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Practical Obesity Care: Meds, Messaging, and Case Decisions · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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This is Pediatrics Now, brought to you by the Department of Pediatrics at UT Health San Antonio.
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Today, I'm bringing you grand rounds. Let's listen in.
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Today, it is my great pleasure to introduce Dr. Sarah Ditch.
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She's an Associate Professor of Pediatrics at Washington University School of
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Medicine in St. Louis, Missouri.
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She's board certified in pediatrics and adolescent medicine and is a diplomat
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of the American Board of Obesity Medicine.
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Dr. Ditch graduated from the University of Missouri School of Medicine.
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She completed residency and fellowship training through the San Antonio Uniformed
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Services Health Education Consortium and while serving on active duty in the
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United States Air Force.
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Currently, Dr. Ditch divides her clinical time between working as a pediatric
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hospitalist and caring for patients in the adolescent clinic,
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where her clinical focus centers heavily on pediatric obesity medicine.
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Her professional interests include pediatric obesity, adolescent gynecology,
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and gender-diverse care, fields in which she is actively engaged in clinical
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education, research, and patient advocacy.
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And I will add that I have known Dr. Ditch as a sub-I, as a resident,
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and most importantly, as the pediatric PCP adolescent medicine specialist for
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all three of my children.
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So she is very near and dear to my heart. So everybody give a great welcome to Dr. Ditch.
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Thank you, Dr. Sutter. Thank you guys for this invitation. I'm excited.
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I love talking about this topic.
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My focus today, it's labeled Practical Approaches for a Treatment of Pediatric
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Obesity because I really want to talk about what this looks like in clinic and
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so all the nuances that that comes with.
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So that's my focus for today. And I will talk about the meds and GLP-1s,
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but other meds as well. And so hopefully you find that helpful.
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I'll talk about framing the condition that we're addressing,
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and then go over the FDA-approved medications for pediatrics.
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We will talk about the GLP-1s. I have added a section on GLP-1s and eating disorders
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that is, especially in the adolescent medicine world or the conferences I attend,
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that's a concern and comes up a lot.
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So I'm going to share what data we have, talk a lot about the non-GLP-1 medications
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that are available, more available to our patients.
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And if we have time, we'll get to some future treatment options.
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I have a case. I don't know how big it shows up on your screen,
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but just to kind of, we'll come back, if we have time, we'll circle back to
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the end to see what you might think to treat this patient.
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So this is a pretty typical patient that I see in my clinic.
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So she's, this is her growth chart showing her BMI percentile.
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And hopefully if you guys use Epic or your EMR lets you expand it out,
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we really want to classify like the percentile of the, the percentage of the
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95th percentile for our patients.
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So she's a 14-year-old female. She has anxiety, ADHD, binge eating disorder.
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She's here for weight loss medication.
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Her weight gain started around the time of puberty, super common for our patients.
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She does have a history of binge eating disorder that did require intensive
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outpatient treatment, which she completed. I'm seeing her just now,
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so this was like six months ago.
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She feels better after her program feels like her symptoms are more controlled
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and has lost about 10 pounds on her own by less binging, more mindful eating.
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She's still very much engaged in care for her eating disorder,
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seeing a dietician weekly and a therapist biweekly.
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And it was her dietician that referred her to me feeling like she was stable
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and ready to go on this journey.
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What other meds she's on is super important. So, I never say it's a generic name.
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Adamoxetine, which is trotera, duloxetine, gabapentin, and guamphacine.
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Her she did already have lab work not everyone that comes to see me has had
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lab work but her labs are normal so she really as far as I besides the binge
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eating disorder no real comorbidities,
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her insurance is important uh so I'll talk about those caveats it's through
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her parents employer and then I have her exact percentile down there she's 125th
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percentile the 95th percentile which is class two obesity.
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So keep that case in mind as we kind of go through how we approach these patients.
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So off the bat, this can be a sensitive subject for us, our patients, everybody.
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And so I really try to frame the visit at the very beginning when I first meet
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a patient of that I am interested in my patient's health, that this is not beauty
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clinic or for cosmetics.
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And I kind of address those concerns and that my focus is really on their health,
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and emphasize that their body size and their weight doesn't define their human
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dignity, their beauty. There's beauty at all sizes.
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And then recognizing the psychological and behavioral harms of the condition
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of obesity or previous attempts at treating it.
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You know, they may have had not great experiences in the past.
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And then being mindful of thin culture and, you know, are we contributing to
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thin culture is something that comes up a lot.
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Thin culture is always around and kind of swings on a pendulum.
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So I like to give examples from the 90s because it was pretty intense then,
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but I wonder if we're kind of swinging back.
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So hopefully you guys have seen the Titanic or at least seen clips or pictures
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from it. But Kate Winslet was a perfectly naturally proportioned size 4'6 woman playing this role.
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And a couple of years ago, she started talking a lot more about how she was
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criticized about her weight and was told she was too heavy for Leonardo DiCaprio.
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And then the famous or infamous floating door scene is what became like a cruel
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joke about her size and that Jack might not have had to die if she wouldn't
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have been so heavy, which is horrible.
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More recently, I'm a huge Wicked fan. So on the right was Wicked for Good at
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their debut, and they're very thin-appearing actresses.
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A lot of fans kind of commented for Wicked for Good that it appeared—I don't
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have any of the data, but it appeared that they looked even thinner.
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You know, which, again, was very concerning to me, concerning to a lot of fans.
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I have no evidence that they were on weight loss meds or anything like that.
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And then these are all from my personal social media feeds, like that I get
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ads because I am researching and Googling GLP-1s all the time. And so I get all the ads.
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And these examples are just to illustrate like what our patients are seeing.
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And I kind of bring this up, especially either them or their parents are for sure on social media.
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And this is not how these meds are supposed to be used. Like they're like,
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you're not obese. We don't care.
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And then we're flooded with even more of them. I'm showing, you know,
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patients with normal BMIs and swimsuits and showing that they're on GLP-1.
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So recognizing that this is what our patients are seeing and being exposed to.
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During the appointment.
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So how to approach your patient? Even though my appointments are for obesity,
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I still start all my visits with, what are we here to talk about today?
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Some parents don't tell their children that that's what we're talking about
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or sometimes they forgot that that's what we're talking about.
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So I always make sure they know and that they're okay to talk about it.
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And I say, if we start talking about something you don't want to, you just tell me to stop.
