07So gastroparesis is a I'd say,
36:11a relative contraindication.
36:12There's data out there that GLP
36:15one agonist worsen races just
36:17by nature of the way they work,
36:19and so I would say this is a relative
36:22contraindication if the patient
36:23had to be on it and they have a
36:25history of cash places you want to
36:27have them monitor for whether they
36:29have worsening of their symptoms
36:30when they start the medication,
36:32and if they do,
36:33then you may want to stop the medication.
36:38So some angle tide is the newest kid
36:41on the block and was approved as we go
36:44V for weight loss in June this year.
36:46So this is all very exciting before
36:48the FDA approves the magnetite
36:50as we go before weight loss,
36:52we were using it as MPEG for weight
36:54loss because it is the most effective
36:56out of all the weight loss medications.
36:59So it was really exciting when
37:01they finally approved it as we
37:03go before weight loss.
37:04The difference between ozempic
37:06and we go V is that you can go up.
37:09Two dose of 2.4 milligram with whereas with
37:13zampach you can only go up to 1 milligram.
37:17So of course in the first
37:18few months after we go,
37:20we was approved,
37:21there was a a countrywide shortage,
37:23but I think things are improved now
37:25and so we are able to get we go before
37:28our patients and and even better
37:30that the Yale Health plan covers.
37:33We go and liraglutide which is which
37:36is great because one limitation
37:39to prescribing these weight loss
37:42medications is insurance coverage.
37:45So the weight loss percentage for
37:49some appetite is about 15 percent 15%.
37:53So again,
37:54that is way higher than we've seen
37:56with any of these other weight loss
37:58medications that I've been talking about.
38:01Again,
38:01at the the,
38:02just like other medications you want.
38:04So if you've noticed a trend,
38:06the trend is that you start slow and
38:07you go up with time and the other
38:10other thing that will stick out
38:11from this talk is about pregnancy.
38:13I think I think those two are
38:14standing out so far.
38:15So with Rigo V you start at 0.25 milligram.
38:19This is a weekly dose.
38:21It's not a daily the the liraglutide
38:24which is also a GLP one agonist was
38:28daily but semaglutide is weekly so you start.
38:320.25 subq weekly.
38:33And actually after every four weeks,
38:35then you go up to the next dose
38:37and you can go up to a maximum
38:39of 2.4 milligram weekly.
38:42Yeah,
38:43side effects.
38:43Like I mentioned you want to watch
38:45out for them and treat them if it
38:47happened again the risk will high.
38:48These are all very similar between
38:50Samagra tide and the regulated
38:51because they're essentially the
38:52same medication the same category.
38:56Contraindications, pregnancy,
38:57breastfeeding that should process
39:00against same as the regular type.
39:07So Planetis was recently recently approved.
39:10It is a superabsorbent hydrogel
39:13which was developed for treatment
39:17of overweight and obesity,
39:18so it's indicated for patients
39:21who have a BMI over 25.
39:23It's actually made from some
39:26naturally derived building cellulose.
39:30Blocks which crosslink with
39:32citric acid and what happens,
39:35is that the patient drinks.
39:37It is a capsule that the patient
39:40drinks with water before a meal,
39:42and once the patient starts eating and
39:44with that water that they drink with it,
39:47the gels rapidly absorb water and swell.
39:51So the swelling in the stomach and
39:53they swell in this one test in and
39:56they create that feeling of fullness
39:58such that the patient feels situated.
40:00Early and then reduces
40:02how much they're eating,
40:03so that is essentially the main
40:05method through which this works,
40:07so that is an option as well,
40:10and it has been shown to have slightly
40:13improved weight loss compared to placebo.
40:18So I've mentioned a number
40:20of weight loss medications.
40:21So how do you pick between
40:24these different options?
40:25The first question we ask is,
40:26is there any contraindication?
40:30So for instance, I mentioned pancreatitis.
40:33I mentioned the family history of
40:35medullary thyroid cancer that you want
40:37to look up for in these patients.
40:40Glaucoma is a contraindication to
40:42using can't rave and QC Mia, so again,
40:45those contraindications give you a
40:48sense of which medication may not
40:50be a good option for the patient.
40:52The other question you ask is,
40:54are there some drug drug interactions?
40:57So for instance.
41:00Something like kasenia or country
41:02which have the psychotropic effects
41:05can interfere with other psychotropic
41:07medication that the patient may
41:09be on for depression and anxiety.
