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Weight loss medications (part 2)

weight loss Jul 13, 2022

In last week’s blog, we discussed the fact that Low Carb Real Food along with other lifestyle changes (sleep, gut health, movement, stress management) are the foundations for permanent weight loss. Some people need some help to lose weight with medication or even surgery and if so, that is not a failure. 

The discussion around using medication (and indeed surgery) must be robust as all medications have side effects. There are always pros and cons and patients need to be fully informed of all of these. 

Last week we discussed Semaglutamide also known as Ozempic or Wegovy. It is extremely popular and as such, there is currently a worldwide shortage, especially in Australia.

This week we are discussing 

  • Liraglutamide (Saxenda)
  • Naltrexone/Bupropion ER (Contrave)
  • Phenteramine (Duromine)
  • Liraglutamide (Saxenda) 
  • Topiramate (Topamax)
  • Orlistat (Xenical)
  • Metformin (Diabex)


Liraglutamide (Saxenda)

This was the first GLP-agonist (same drug class as Ozempic) to be used for weight loss and to tell you truth, I  rarely prescribe it. In fact, I (Dr Lucy) only prescribe if people are unable to get Semaglutamide. 

How much weight will I lose on Saxenda?

Saxenda is really quite underwhelming in its results. The trials show after 2 years the average weight loss is 5%. So if you weigh 100kg, you can expect to weigh 5 kg less after 2 years. Like the Ozempic trial, some people are hyper responders and lose more, and some people lose less. Also, note that the trials weren’t using a low carb approach, so maybe if you are eating a low carb diet then you will see better results. 

What is the dose of Saxenda?

Saxenda is a daily injection and the cost in Australia is $379 a month.

It does seem to be better tolerated than Ozempic as far as gastrointestinal side effects go and as such, the maximum dose can be reached much quicker. 

Week 1

0.6mg once daily

Week 2

1.2mg once daily

Week 3

1.8mg once daily

Week 4

2.4mg once daily

Week 5+

3.0mg once daily

Like Ozempic, don’t increase the dose if you are having side effects. Some people will see weight loss occurring at the lower doses, but it is important to remember that the trials were all conducted at the higher dose of 3.0mg 


Naltrexone/Bupropion ER (Contrave) for Weight Loss 

Contrave is a mixture of 2 medications that are used to manage addiction. 

Contrave combines an opioid receptor antagonist (naltrexone) with a dopamine and norepinephrine reuptake inhibitor (bupropion). It is thought to be helpful for these people who experience food addiction. 

How much weight will I lose on Contrave?

The studies for this were quite underwhelming. After 12 months a person can expect to lose 9% of their body weight compared to 5% of the people who took a placebo. Now it may be that for people who do have a serious food addiction, this result could be more but the data doesn't state that. As always there are hyper responders who lose more. If weight loss is less than 5% at 16 weeks, it is not recommended to continue with Contrave.

How much does Contrave cost?

Weight Loss medications are not subsidised in Australia. The cost at the time this article was written is $225 per month 


What is the Dose of Contrave for Weight Loss?

What are the side effects of Contrave?

Contrave has a large list of side effects. The most common is dry mouth and gastrointestinal side effects such as nausea, vomiting and constipation. Other common side effects include dizziness, tremor, and lethargy. 

There are less common but serious side effects of Contrave including seizures, blood disorders, 

Can everyone take Contrave? 

The short answer is No! 

You can not use Contrave if you a pregnant or breastfeeding. 

You can not take it if you have uncontrolled hypertension, a seizure disorder or a history of seizures.

You can use it if you are going through alcohol or benzodiazepine withdrawal or if you are dependent on chronic opioids or opiate agonists (e.g. methadone), or if you are in acute opiate withdrawal.

You should not use it if you with a history of bipolar disorder or a current or previous diagnosis of bulimia or anorexia nervosa.

You cannot use Contrave if you have severe liver or kidney disease.


Phenteramine (Duromine) for Weight Loss

This is an old medication. Duromine has been used as a weight loss medication for many years

How does Duromine work?

It works by mimicking the sympathetic nervous system and as such is an appetite suppressant. 

How much weight will I lose on Duromine?

The studies on Duromine suggest at the end of 3 months a person can expect to lose 3% of their body weight and 6% by 6 months. The weight loss is not necessarily maintained once the medication is stopped.

What are the side effects of Duromine?

Duromine can have significant side effects for many people as it acts as a sympathomimetic meaning it acts on your fright and flight nervous system. 

The side effects include rapid heart rate, increased blood pressure, tremor, feeling uneasy, anxiety and insomnia.