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Or if you're in your primary care, but you know that their condition of obesity
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might be contributing to their symptoms, you know, say, hey,
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is it OK if we spend a few minutes talking about how I use metabolism?
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So I would say how your metabolism might be affecting your blood pressure,
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your sleep, your joint pain or whatever it is that you're addressing.
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Using people-first language, and you really have to practice this both in your
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documentation and when you're presenting patients.
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This is a patient with obesity or with the condition of obesity.
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I use condition and not disease. You know, it is a disease, but that's the language
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I use. Not this is an obese patient.
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And I have a whole speech I give my patients about our understanding that body
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composition is from multiple factors, genetics, environment,
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social determinants of health.
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Many things are patients that are not choices they made or things in their control
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and that this is not a problem of willpower.
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So what is the condition of obesity? It's a complex chronic disease.
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There's kind of three categories of the pathology.
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The adipose tissue itself isn't functioning normally, and that leads to an endocrine
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immune response, and that's your symptoms of or complications of metabolic syndrome,
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hypertension, PMOS, the new PCOS, puberty disruption, dyslimidemia.
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The presence of the The extra adipose tissue causes symptoms as well,
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such as it can cause breathing issues or even asthma, immobility,
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conditions from tissue compression, such as acid reflux or sleep apnea.
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And then the psychological complications, feeling isolated, less participation
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in activities, bullying, and eating disorders, which, like I said, we'll talk more about.
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I'll go a little bit quickly through these slides, but we all,
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we see this in our practice that this is very prevalent.
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So orange is born male, purple is born female, and you can kind of see once
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puberty hits, there's a little bit more of a female predominance.
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And then when you combine overweight and obesity, so on the left is 5 to 14,
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on the right is 15 to 24, and when you get in that category for females,
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it's more than 50%. So you will see this in practice.
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This is, you know, this is not something you can just not ever address,
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particularly in primary care, and it's something that affects a significant
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proportion of our patients. Here's a heat map.
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As you get more orange and red, that's higher prevalence. And so you can see
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where Texas is. Males is on the left, females on the right.
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For Missouri, I'm about the same for females, a little bit different for males,
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but not much different moving here to Missouri.
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So I also have kind of talked to my patients and when I,
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teach residents in my clinic is that we really need to think about treating
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metabolism the same as other chronic relaxing remitting conditions.
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And there's so many to compare it to. Asthma, ADHD, epilepsy,
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all kinds of conditions that our patients will have lifelong and that they at,
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some points or for all of it may need a controller medication.
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And so offering medication is a part of comprehensive care of these conditions,
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and that should be the case for obesity as well.
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Intervention prevents or treats complications. So the other thing I share with,
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I always talk about is doing nothing is not without risk or harm.
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So, yes, there's hesitancy. Yes, we need to be at the right time in the right
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patient. But you also need to compare it to what's the risks of doing nothing.
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There's no evidence that early intervention affects growth or development.
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There is a lot of evidence that obesity affects growth and development and precocious
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puberty and effects on bone health and all kinds of things.
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There's no evidence that staged management achieves faster or better results.
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So, you know, hey, work on your diet for three months and then let's work on
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exercise for six months and then we'll bring up medication.
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Not that that approach is wrong, but there's no evidence that that produces better results.
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And then the other thing to think about as well, when we're proposing a medication
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this child might take for life or for a really long time,
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is hopefully we're substituting one medication,
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to manage their obesity as opposed to four or five medications to manage later
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in life when they develop complications of diabetes, hypertension.
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Now they're using a CPAP machine.
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Maybe they need more than one medicine for their diabetes or they've developed
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PMOS and our medications for that.
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So trading one medication for four or five is definitely better.
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I love these graphics. There's a website, Obesity Visuals, that is made, that is free.
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It's made by Joseph Zucchi, who's an obesity provider, and they're free.
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And I did get his personal permission to use these slides.
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But he puts, really helps, the drugs, there's so many, and there's so many more in the pipeline.
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And so really, knowing all of them, the visuals I like, that helps.
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So the stars on the left are the ones that are FDA approved for kids.
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So we have the semaglutide injection, or WAGOVI, that is the most effective
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medication that's approved for kids. And then on the right, it has the age for the FDA approval.
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Phentermine and topiramate combined in an extended release capsule,
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QSIMIA, next most effective.
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Loraglutide is the daily injection, GLP-1, that is approved for kids 12 and up.
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You don't hear about it maybe a lot because it's less effective and it's a daily
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shot. I have like maybe one patient on this because that's what their insurance
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covers, but it's not as popular.
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And then Fentermy myself is approved for 16 and up.
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And then the last one, I have an X over it. Hopefully nobody's using oilist
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fat. That's the one where you don't absorb fat and you have lots of diarrhea.
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So not, and it's not very effective.
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What's not starred is Trisepetide, but you see that at the top. Keep that in mind.
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And then, because that one will show up on later sides. And then,
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I don't, this drug name, Orfaglipron or Fondeo, which is the oral from Eli Lilly
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that also makes terzepatide, that's right above Qsumia.
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Keep that one in mind as well for later slides.
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I'm going to talk briefly about monogenic obesity. The majority of what I treat
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is polygenic or non-monogenic obesity. But there is another drug.
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It's an injectable medication. It's not a GLP-1. It's an MC4R receptor agnist.
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But setmelanotide is a drug approved for children for obesity,
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specifically monogenic obesity age 2 and up, and recently acquired hypothalamic
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obesity age 4 and up. So those are some examples listed there of monogenic obesity.
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It is a daily injection.
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I can't really quote its effectiveness because it depends on what you're treating, but it is effective.
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It has kind of not great derm side effects. That melano in the name means it
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activates your melanin receptors, and there's a bronzing of the skin effect,
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which I have seen in clinic, and it's quite impressive.
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It definitely looks like the patients were hanging out in the tanning booth.
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What is important, though, is if you think your patient could have monogenic
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obesity, it can change their insurance coverage for medication.
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So, if not, the issues with the MC4R receptor, which I'm not getting into how
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that works, it's in the brain, has to do with your satiety center.
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It only accounts for 2% to 5% of severe obesity.
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So, less than that of all obesity, but even severe obesity is not a huge cause of it.
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The things you want to think about is if you have a patient who had obesity
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before age five or rapid weight gain before age two, that the parents are normal weight.
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And then hyperphagia is the big symptom to think about. So we're not talking
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about just that they eat a lot.