41:10So you want to look up for that.
41:13And then is there another health condition
41:15that can be addressed with the drug?
41:17So if the patient has a,
41:22you know,
41:22smokes and is trying to stop smoking,
41:24then maybe a combination that includes
41:27Wellbutrin may be a good option for them.
41:29If the patient has diabetes or prediabetes
41:32a joke in one arguments will be a
41:35perfect option in that situation.
41:37If a patient has headache,
41:39then to permit will be a good
41:41choice because to permit as a
41:43treatment for headaches as well,
41:44so that is the other consideration
41:46that goes into the choice of
41:48weight loss medication and then
41:50finally does insurance cover?
41:51Maybe I should put that first
41:54because unfortunately when insurance
41:55doesn't cover the medication,
41:57it really limits what we can use.
42:00GLP one are going is if it's
42:02not covered by insurance.
42:03It costs about 1000 to $2000 a
42:05month and I don't recommend that
42:07for even my richest patient.
42:09So insurance considerations are
42:11a big deal for the choice of
42:14antibiotic medication.
42:18And then patients ask,
42:19how long will I use this for the answer
42:22is as long as possible as long as
42:25there are no side effects as long as
42:28nothing comes out in literature that
42:30says we can't use this medication anymore.
42:33For instance low clustering or BELVIQ
42:34was one of the approved weight loss
42:36medications until a few years ago
42:38when there was some data suggesting
42:40the increased risk for GI cancers.
42:42So we spoke to the patients and
42:44everyone who was taking it stopped.
42:46So as long as nothing comes out.
42:49Review that says we can't use this
42:50medication or has some side effect
42:52that we didn't know about or as long
42:54as you don't have any side effects
42:55or anything else developing that we
42:57can attribute to this medication,
42:59we need to be or as long as
43:01you don't get pregnant,
43:02we need to plan to continue this
43:05medication because obesity is a
43:07chronic medical condition and
43:08when you stop the medication you
43:11probably will gain the weight back.
43:15So this chart just sort of gives you
43:19a quick comparison of a different
43:22medications that I I mentioned with all
43:24this that create giving us the least
43:27weight loss over the course of the year.
43:31With liraglutide is the next that
43:33gives us about a little more
43:35than 4% and then not red zone,
43:38broken combination or country
43:40gives us about 5% weight loss.
43:44Fentiman about getting to 6% sentiment
43:49combined with the permit or QC Mia
43:51going to move the order of around
43:537 to 8% up to 10% and then the
43:56new kid on the block Samagra tide
43:58we go that is off the charts.
44:01So as I mentioned above, 15%.
44:06So here the metabolic weight management.
44:09As center we also you know trying
44:12to push the envelope to see in
44:15patients who historically are not.
44:17You know, don't have these
44:19medication approved but needed.
44:21Can we see what may be an
44:23option in these medications?
44:26And a group that is being dear to my heart?
44:29Patients who have advanced liver
44:32disease and so we looked at our patient
44:35population and ask the question.
44:37That for patients who are on GLP 1
44:39agonist and have a diagnosis of cirrhosis,
44:42what is the effectiveness of these?
44:48With that of the GLP 1 agonist in
44:50producing weight loss in these patients,
44:52and are there any other side effects
44:55that are different from the non cirrhotic
44:59patients who are on GLP one agonist?
45:02So this was a a retrospective case
45:04series of eight patients that I saw
45:07in our panel that have a concomitant
45:10diagnosis of cirrhosis and who are on GLP.
45:131 agonist,
45:13and you can see the different medications
45:16that they're on the regular side.
45:18Dulaglutide and their baseline
45:23BMI ranged anywhere from 30 to 53,
45:28but they were all companies that
45:30are cirrhosis and so there are.
45:31Males were relatively low between
45:336:00 and 9:00.
45:37So on this graph here you see for
45:40each patient in terms of their
45:43baseline weight or starting at 100%
45:46and then over time looking to see how
45:50their weight loss trajectory goes.
45:53And essentially you know some
45:54patients have gained a little
45:56bit of weight in the beginning,
45:58but everyone seems to be coming down
46:01and so right now we have a number of
46:03patients who we have did it up till
46:0512 months and and some on the way.
46:07So this results are promising and
46:11the average weight loss within
46:14the first three months was about.
46:17Three or four pounds,
46:20and progressively up until around
46:238 to £10 over this time period.