Can everyone take Duromine?

There are some people for whom Duromine should never be prescribed. This includes uncontrolled hypertension (Very high blood pressure) and cardiac valvular disease.

There is also a condition called pulmonary hypertension and people with this should not take Duromine. Anyone with underlying anxiety and other mental health condition needs to be cautious. Women who are pregnant or breastfeeding should not take Duromine. 

Duromine should always be prescribed and monitored by a doctor due to these side effects and risks. Whilst this seems obvious, people do buy these medications online but at Real Life Medicine, we do not recommend this. 

How long can you take Duromine?

Traditionally Duromine has been used short-term to kick-start someone's weight loss journey. There were fears about its safety long term. These days it can be prescribed long-term with the caveat that it does require monitoring of blood pressure, heart rate and other side effects. 

How much does Duramine cost?

The price varies on the dose. In Australia, Duromine costs between $110 and $147 per  month

What is the dose of Duromine?

There are 3 doses of Duromine- 15mg, 30mg and 40mg.

The dose needs to be titrated in consultation with your doctor. The principles are the same with all medications, the lowest effective dose with the least side effects 


Duromine is now becoming less and less prescribed due to the effectiveness of GLP-1 agonists like Ozempic and should be used when Ozempic is not available or not tolerated. 


Topiramate (Topamax) for Weight Loss

This is a medication that is used to manage epilepsy and prevent migraines. It is used off-label as a weight loss drug, meaning its principal use is not for weight loss and the TGA in Australia has not approved its use for weight loss. 

It acts by reducing hunger and increasing satiety (fullness). 

How much weight will I lose on Topamax?

The average weight loss is approximately 5 kgs but again there will be hyper-responders who lose more. 

How much does Topamax cost? 

It is by far the cheapest medication and usually under $10 per month.

What is the dose of Topamax? 

The dosing for Topamax is complicated and needs to be discussed with your doctor. As always the principles are the lowest effective dose with the least side effects 

What are the side effects of Topamax?

Topamax has side effects including tingling in hands and feet, dry mouth, constipation, altered taste sensation, insomnia, dizziness and increased risk of kidney stones 

It has the rare side effects of glaucoma, depression or suicidal ideation. 

It should not be used if you have glaucoma, kidney stones are pregnant or breast feeding. It needs to be monitored for effects on mental health.

There is a combination drug of Topamax and Duromine but this is not yet available  in Australia 

Orlistat (Xenical) for Weight Loss 

This medication blocks the absorption of dietary fat. Fort this reason we do not recommend it at Real Life Medicine. Dietary fat is not the problem with obesity. It is excessive carbohydrates resulting in insulin resistance.  It has hideous side effects including oily diarrhoea and faecal incontinence. 


Metformin for Weight Loss

Metformin is a medication that has been around for a long time. It is a medication that was previously only prescribed to people with Type 2 diabetes. However, it is useful for hyperinsulinaemia (high circulating insulin) and so can be prescribed to women with PCOS, people with insulin resistance and pre-diabetes as well as diabetes. 

Its usual side effects are gastrointestinal: nausea, vomiting diarrhoea (are you seeing a theme?)

It is not really used as a weight loss drug as such but can certainly help with opening your woodshed  if you have high circulating insulin levels.


Are Medications Good for Weight Loss? 

We think you will all agree that medications come with the risk of side effects and some of these are serious. The decision on using medications involves the assessment of the risk (side effects and the cost) vs the potential benefit. 

The medication that we use most frequently (apart from metformin) as an adjunct for weight loss is Semaglutamide(Ozempic). This is because the benefit of potential weight loss outweighs the side profile.  We rarely prescribe other medications because the risk of side effects outweighs the benefits of the small amount of weight loss in most people. 


At Real Life Medicine, we firmly believe that long-term weight loss requires 2 steps. 

We must address the 

1/Physiology (metabolic hormones of insulin and leptin) and the most effective and safest way to do this is with a low carb real food diet. You can find more about that here

2/ Psychology which is really understanding your unique relationship with food. This is complex and takes time. The processed food industry plays a huge role in this, for which it takes no responsibility- Just like the alcohol, gambling and tobacco industry. Unpacking years and years of conditioning and understanding the nature of addiction and learning to process emotions are entirely possible and in the end, will give you food freedom. 


Permanent weight loss requires more than a meal plan.

Permanent weight loss requires more than a pill or an injection 

Permanent weight loss requires more than surgery. 

These are tools and can definitely be useful but they are a piece of the puzzle and not the whole jigsaw. 


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