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It's an insatiable hunger, like they're locking up the food.
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The time to feel full takes a really long time. And the amount of time they feel full is short.
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There's a severe preoccupation with food and distress if food is denied.
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And the Endocrine Society also gave some guidelines. So if one study,
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I'm sorry, those guidelines came from the Endocrine Society of the extreme obesity
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before age five with hyperphagia.
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And then another study suggested if there's a BMI of 27 or more or 140 percent
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of the 90, so class three obesity in a two-year-old
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or a BMI above 33 or 184th percentile percentage of the 95th percentile at age five.
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So that kind of gave some cutoffs to think about monogenic obesity.
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And then I listed on the right there, often you don't just have obesity when
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you have genetic conditions. There's often other signs. And those are some of
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the things that can happen with some of these conditions.
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There is a genetic testing available that is free to patients.
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They do need a physician's order, so you are involved. And you should give some genetic counseling.
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There's a phone number. They can talk to a genetic counselor.
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But this doesn't affect, for now, doesn't affect health insurance coverage if
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you test positive or something, but it could affect life insurance.
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So you do want to give a little counseling. But the patients can swab their
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cheek at home and mail it off. And they just need a physician order.
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This is not like whole exome sequencing, so it's not going to catch everything.
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But it is an option to be tested for this.
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Okay, so back to non-monogenic obesity. So I mentioned loraglutide and semaglutide
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are the two GLP-1s that are approved for 12 and up for the treatment of obesity.
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A reminder, and like I said, I'm only briefly going over like the definition
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of obesity and like the pathology of it because I really wanted to focus on
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what it looks like in clinic.
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But briefly, as a reminder, GLP-1 is secreted in the ileum and colon.
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It is secreted in response to eating, which is why these drugs have less concern for hypoglycemia.
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When you activate these receptors, it initiates a series of metabolic responses.
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So enhanced insulin secretion suppresses glucagon secretion,
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delayed gastric emptying. I talk a lot about that with my patients because that's
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where a lot of the side effects come from.
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Less hepatic gluconeogenesis, and then all the effects in the brain.
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So all the things you hear about, like reducing food noise, how it probably
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helps with binge eating disorder, that kind of thing.
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There's a lot of receptors in your brain. In addition to the brain and the GI
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tract, you have GLP-1 receptors in the pancreas, heart, and kidney as well,
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which is probably why we're seeing more indications for these meds,
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such as like prevention of secondary heart attacks or even chronic kidney disease.
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This, I have a lot of the graphs from the phase three trials that showed effectiveness.
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Just to give you, like, you saw that graph showing those, I forgot to mention,
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like, when we were looking at effectiveness.
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When we're quoting, like, effectiveness, it was the average percentage of weight
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loss in the phase three trial of that drug.
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So, and most drugs, it's about a year.
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This one went to 56 weeks. Some went to, like, 68 weeks. So,
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they're not quite apples to apples, but it's the best comparison we have.
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But this is the one for loraglutide. And when you review these studies,
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you always want to compare what was happening with the placebo,
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because they usually were doing some in some like lifestyle modifications or
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something for the placebo patients.
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As a reminder, loraglutide is the less effective of the two approved for kids
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and is the daily injection.
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Another way to compare loraglutide and semaglutide is at 56 weeks in this study, In the treatment group,
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the percentage of patients that lost more, or that, yeah, their BMI decreased
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at least 5% was 43%, whereas in the placebo group, only 18% got that change.
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And then this is semaglutide for pediatrics, their phase 3 trial.
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And to compare that same number in the treatment group, 73% had at least a 5% decrease in their BMI.
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Those are kind of the best ways to kind of try to compare these two.
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When I talk to patients about them, I do tell them, you know,
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all these drugs have an effect. And, of course, there's individual.
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Some people respond very well to some medications. There are non-responders
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to some medications. But just
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to show you, these were the studies that got them approved in children.
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Okay, so practically, what does this look like in clinic? So in 20,
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I just talked to you. You saw there were five drugs that are FDA approved for kids.
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You might be like, great, this is, you know, I have so many choices.
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But you probably have all experienced that these historically have not been
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covered well. And then in 2026, it really, like in January 2026,
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most insurance companies limited coverage or didn't cover GLP-1s at all.
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Or to be honest, most of them say if the indication of whatever you're prescribing
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is for obesity or weight management, not covering it at all.
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And I have one patient whose insurance company won't cover her visit with me,
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because it's coded for obesity.
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And even though she's cash paying for Wagobi, because that's in the visit,
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they're not even covering the visit. So there is definitely a cost barrier.
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And then there's, for adults, there's better luck with other indications,
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but in pediatrics, these drugs are only approved for obesity.
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They are not approved for sleep apnea or other conditions, so we really don't have that option.
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They're expensive. They are getting better. You know, a couple of years ago,
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they were $1,000 a month to get access to these. And then on the right there,
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this was a study showing that not treating obesity is expensive.
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So it's on the top there, you see that's for adults.
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So it's kind of showing as their BMI goes up the predicted expenditure.
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And then on the bottom, it's showing like by Z score for children, the expected cost.
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And for adults, obesity was associated with $1,000 excess annual medical cost
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per person, accounting for $172 billion.
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Per adult, like over a lifetime. And then for children, obesity was associated
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with $116 excess cost per person, and then $1.3 billion of extra medical spending with overall.
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And so there's a lot of advocacy going on to try to change this because this
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would actually save insurance companies money.
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But anyway, this was a map I found recently, which was interesting,
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is that showing which Medicaid programs do cover GLP-1s.
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So y'all in Texas, as you're probably aware, Texas Medicaid does not cover GLP-1s.
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This is for children and adults or any adults that are on Medicaid.
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Missouri does. So I do, I didn't know that when I moved to Missouri,
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but I do have some options for my Medicaid patients.
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GLP-1s still account for a relatively small share of total number of Medicaid
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prescriptions. Only about 1% of Medicaid prescriptions in 2024 are GLP-1s,
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up from 0% in 2020 or 2019.
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However, they account for 8% of drug spending because these drugs are expensive.
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So I'm not going to talk a lot about this, but obviously, when I give this lecture
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in Missouri, we go into it.
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But what's interesting and why I still keep this slide is, yes,
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Missouri Medicaid covers a GLP-1, but not the FDA approved ones.