46:27So one patient among all the eight
46:30that we looked at had an adverse
46:34event of vomiting, and.
46:37Episodes of Nausha,
46:39but these resolved fairly quickly
46:41and did not lead to discontinuation
46:43of the medication,
46:44so they are pretty much all doing well on it.
46:52So in terms of endoscopic weight loss,
46:55I mentioned that we do have and thus
46:58advanced and the scope base who can offer
47:00some of the procedures that are being done
47:03in the realm of endoscopic weight loss.
47:05Here from the figures, a little small.
47:08I apologize, but ABC D and essentially
47:12different introduction balloon systems,
47:15including the Uber balloon or
47:17balloon balloons, past balloon at
47:20least balloon and then in figure.
47:23If you see the endoscopic
47:26sleeve gastroplasty,
47:28which we can do here at Yale, Dr.
47:32Muniraj is doing that in Gee,
47:35you see a figure of the post procedure
47:39essentially doing application
47:41in the funders to reduce gastric
47:44accommodation when the patient is eating.
47:46This is currently undergoing
47:48clinical trials and they just
47:50recently expanded the pilot study.
47:52So that you know this is something
47:54that's ongoing right now,
47:55and it's not currently approved
47:56as a treatment,
47:57but appears to be promising age and age,
48:00you see the aspiration therapy,
48:02which allows for the removal of about 25
48:05to 30% of ingested calories approximately
48:0830 minutes after ingesting a meal.
48:11So these are potentially some available
48:14endoscopic weight loss techniques.
48:18And as I mentioned,
48:19we work very closely with the
48:21surgeons and refer patients who
48:23we think would be appropriate.
48:25Again, going back to the earlier slides,
48:26like I mentioned,
48:28patients who are candidates for surgery
48:30are those with a BMI over 40 and over,
48:33or a BMI within 35 and 40.
48:35Plus complications are very heavy.
48:38So in this chart here you see the lowest.
48:42So this on the left side you're
48:44looking at total weight loss after
48:46surgery and on the on the X axis.
48:48I'm just saying time, so the lowest.
48:53This line here is those who have
48:56undergone the ruin Y gastric bypass,
48:58and they actually lose the most weight.
49:01So in the order of around 35% weight
49:05loss and then the middle line is
49:08those who have undergone sleeve
49:10gastrectomy losing about you know 2025%.
49:16In starting weight and then the highest
49:19one is those who have undergone the
49:22adjustable gastric banding and this is
49:25actually falling out of favor currently
49:28in regards to the surgical approaches
49:30that we use for for weight management.
49:33So the adjustable gastric band is really
49:37falling out of favor and the sleep
49:40gastrectomy is the one that is really
49:42being adopted at the most so so surgery.
49:44Essentially this is just
49:45show that surgery is.
49:47Effective for weight loss and
49:48effective in helping to reverse some
49:51of those complications that we see
49:53in patients who are heavy prior to
49:55undergoing their weight loss surgery.
50:00We recently developed a
50:03collaboration with you all,
50:05and this allows Fellows to rotate
50:07with us in our weight management
50:09clinic and the goal of the rotation
50:11for the fellows is to sort of get a
50:14sense of the problem of obesity and
50:16type of treatment that we offer.
50:18To understand the rationale for
50:20charging patients to surgical
50:21versus medical weight loss.
50:23To get a sense or feel for a
50:25meal replacement program and to
50:27get some first-hand exposure to
50:29how we make decisions.
50:31In regards to the anti obesity
50:34medication to use for patients.
50:39So I'm going to end with A1 slide summary.
50:42I've told you that obesity is a chronic,
50:44relapsing, and multifactorial disease that
50:47results in adverse metabolic, biochemical,
50:50and psychosocial health consequences.
50:53The prevalence of obesity
50:55unfortunately continues to rise both
50:57in Connecticut and the US and globally,
51:00so we really need to start to
51:03develop Ways and Means to try and
51:06get this problem under control.
51:08The lifespan of patients with obesity
51:11is decreased by up to 14 years.
51:13I showed you that tableware in patients
51:15who are in the severely obese category,
51:18their lifespan is decreased by
51:20up to 14 years compared to those
51:23who have a normal BMI.
51:25Our program provides a stepwise and
51:29combinatorial approach to addressing
51:31obesity and medications for obesity.
51:34Can help patients achieve lasting
51:37obesity control overtime.
