" 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
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- 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.
- 01:38she 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.
- 02:15she 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
- 10:17it 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,
- 17:31Unfortunately 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.
- 19:13but 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.
- 26:25if 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,
- 30:51sometimes 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.
- 38:01at 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.
- 38:43side 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.
- 54:48If 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.