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So clearly, it's also clearly like a cost game. So when I first started practicing
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here in 2025, semaglutide as Ozempic, which is for FDA approved for diabetes,
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was the one that my patients had access to.
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But it's still the same drug, semaglutide. So that's cool. But then I started
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all my Medicaid patients on that.
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And then in 2026, because terzepatide became approved for pediatric obesity
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or for pediatric diabetes as Manjaro, Missouri Medicaid changed to,
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ZepBound as their preferred GLP-1 for 12 and up, even though it's not FDA approved for kids.
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It they are doing studies for 12 to 17 year olds so it may be coming as an option
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but so yeah I got to switch all my patients to terzepatide but because they
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have that Manjaro study which I do have a graph of it later we do have safety data and stuff but,
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terzepatide if you remember from that graph is a little more effective because
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it has a second drug in it the GIP and so just briefly GIP is glucose dependent
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insulinotropic polypeptide how it works is listed there and it It should sound familiar,
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where it says, like, stimulates insulin secretion and suppresses glucagon secretion,
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similar to how GLP-1 works, but when you combine them, you get more effectiveness.
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I do have some slides on here on cost and, you know, that I think and it's just
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really important to recognize this is what our patient, some of my and some
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of my patients come to me knowing all about this. You know, they've got family members on GLP-1s.
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Some this is a don't know. And I have to explain to them.
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First, I go on and talk about how, you know, how these medications are appropriate
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to be prescribed and are not cheating or the easy way out.
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Like this is the right thing to do. But then we get to the med talk and we're
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like, oh, man, these are not accessible because of price or not covered by insurance.
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So these are the different GLP-1s and showing kind of the price.
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And when you see the price goes up, that's because the first two doses are the
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cheaper price. But then when you get to actual treatment doses, it's more expensive.
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We were all very excited about the oral GLP-1s, but they are only like $50 cheaper than the injectable.
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And then most of the coupon prices, especially from Eli Lilly,
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are through the manufacturer, and they do not approve off-label prescribing.
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So even though I told you I'm prescribing terzepatide to all my Mo Medicaid
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patients 12 and up, if I have a non-Medicaid patient that's willing to cash
25:21
pay for terzepatide, we can't get it to the affordable price.
25:26
They can get the $1,000 a month price, but the manufacturer won't approve the
25:30
coupon for a non-FDA indication.
25:33
And then loraglutide, the daily one that I said I don't really have a lot of
25:36
patients on, is generic, but the price didn't go down. So it's still very expensive.
25:42
I do want to mention, talk a little bit about oral semaglutide because,
25:48
I have heard in states like Texas where there's no GLP-1 option,
25:52
this is the most affordable cash
25:55
pay option for a GLP-1 and they are prescribing to 12 to 17-year-olds.
26:01
Again, you have to get a coupon that's not through Novo Nordisk.
26:06
But what I really want to emphasize about it, well, first, the two points at
26:09
the bottom, same side effects and same effectiveness.
26:12
It was right next to injectable semaglutide on that graph I showed you.
26:16
However, for it to work, it must be taken in the morning on an empty stomach,
26:22
with water only, no more than four ounces, and then you must wait at least 30
26:26
minutes to take any other morning meds or to eat or drink.
26:30
As an adolescent doc, when I first read this, I was like, I can't even get my
26:34
patients to do Prilosec properly, and this is even worse.
26:37
And if they don't do this, it's going to be less effective. So that is a little
26:41
bit of a barrier, I think, to anybody, even adults would kind of struggle with
26:44
that. And of course, a lot of my patients are on other morning meds and they're
26:47
kind of rushing out the door to go to school.
26:49
So just be aware that that's how to take it. And then the other thing is it
26:54
has the same or even more stomach side effects.
26:57
So if we're switching to oral semaglutide because of like an intolerance of
27:02
injectable semaglutide, it may not be helpful.
27:05
Briefly, this is the study showing the effectiveness. I will say,
27:09
if you notice on this graph, it shows 13%, but the other graph I showed was 16%.
27:14
And that's because they reported both like real world, like intend to treat,
27:18
and that's the 13% effectiveness.
27:20
To get to the 16%, which makes it equivalent to injectable semaglutide,
27:25
that was under ideal conditions.
27:27
And that probably goes back to how to take it. And if anyone,
27:31
it's the oral semaglutide is the same as ribelsis.
27:34
And if anyone has any experience treating diabetes, that drug had a lot of,
27:38
a lot of people didn't like it because of the side effects. And then to make
27:41
it an obesity drug, they went way up on the dose.
27:44
And so there was a lot of, I think a lot of patients are tolerating this well,
27:47
but there was a lot of trepidation that this might have even more stomach side effects.
27:52
I have just one slide because you may get asked about, well,
27:55
can I just go buy some compounded GLP-1s? Or maybe I have a lot of parents that
27:59
are on compounded GLP-1s that
28:01
are coming, you know, that are bringing their kiddo to get on a GLP-1.
28:05
And I do not have any idea how, if even the online companies will accept minors.
28:11
I don't know anything about that. And I tell them I don't manage compound GLP-1.
28:14
So I completely understand why there's such a market for them because of the cost.
28:20
But I don't, I can't recommend them and I don't manage them.
28:24
Some things to know about it if they do, if you get asked more question is the
28:28
semaglutide is different in most of these drugs. it's a salt that is chemically
28:32
different than the FDA approved semaglutide.
28:35
There have been case series of dosing errors. Either what's mixed in is not
28:40
correct or the patients are drawing up their own volumes.
28:45
And if it's pretty concentrated, even like a little volume error can be a big dosing error.
28:51
And then there's, these aren't regulated by, you know, the FDA.
28:57
These are, they're regulated by the state boards, which can be extremely variable by state.
29:02
One compounded pharmacy was using a toaster oven to sterilize their equipment.
29:06
So it's not saying all of them are doing that, but that exists and just something,
29:11
to be aware of that your patients may ask about.
29:14
I like to keep this slide in, too, because this can come up.
29:20
I go over all this when I prescribe these to my patients. But if you're admitting
29:24
a patient on a GLP-1 or maybe they're seeing you in the ER and you're talking
29:29
about like, or maybe your patients, you're filling out a camp form for them
29:32
to go to camp and they're on a GLP-1.
29:34
I think it's helpful if you're aware of how the logistics of storing the pens and using the pens.
29:40
They do need to be refrigerated. And when they are, they're good till their expiration date.