51:40And we are open and willing to collaborate
51:43on clinical and research endeavors.
51:46Thank you for attention and
51:48I'll take any questions.
51:50Thank you Doctor Mini that was excellent.
51:52Really. A wonderful, wonderful overview.
51:55I certainly learned a lot about the
51:57complexity of using these medications
51:58and you actually answered a lot of
52:00my questions even before we started.
52:02I'm interested in that in the the
52:05meal replacement program, you know?
52:07I mean, obviously insurance is
52:08a big factor in all of this.
52:09And let's say patients do come in,
52:11they don't feel they're really
52:12ready for surgery.
52:12They're not really ready for medication yet.
52:14Not sure interested in meal replacement?
52:17Is that something insurance covers
52:18or I would imagine 16 weeks of meal
52:20replacement would be very expensive.
52:22So what what is the cost there for patients?
52:25Question, doctor, hilbert? Yes,
52:27so unfortunately insurance doesn't cover.
52:29We always encourage patients to reach
52:30out to the insurance and call them and
52:32tell them what they're trying to do.
52:34I think there's been a situation
52:36where one or two patients actually
52:38got some relief from insurance.
52:39It was they didn't recover the whole thing,
52:41but they were able to get some partial,
52:43you know, coverage from insurance.
52:45So the average cost is about
52:48160 to $200 a week.
52:51So you're looking at Thorpe Park round.
52:53$800 a month for the first three months,
52:57during which everything they're
52:58eating is from up to fast,
53:00so $800 for three months and then the
53:04remaining six weeks is a hybrid phase,
53:06so that definitely reduces
53:08their cost with up to fast.
53:10What they're paying for is their meals,
53:13so they're not paying really for being in
53:14the program they are paying for their meals,
53:16so they they they order their meals,
53:18they pay for their meals,
53:20and the meals get shipped to their home.
53:21So that is where the money is going.
53:24And how much they spend on the meal depends
53:26on how many products they are they need.
53:29So depending on their starting BMI they
53:32need anywhere between 4:00 and typically
53:34seven small meals spaced through the day,
53:37and the more meals you need,
53:38the higher the cost.
53:39But ballpark,
53:40around $800 a month for three months and
53:42then less than that for them in six weeks.
53:46Thank you alright.
53:47I'm going to see if there's any questions.
53:50I'm interested. I was interested
53:51also in your point that patients
53:53could take these medications.
53:54You know, for as long as necessary.
53:56And I mean you mentioned fenter mean
53:58was one of the early ones in your how
54:01long have like patients within the
54:03practice give me some sense of a range?
54:05'cause a lot of these medications you are
54:06new and so they have been out that long.
54:08People have taken that one,
54:09but how long do patients like our
54:11patients on these medications?
54:1210 years, 15 years,
54:1320 years already we're talking five years,
54:15so that's. How is the one who's been doing
54:18this longest and then Doctor Vienna joined?
54:20I know certainly they have had patients on
54:22it for as long as they've been doing this,
54:25which I would say maybe the maximum
54:27would be 5 years from our experience,
54:30but suddenly it is. The is the same at
54:33other places that are doing this. You know.
54:35You just keep the patients on it. Yeah?
54:38So again, in the absence of any adverse
54:41side effects and and for the the biggest
54:44concern with sentiment would be cardiac.
54:46Right?
54:48If you called friend Fenn was sort of like,
54:50you know older version,
54:52but combine something else and
54:54you had cardiac side effects so.
54:56But so you have to pick the
54:59population you know with that in mind,
55:01you don't want to be people who have,
55:03you know, those cardiac issues.
55:04To be on phentermine,
55:06but otherwise I would say in in in
55:08answer to your question I would
55:10say five years at least great,
55:13thank you sure, alright
55:15and I'm just going to see for
55:17my from the chat. Let's see,
55:20I am not seeing anything right now.
55:23If anyone wants to unmute
55:24or type anything in please,
55:26this is your chance we have
55:27about we about one minute left.
55:29I know we need to get off
55:30to another conference.
55:38We have quiet.
55:42Alright, well I think that was really true.
55:44If like I really really enjoyed the talk,
55:46I think we all learned a lot and I we
55:47thank you so much for your time today.
55:49Thank you for having me thanks.
55:51Enjoy the next meeting.
55:52All right, we got some kudos to you.
55:54Thank you so much. Bye bye bye.