SARAH: Hello, friends, and welcome back to the QI Southeast Ohio Hub video series. And you will notice I'm all alone at this table today. I'm not even sitting with myself. It's just me. So I think before we talk about weight loss and what medications we have for weight loss, including ones that cause anal leakage, we should really think about weight gain. 

What can cause weight gain and the complications from weight gain? There's a lot of obesity-related complications, and we want to prevent those from happening. We want to prevent those. Type 2 diabetes can be an obesity-related complication. Metabolic syndrome, dyslipidemia, GERD. There's a lot of things that can come with obesity. There's also medications that can cause weight gain. So let's think about those meds. Sulfonylureas in patients with diabetes can cause weight gain. So what's super cool is on our charts we covered at our last town hall, we saw that our sulfonylurea prescribing in this region has gone down, which is actually a very good thing. There's not really a whole lot of benefits to sulfonylureas besides the fact that they're cheap, because they do cause weight gain, and that's really not helping anyone. 

Another thing I think about with weight gain is maybe TZDs, thiazolidinediones, if you will. And what I would like is if you could say that fast three times. That's thiazolidinediones. And I can say it again for the people in the back if you would like. Those tend to cause edema, and that can be weight gain. But remembering what is that weight gain from, maybe just water retention from those TZDs. Antipsychotics, especially now with treatment-resistant depression, you may see someone using antipsychotics as an add-on for depression, and these can cause significant weight gain. We know that some side effects of that are weight gain and Type 2 diabetes. So that can be a problem. 

Other medications that can cause weight gain, mirtazapine, gabapentin, and pregabalin have been shown to cause some weight gain, and we use those for diabetic neuropathies. Beta blockers, antihistamines, corticosteroids, hormones, and estrogens, all these can lead potentially to some weight gain. So remembering that medications also can cause weight gain. 

All right. Weight loss. It's a hot topic. We all talk about weight loss, and especially now with this GLP craze that we have going on. GLPs really do help with weight loss. We know that. They really are beneficial in a lot of our patients with Type 2 diabetes. This we know. I also feel that GLPs have gotten way popular. Now we have med spas in the state of Ohio that are shutting down because they are ordering GLPs on Etsy and Amazon and online from random places, and potentially reusing needles. There's a lot going on around the business... I'm going to call it the business of GLPs. We also know that GLPs can cause muscle wasting. They can cause decreases in micro and macronutrients. They're very expensive. They're not covered under the plans. We know they're not covered under Medicaid, and we know when patients go off of it, the potential is that they're going to gain that weight back again. Because have their habits changed? No. The habits haven't changed. 

So a few months ago, I was thinking to myself, "Self, what other options are there for weight loss?" So lucky for us, we have some guidelines. So the ADA Standards of Care, in Section 8, they have a great table. So this is Table 8.2. And in this table, it lists some alternatives for weight loss. The GLPs are on there. That's just part of it. But there are a few other things on here that I think we should talk about today as far as weight loss, weight management goes. All right. The other things that are on here can tend to cause a weight loss of maybe 5% to 10% of body weight. So not huge. GLPs aren't huge either, but tend to be 15%, maybe 20% if somebody's really getting a lot of weight loss with those GLPs. 

So these medications don't quite have the weight loss with those. But I think it's important for us to talk about. All right. Let's go to our Table 8.2 in, surprisingly, Section 8 of the ADA Standards of Care 2026. So the first thing on this list is phentermine. I think we all know this. It's been around for a really long time. Did you know that phentermine is similar to an amphetamine? Did you know that? This is why it's a controlled medication. This is why it can cause hypertension. This is also why it causes weight loss. 

Before 2023, phentermine was a very restricted medication in the state of Ohio. It was only allowed for 12 weeks. Even if there was success in that 12 weeks, the person had to stop taking it and take a break from that drug. As of February 2023, that has now ended. So as long as there is a weight loss with phentermine over those 12 weeks, if there's a 5% weight loss, that person can stay on that medication. Again, with close monitoring for hypertension, making sure there is weight loss and there is success in that, but watching for those signs of potential addiction. It is amphetamines, so keep that in mind. Phentermine is also in combination with a medication called topiramate. The brand name for that is Qsymia, and that is expensive. That is actually approved for weight loss, Topiramate on its own, as a medication for migraine prevention or seizure control, can also cause weight loss. It is not FDA-approved for weight loss. So even though it can cause weight loss, maybe 5%, again, it's not approved for that. But it's not expensive by itself. All right. So that's phentermine, that's topiramate. 

The next one we want to talk about on our lovely list here, I think we're going to talk about orlistat just briefly. In 1999, when orlistat came on the market, it was amazing. Everyone's like, "Oh my gosh, it's the best weight loss med ever." And what the drug does is it actually prevents fat absorption in the gut. So it was sort of like punishment. If you use orlistat and eat fatty foods, you will have anal leakage. And that, my friends, is something that people didn't like. I will say it's still available. It is over the counter, still an option. So if you are a person who eats a lot of fatty food and you want to punish yourself for eating fatty food, then you may want to try orlistat, and watch for anal leakage. All right. That's enough said about orlistat. 

Let's move on. Bupropion. So bupropion is approved for major depressive disorder and smoking cessation, also seasonal affective disorder. Not approved for anxiety, and you have to be cautious in patients who have a seizure disorder, because it can lower that seizure threshold. It also causes weight loss. Why? Because it increases norepinephrine and dopamine. That is why it causes weight loss. It is not approved for weight loss on its own. It is cheap, though. It is approved for weight loss in combination with naltrexone, which is an opioid antagonist. Why this works? We think it just maybe helps lower the food cravings. So bupropion in combination with naltrexone is called Contrave, and that is more expensive. But together, it is approved for weight loss. 

So that's about it. That's what I have found for you for weight loss medications. I am disappointed in the things that I found. But what I also came across was how important it is for providing support for our patients to meet them where they are with their weight loss goals. Encouraging really good sleep hygiene, encouraging healthy meals to the best of their abilities, and maybe a 10-minute walk after dinner, if they can get to that. Maybe a weight loss visit. We had kind of talked about that for some of our PDSAs, maybe scheduling a visit just to talk about weight loss with your patients and what their options are. I really think that will lead to the best outcomes. 

Sleep hygiene, healthy eating, and a little bit of exercise. Not skinny exercise, but a little bit of exercise will be excellent support for our patients. I'm not a huge fan of orlistat, because of the anal leakage. But sleep hygiene, that might be good. 

All right, friends. Thanks for listening. Have a great day.