29:44
However, I tell my patients to let them warm up before you inject it.
29:47
And then once it's to room temperature, okay, terzepatide and semaglutide have
29:51
slightly different guidelines. So for terzapatite, it says it's good for three
29:55
weeks, semanglutide up for four weeks.
29:57
So it's important to know that they don't need to travel with a cooler if they're going on vacation.
30:02
They can go to a week or two summer camp and bring their meds and they don't
30:05
have to be in the fridge. They just can't get above, I think it's like 86 degrees.
30:09
It needs to be at room temperature.
30:12
And then once it's warmed up, it can't go back in the fridge.
30:15
So once it's warmed up, it's only good for three to four weeks.
30:17
It's no longer good till its expiration date.
30:19
And they need to check the liquid and make sure it still looks clear and not foggy.
30:24
They should throw it away if the liquid doesn't look clear. Light does damage
30:28
it. So they are supposed to keep it in the box it comes in.
30:31
And then this one I think is important. If you're admitting a patient,
30:35
they're going to miss their dose. Or maybe they call your clinic instead of
30:40
their obesity prescriber. And they're like, I didn't get it from the pharmacy.
30:43
I'm going to get it tomorrow. Can I still do my injection?
30:47
So semaglutide gives you an extra day. But basically, you can be a couple days
30:53
late and still take your shot. But you need no less than three days between
30:56
two injections for semanglutide and no less than four days between terzapatide doses.
31:02
That can get confusing for patients. So I think this next bullet point is the
31:05
most important, is that you can miss one dose.
31:08
So you can go up to two weeks between doses and not have to restart at the lower dose and retitrate.
31:16
So if you're admitting a patient, especially if it's for, like,
31:18
gastroenteritis or belly pain or something, you can hold their one dose as long
31:24
as they don't go more than 14 days between doses.
31:26
If they're admitted longer and need to go more and you can't give them their
31:29
GLP-1 while they're admitted, that's okay, just they need to contact their prescriber
31:33
and start at a low dose and go back up.
31:35
I also told my patients, like, if you get the flu or a stomach bug,
31:39
go ahead and skip a dose. You don't need to be, like, also having your side effects.
31:43
And then I have this blurb at the bottom. I just double-checked this the other day.
31:47
This is still the case. So UpToDate on terzepatide has that because of delayed
31:52
gastric emptying, the oral hormonal contraception may be less effective for
31:57
four weeks after starting the medicine and each dose change.
32:01
And because these are titrated every month, that could be the whole titration
32:05
time, four or five months, the patient's oral hormonal contraception may be less effective.
32:12
So maglutide, which also delays gastric emptying, doesn't have that precaution
32:16
on their labeling, so I'm not really sure the difference.
32:19
So it's something to think about. The other non-oral options still are going
32:25
to be effective, but it is something I tell my patients.
32:29
All right. Side effects.
32:33
Just things to be aware of, and then things also that you could see patients
32:36
coming into urgent care of the ER for, mostly GI. So like, and that's mostly
32:42
the delayed gastric emptying. So nausea, vomiting, diarrhea, can be constipation.
32:48
Pancreatitis was talked about a lot at the, when these first came out,
32:52
it's really not caution and you don't need to like trend lipase levels on these patients.
32:58
The gallbladder and biliary concerns is unclear if it's due to the medications
33:02
or if it's more just the rapid weight loss.
33:05
I do talk to all my residents and patients about the eye concerns,
33:10
retinopathy and NAION, rare.
33:14
But we have seen case, or there are case reports of it. I haven't seen any.
33:18
But so I tell my patients if you have eye pain or change in vision,
33:21
that's go to urgent ophthalmology visit and stop your GLP-1.
33:28
And then hypoglycemia, I mentioned already, is rare. in these drugs,
33:33
and even if you're on metformin as well, is rare.
33:36
If you see these patients with abdominal pain, recognizing 70% of patients have
33:42
GI side effects, and it increases at higher doses, especially if there was a recent dose change.
33:46
But severe or sudden abdominal pain, especially if they've been on it for a
33:51
while, is common, and don't just blame the GLP-1.
33:57
The GLP-1 is probably not helping, but it suspects other causes.
34:01
And you work them up the same as any patient with abdominal pain, labs, maybe imaging.
34:06
If it's mild and you're able to get symptom control and rehydration pretty routinely,
34:11
you can discharge and you're discharging them from the ER, you can continue their GLP-1.
34:16
But if it was severe, it took multiple boluses, maybe they were admitted overnight,
34:20
I would, you know, it's also reasonable to have them stop their GLP-1 and follow
34:23
up with their prescriber.
34:25
The GLP-1s, if your patient's on a GLP-1 and you're starting other medication,
34:30
the good news is it has very little med-med interactions and there's no dose-changing recommendations.
34:37
I mentioned oral contraceptives. Just know some drugs may have a delayed onset,
34:41
but there's no recommendations to change any doses.
34:45
Okay, so to get to my little section on eating disorders, it's important to
34:51
recognize that adolescents with obesity, it's more common that they have disordered
34:55
eating than adolescents with a normal BMI, especially binge eating.
34:59
And it might be due to tried and unsuccessful intentional weight loss or that
35:03
there's shared genetic and psychological risk factors.
35:07
We don't have a lot of great data on this yet.
35:12
Most of the data was after bariatric surgery, and it did show that rapid weight
35:16
loss increased the risk of developing an eating disorder later.
35:20
So I did a literature review on this recently, found two meta-analyses that I wanted to share.
35:26
They don't really answer our question with, like, super firm data.
35:28
I think we need, you know, this is relatively new, but the preliminary results are promising.
35:35
But again, this still needs to be ongoing. So this meta-analysis was 38 trials
35:41
from 10 countries. So to our knowledge, the largest review is from 2025.
35:46
Some limitations, most of the patients were female, which is common in weight
35:50
loss trials. There was short follow-up, not more than a year.
35:54
Most of the eating disorders studied were binge eating disorder,
35:57
not like our restrictive eating disorders.
35:59
And what this meta-analysis was looking at was any weight loss intervention,
36:03
lifestyle, bariatric surgery, anything.
36:07
And so only two of the studies were GLP-1 trials.
36:10
But what they found was that.
36:13
If there was modest weight loss, there was an improvement in disordered eating's symptom scores.
36:18
The improvement was maintained at follow-up. The magnitude of weight loss did
36:22
not predict changes in disordered eating.
36:25
And the improvement in the disordered eating was larger in the patients with
36:29
pre-existing eating disorders.
36:31
The second study was in 2026. So this was 25 studies specifically with GLP-1
36:38
ones, and two of them were adolescent trials.
36:41
They looked at patients that did not have eating disorders at baseline.
36:44
And what they did, seven of these trials did look at more than a year out,
36:49
so that was a little better.
36:51
But again, few of them had eating disorders that were restriction as opposed
36:56
to binge eating. It's just hard in this population.
37:00
But what they found was the eating behaviors and eating disorder symptoms either
37:05
improved or did not change during GLP-1 treatment.
37:09
There was none of the trials reported on changes in eating behaviors following
37:12
stopping the medications.
37:14
And most disordered or obesity-related eating behaviors improved during treatment.
37:19
So emotional eating, food cravings, binge eating, which makes sense.
37:23
That's consistent with how GLP-1s work.
37:25
So again, that's all the data that we have so far.
37:29
It is promising that this could be helpful. But how do you, so what practically do I do?
37:35
Like our patient in our case study has a history of eating disorder.
37:39
I do screen all my patients for eating disorders. The EAT-26 is great.
37:43
I use the E-D-E-Q-S, and I have very close follow-up.
37:47
And then I make sure there's stability. So if there's either the eating disorder
37:50
or other mental health comorbidities are not stable or well-controlled,
37:54
it's probably not time to start a weight loss journey.
37:57
All right. Okay, good. I want to make sure I have time to talk about non-GLP-1s.
38:02
So, like, my MoMedicaid patients have access to a GLP-1 if it's the right med
38:09
for them. That doesn't mean that's necessarily the one we choose.
38:12
So, the other, the non-GLP-1 medication that I do talk to my patients about
38:16
is Phentermine topiramate extended release capsule known as Q-Semia.
38:20
So, I'm going to go over the individual components. So, Phentermine,
38:24
I describe it as high-dose caffeine for my patients, but it's a stimulant and
38:28
it suppresses appetite.
38:29
And it has a single mechanism of action or a single way it helps with weight
38:34
loss of suppressing appetite. And it's pretty effective at that.
38:38
It has the same side effects as your other stimulants, irritability,
38:41
insomnia, dry mouth, dizziness.
38:44
It can have some GI symptoms, but nothing like the GLP ones.
38:48
It can be used with hypertension that's well-controlled. So that's not a contraindication,
38:52
but hyperthyroidism and cardiovascular disease, most of which our patients don't
38:55
have. So most patients can be on fentramine.
39:00
Topiramate, it works in the brain. So I kind of talk about that fentramine tries
39:05
to recreate what the GLP-1s do in the brain.
39:08
It helps with the like food cravings or dopamine release or kind of binge episodes,
39:15
working mostly with GABA activity.
39:17
Side effects, It was studied as an anti-epileptic at higher doses.
39:21
So I do talk about the side effects, especially the cognitive dysfunction,
39:25
which can be like word-finding difficulty.
39:27
Most of my patients tolerate it just fine.
39:29
And then I don't routinely get labs, even though we know it can cause a metabolic
39:34
acidosis. Again, those are at higher doses.
39:36
But I do talk about decreased sweating and that they need to drink water.
39:40
And then you may have read about that topiramate can interact with birth control.
39:44
That's really only at doses above 200 milligrams, and we don't go above 100.
39:48
For this indication, but it is teratogenic. So it can cause oral and cleft palate and SGA.
39:56
So it's contraindicated in pregnancy.
39:59
Topiramate by itself, it's not FDA approved for obesity. It wasn't on our list
40:04
of meds that I showed you.
40:06
But it is used off-label, again, because it works in the brain as like night
40:10
eating syndrome or sleep-related eating or binge eating.
40:14
And then along with metformin, it is one of the medications that you can prescribe
40:18
when you start obesogenic medication like an atypical antipsychotic to try to
40:23
prevent the weight gain.
40:26
So here's the study for the phase-through trial for phentermine topiramate extended release.
40:31
It comes in two doses. So the red is the mid-dose and the orange is the high dose.
40:35
And that high dose was about, you know, 10% change in BMI is what we saw on its effectiveness.
40:42
The combination capsule, so it combines phentermine with extended release topiramate,
40:47
which is great because you don't want to take phentermine later in the day because it's a stimulant.
40:51
So you get kind of all-day effectiveness works by reducing appetite,
40:56
enhancing your fullness.
40:58
And then there is a mechanism that they work together. We don't fully understand,
41:02
but that does together really does produce more weight loss than either drug separately.
41:07
And so they definitely complement each other.
41:09
And they're better tolerated doses of each in the combined capsule.
41:16
It comes in weird dosing. I don't know about all these numbers.
41:18
If you see those topiramate numbers, like why not 25, 50, 75-100,
41:22
like we would do with topiary mid-by-self.
41:24
But there's four doses, but the mid-dose is the 7.546 and the high dose is 1592.
41:31
And all that says there on the right is basically you try the mid-dose for 12
41:35
weeks. If you don't get effectiveness, then you go up to the high dose.
41:37
But there are four doses of it available.
41:40
Things to know about it is it is in a REMS system, like Accutane is,
41:45
if you're prescribed up and around that. Now, Accutane is more complicated,
41:48
like the prescriber has to do something.
41:51
But for this one, the prescriber doesn't have to do anything special,
41:54
but just not all pharmacies will carry it.
41:56
And it's in that because it's teratogenic. So should your patient be on birth control?
42:00
I mentioned I don't do lab monitoring. And then, so what does this drug cost?
42:04
Because if their insurance doesn't cover GLP-1s at all, it may not cover or
42:10
doesn't cover drugs for weight loss at all. It may not cover this medication either.
42:15
So I looked these up for the zip code for Fort Sam because that's the one I knew.
42:19
It is not bad. It's generic. So make sure your patients are looking for the generic.
42:25
And of course, cost does vary. So this was just one example.
42:28
But typically, patients can get it for about $60 a month for a one-month supply.
42:34
Or fentamine and topiramate can be prescribed by themselves because while $60
42:39
a month is a lot more affordable than the GLP-1s.
42:42
That is still a barrier for a lot of patients.
42:45
So, phentermine doses are listed there, and topiramate doses are listed there.
42:50
The topiramate dosing is similar. Phentermine, by itself, though.
42:56
Does not come in lower than a 15-milligram capsule.
42:59
If you look it up, there is a 4 and an 8-milligram, but those have to be taken,
43:04
multiple times a day before each meal, which nobody's going to do.
43:07
So I do try to mimic QC dosing, but it is different.
43:12
But Phentermine is a lot cheaper. So even if the insurance won't cover Phentermine
43:16
because it's for weight loss, about $10 a month.
43:19
And then Topiramate, again, about $10 a month. It doesn't matter if you do 25-milligram
43:28
two tablets or 50-milligram one. They're about the same.
43:31
I mentioned that Q-Semia has extended release Topiramate in it.
43:35
50-milligram Topiramate extended release is $70 to $90 a month.
43:39
So they might as well be getting Q-Semia. So I'm not quite mimicking that they
43:43
are on the shorter-acting topiramate.
43:46
So if my patient, this is the most affordable option, and I have a lot of patients on this combination.
43:54
So I take the Phentermine 37.5 milligram tablet and have them break it in half to get that 18.75.
44:00
And then I have them do topiramate 25 milligrams for a week and then go up to 50.
44:04
I do have them take it in the morning to mimic Qsemia, but you do have options
44:09
to divide it twice a day if they have some night symptoms.
44:12
And this is a very well-tolerated and effective regimen.
44:16
If it's not effective, you do have more options. We certainly can go up on the
44:19
dose of fentramine. We can increase or the topiramate.
44:23
And so I do have options to kind of tweak that.
44:26
Okay, so hopefully we have a little bit of time to get, I think we do, to get back to our case.
44:30
Choosing a medication. So just like any other condition, you want to think about
44:35
how effective it is, side effects, contraindication, patient preference.
44:39
Some of my patients say no needles.
44:41
Nope, that's not okay for me. And then we go down our oral medication options.
44:46
GLP-1s are the most effective and very few med-med interactions,
44:51
but insurance coverage is a huge issue.
44:53
Simaglutide is the really only realistic cash pay option for people 17 and under.
44:58
And then some patients really want a GLP-1, even if they have coverage for it.
45:04
If they have a lot of stomach issues or chronic GI issues or DGBIs or,
45:11
you know, like cyclic vomiting and that kind of thing, I would hesitate to start a GLP-1.
45:15
You're just going to make that worse. Phentamine and topiramate separately is
45:19
the most accessible option.
45:21
Phentermine, there is a FDA warning about serotonin syndrome,
45:25
but that's lack of data, not any known data.
45:29
And the Endocrine Society still recommends prescribing phentermine with SSRIs or SNRIs.
45:34
Where I run into issues is if my patient's also on a stimulant.
45:38
I'm not going to prescribe phentermine if they're also on Adderall.
45:40
So a patient with ADHD, this can become problematic.
45:43
And I mentioned with topiramate, really, the only patient with topiramate besides
45:48
pregnancy consideration is if they have epilepsy.
45:51
You'll need to work with their neurologist.
45:53
For treatment goals, I do talk to them about slow and steady weight loss is
45:57
the way to go. So no more than one kilogram per week.
46:00
Slower is kinder to their body.
46:03
And especially to tolerate the GLP-1s that they must eat regularly.
46:08
A lot of my patients are skipping breakfast and even skipping lunch.
46:11
And so talking about that is something I go over in a lot of detail.
46:14
And then as far as like, I do talk to them, you know, you're not signing up
46:19
that you're taking a medicine for life, but these are controller medications.
46:22
And if you do take this and lose some weight and then stop them,
46:24
most people gain weight when they stop these medications. So we have a,
46:28
I talk a lot about that as well.
46:30
All right, we made it back to our case.
46:34
So remembering our patient, she has some psychiatric comorbidities,
46:37
history of binge eating disorder.
46:39
Her stratera is not a stimulant. So even though she has ADHD,
46:43
we don't have that med-med interaction.
46:46
So, does she meet criteria for treatment? She does have class 2 obesity.
46:50
She does have her history of binge eating disorder, which is not a contraindication,
46:54
but we do want to be cautious in this patient, although there might in the future
46:58
be an indication for GLP-1s to treat binge eating disorder.
47:02
And we also know topiramate is used off-label for binge eating disorder.
47:06
She gets insurance through her parents, so GLP-1s are not covered.
47:10
She's also on two SNRIs, which I had to—and that's quite a dose of duloxetine.
47:16
But that's managed by her psychiatrist, so that was on purpose.
47:20
And again, it's a theoretical risk, so fentramine is still an option.
47:24
So for her, we ended up—really all the options are available,
47:29
and so shared decision-making.
47:30
For her, we ended up doing the Q-Semia capsule.
47:33
She was very nervous about being on a stimulant because she had not great experience
47:38
with like stimulants for ADHD. So the QSIMIA extended release capsule has a
47:44
much lower dose of fentramine.
47:47
All right. I'm going to get to questions. Just this slide was talking about,
47:52
that there are trials going on for 6 to 11-year-olds. Nothing's approved yet.
47:58
But loraglutide will probably be the first one we see in 6 to 11-year-olds.
48:02
Semaglutide is done collecting enrolling patients and should be their data should
48:08
be available at the end of the year and then terzepatide still working on getting
48:12
approved for 12 to 17 year olds and then q simia is not,
48:15
actively pursuing approval under age 12 at the moment,
48:19
I was just showing the study with Manjaro for diabetes, but that it did produce weight loss in kiddos.
48:27
All right. So I think I left some time for questions, if we have any.
48:33
Thanks so much, Dr. Ditch. I just wanted to, okay, so I'll go ahead and read
48:38
a couple questions out here.
48:39
Dr. Krollman was asking, we use compounding pharmacies all the time for other
48:44
medications. Why can't we find and recommend a quality compounding pharmacy
48:47
for GLP-1 meds too, rather than throwing up our hands and saying it's too risky?
48:52
So, I mean, certainly I know of physician colleagues that that is their full-time
48:56
job, that they partner with a pharmacy and do compounded medications.
49:01
So I wouldn't say that's not something that you can do.
49:05
If you are going to incorporate that in your practice, there that would be,
49:12
you would you know like I said you would want to know where you're who you're
49:15
getting it from where you're getting it from and like develop that relationship,
49:18
just just because they're not.
49:22
Regulated all the same and widely available so it's not that we you can't do
49:26
it it's just you know you become kind of the prescriber in the pharmacy you know working with them.
49:33
It's just, what I don't, what I meant by that I don't do them is that like,
49:39
if I don't have my patient go get them online from, and they're getting them
49:44
from some other prescriber that's like filling it and like ordering it and coming to the mail.
49:47
Like, I'm not going to manage that, like tell, give them dose advising and stuff
49:52
like that. Like they got to do that. So if you guys, there are,
49:55
there are physicians working for these companies to do it. So that's not like, that's not an,
50:00
And then some of them are very legit. So some of them are safe and definitely
50:07
a lot of people take and do well. Some of them are not.
50:10
And they're just not universally regulated. So you just have to be careful with them.
50:15
Okay, thanks. We have a question on that topic, which is, any research U.S.
50:21
Or worldwide using hypnosis with non-genetic, non-disease-driven obesity?
50:26
Anything you've heard about that? Any psychiatry interest in these kids been using any of this?
50:33
I don't. I can't quote any data. So full disclosure with that.
50:37
I do know we are recognizing.
50:42
The food noise thing. And with the GLP-1s, this dampening of the dopamine release
50:47
from eating these hyperpalatable foods is how some of these medicines are helping.
50:51
And in fact, that's why they're and then they're finding people in GLP-1s like
50:54
there's less alcohol use disorder.
50:56
It's helping with other addictive behaviors. And we know hypnosis works for
50:59
like smoking cessation.
51:01
So I would fully believe that there could be a role for that.
51:05
I'm not, you know, I'd have to research if there's any ongoing studies.
51:09
I'm also a medical acupuncturist and there are acupuncture protocols as well
51:13
for obesity. So the roles of complementary and alternative medicine,
51:17
absolutely. Like, and people could pursue both at the same time if they wanted to.
51:22
Okay. Dr. Gross is asking, has extended-release methylphenidate been studied for weight loss? Dr.
51:30
Not to my knowledge, but certainly we know that all the stimulants can suppress appetite and,
51:38
I don't actually know the data comparing the different long-acting stimulants,
51:41
but I personally, in my experience, feel like that, I think you're referring
51:45
to Concerta, does have a pretty potent appetite suppression.
51:50
And then, of course, if my patients, or a lot of my patients,
51:53
I can't give them fentramine if they're on those.
51:56
But I do talk to them about, well, if you did get some appetite suppression
51:59
and you're, you know, let's go to your max tolerated dose of your stimulant,
52:03
it'll help with your ADHD.
52:04
And then you can add just topiramate to that.
52:07
And see if you get the same synergenic reaction with that stimulant into a pyramid.
52:13
So I have done that in some patients.
52:15
But I do talk to them about optimizing their ADHD stimulant,
52:19
especially if they're getting that added benefit of weight loss.
52:23
If they're on their stimulant and it's not causing any weight loss and it's
52:26
not controlling their ADHD symptoms, then we have some shared decision-making like,
52:30
do we want to try a different stimulant or do we want to try a non-stimulant
52:34
ADHD medicine and then go with, then that does open up fentramine and topiramate
52:39
as an option for their obesity.
52:42
Okay, thanks. And then our last questions are, any thoughts about retatridide,
52:49
trutide? Sorry, I don't know who said these words. And will it eventually replace trisepatide?
52:55
Yeah, so I had to kind of go quickly over this, or skip this slide because it's very busy.
53:00
But yeah, everyone's very excited about retatridide.
53:04
It is a GLP-1 and a GIP like trisepatide, but then has glucagon in it as well. So we got three drugs.
53:10
They're in their phase three trial for adults. So if you look around the effectiveness,
53:14
that's the phase three trial so far that we've seen the most effective intervention,
53:19
weight loss treatment drug.
53:22
I, so I don't, I think, I don't know, I think we're expecting it in 2027. That will be for adults.
53:28
So when it comes out for kids is probably quite a while, but yes,
53:32
I've heard a lot of excitement.
53:33
There's some other ones on here. There's some more oral options coming out.
53:36
There's some that are like a combo injectable and oral. There's a once monthly
53:41
drug on here. So there's a whole bunch of drugs in the pipeline.
53:45
If you look at all of them, all those effectiveness are above 10%,
53:48
which that's what QSIMIA is.
53:49
So we've got a lot in the future, which at least for children,
53:54
hopefully makes the ones we're currently offering more affordable,
53:56
like while these new ones come out.
53:58
But there is a lot on the horizon in this, which is exciting that we have actually
54:04
effective things to offer for this condition that we've kind of struggled to treat in the past.
54:09
Okay. And then real briefly, and a couple of questions about accessing genetic
54:14
testing for obesity and also online questionnaires about obesity,
54:18
if you have any recommendations on that.
54:21
For the genetic testing. So the only one I'm offering in my clinic,
54:25
because I'm not a geneticist or an endocrinologist, and I really don't see them
54:28
until they're older, since I do adolescence is the one I showed you.
54:32
But endocrine definitely, the endocrinologists in our practice,
54:36
they definitely refer, if you're really thinking about it, there's more extended
54:40
testing to do to find these drugs or to find these conditions.
54:45
The testing is covered by insurance as variables, so the genetic testing is expensive.
54:49
So if it's not picked up on the free test, it's just a variable of whether further
54:53
genetic testing will be picked up, but that definitely is an opportunity.
54:58
And then online questionnaires for obesity, I'm not 100% sure what we're referring
55:03
to for that, like for screening for it, or I'm not sure.
55:09
Yeah, I'm not entirely sure. Maybe some questions about, you know,
55:14
history, diet, that kind of thing, like just a.
55:18
Developmental screening. Yeah, so I have, yeah, I definitely have,
55:25
I get that history. My patients also see a dietitian, So I really get to focus
55:29
on my section to really focus on the medication. But.
55:34
I tell them the comprehensive care is still important. The exercise is still
55:37
important. The diet changes is still important. So all that doesn't go away
55:41
because we prescribe medicine.
55:43
Yeah, and then there was another question about if you have an office-based
55:46
dietitian or you just refer them to somebody else. Both.
55:50
So I have one that they can get back with me, which is great to not miss school,
55:54
but a lot of them either aren't interested. If they're not interested,
55:57
I still see them. I don't require it, but I highly recommend it. Right. Okay.
56:02
All right. Well, I really appreciate your time. That was a great talk.
56:05
Thank you so much, Dr. Dish.
56:08
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56:18
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