I put on 35lbs in 6 months on quetiapine. I lost that weight so fast when I stopped the quetiapine that my GP tried convincing me to have an endoscopy as she was worried I had cancer. It was particularly odd because not a single Dr showed any interest when the weight piled on. When my triglycerides came back elevated I was told to eat porridge.
In the UK patients on antipsychotics are supposed to have an annual health check to monitor weight, BP, cholesterol, etc. GP practices receive money from government to do these checks. In reality you are asked to confirm your next of kin. Nothing else. The 1st time my weight was taken was 2 months after I stopped the quetiapine and was due to weight loss.
Unfortunately, about 9 months later I had to swap from pramipexole to pregabalin for RLS and slowly put those 35lbs on across about an 18 month period. I would rather be fat, and the consequences of being fat, than go through the living nightmare that was uncontrolled RLS.
100% agree that risk/benefit profile of SGAs is crap (have 50 extra lbs, have some dyslipidemia, have a bit of DM2 as a treat; also, if you examine those pharma-funded trials, they don’t even seem to work all that well for a lot of the add-on indications?!)
HOWEVER (*puts on HAES physician hat; yes I am a Genetically Scrawny person who fell into the “BMI normal” category the day I delivered a full term baby; bear with me here*) the place I would push back is the use of pathologizing terms for fat like “obesity” (🤮). So very happy to go down the “BMI is highly flawed” rabbit hole with every single one of my patients (most of whom have, honestly, some form of gnarly BMI anxiety or shame) and at least drop the “greatest hits” of: 1. Diets statistically don’t work (95+% failure rate; reliably lead to weight cycling which is REAL BAD for health) 2. The “best” BMI category to be in, mortality wise, is the “overweight” one (which wasn’t even “overweight” until the late 1990s when Pharma had some blockbuster weight loss drugs coming to market and wanted to rejigger the categories so that more people qualified for like Fen-Phen) and the “worst” is “underweight” (yes, even if you control for all the cachectic cancer patients and the like. I was previously in anesthesiology and we do like our data!) My point is: the fat people are here, it’s hard to make people un-fat once they are fat, and the data on the weight ITSELF is actually NOT clear (if you’re talking DM2 or HLD or HTN, by all means treat that, of course) so let’s not also stigmatize the people in addition to having iatrogenically caused their body shape/weight distribution pattern/what have you in many cases. I am told by fat people that the preferred term is “fat” so that is what I use. ✌️
I will say that at least one of the other physicians in my clinic “qualifies” for a GLP-1 agonist based on BMI and has said “no thank you” based on the hazy stuff trickling out about long term risks (I don’t necessarily think she is a HAES person, for whatever that is worth!)
I honestly would be giving a side eye to the GLP-1s if I were a fat person, given what is known and also not known (long-term risk wise) about them, but of course anyone is free to do their own math about this.
Totally fair and that is another indication! (I do know the indications overlap not uncommonly). I meant to be speaking about their use for intentional weight loss specifically and only (vs. for DM of any flavor). Did not mean to blanket demonize the class of medication, because you are right - it’s always a risk benefit calculation and my guiding principle is: let’s make sure people have good, full information so they can weigh those risks and benefits for themselves. (I feel that medicine as a field is not actually great at delineating risks when we’re trying to nudge someone to do something we as a field “want” them to do, and I think this is a major issue).
I suppose I also see the twin issues, within psychiatry or medicine more generally, of: let’s push everyone into using metabolic nightmare medications without full information, and then out of the other side of our (collective) mouth, go on about “AAAA OBESITY” such that people feel like absolute shit about themselves. My understanding (as well as clinical experience thus far) with GLP-1 agonists is that when used for weight loss specifically, there will be some initial loss, which depending on your starting weight might seem significant or like a drop in the bucket, and then a plateau. And then you have to take the med for the rest of your life to maintain the weight loss. Which depending on your perspective or experience might seem like a great deal or a pile of crap. I have heard both takes from my patients!
I view this as a real problem. Obesity often contributes to depression and these meds contribute to obesity. We should always pick treatments that are weight neutral or than favor weight loss. Meds that cause weight gain should only be used after a very careful consideration of risks and benefits. I follow this rule in treating cardiometabolic diseases and it definitely helps in that setting.
I couldn't agree more bill. The data keeps getting worse for interventions that don't work well enough as it is! Thanks for the comment and make sure to check out some of the prior pieces about obesity and antipsychotic medicines too :)
I put on 35lbs in 6 months on quetiapine. I lost that weight so fast when I stopped the quetiapine that my GP tried convincing me to have an endoscopy as she was worried I had cancer. It was particularly odd because not a single Dr showed any interest when the weight piled on. When my triglycerides came back elevated I was told to eat porridge.
In the UK patients on antipsychotics are supposed to have an annual health check to monitor weight, BP, cholesterol, etc. GP practices receive money from government to do these checks. In reality you are asked to confirm your next of kin. Nothing else. The 1st time my weight was taken was 2 months after I stopped the quetiapine and was due to weight loss.
Unfortunately, about 9 months later I had to swap from pramipexole to pregabalin for RLS and slowly put those 35lbs on across about an 18 month period. I would rather be fat, and the consequences of being fat, than go through the living nightmare that was uncontrolled RLS.
100% agree that risk/benefit profile of SGAs is crap (have 50 extra lbs, have some dyslipidemia, have a bit of DM2 as a treat; also, if you examine those pharma-funded trials, they don’t even seem to work all that well for a lot of the add-on indications?!)
HOWEVER (*puts on HAES physician hat; yes I am a Genetically Scrawny person who fell into the “BMI normal” category the day I delivered a full term baby; bear with me here*) the place I would push back is the use of pathologizing terms for fat like “obesity” (🤮). So very happy to go down the “BMI is highly flawed” rabbit hole with every single one of my patients (most of whom have, honestly, some form of gnarly BMI anxiety or shame) and at least drop the “greatest hits” of: 1. Diets statistically don’t work (95+% failure rate; reliably lead to weight cycling which is REAL BAD for health) 2. The “best” BMI category to be in, mortality wise, is the “overweight” one (which wasn’t even “overweight” until the late 1990s when Pharma had some blockbuster weight loss drugs coming to market and wanted to rejigger the categories so that more people qualified for like Fen-Phen) and the “worst” is “underweight” (yes, even if you control for all the cachectic cancer patients and the like. I was previously in anesthesiology and we do like our data!) My point is: the fat people are here, it’s hard to make people un-fat once they are fat, and the data on the weight ITSELF is actually NOT clear (if you’re talking DM2 or HLD or HTN, by all means treat that, of course) so let’s not also stigmatize the people in addition to having iatrogenically caused their body shape/weight distribution pattern/what have you in many cases. I am told by fat people that the preferred term is “fat” so that is what I use. ✌️
Well, GLP-1s are also here. Thoughts?
I will say that at least one of the other physicians in my clinic “qualifies” for a GLP-1 agonist based on BMI and has said “no thank you” based on the hazy stuff trickling out about long term risks (I don’t necessarily think she is a HAES person, for whatever that is worth!)
Given the system I work in (VA) I leave that bit of counseling to endo, and I do not interfere unless someone specifically asks for my opinion.
I honestly would be giving a side eye to the GLP-1s if I were a fat person, given what is known and also not known (long-term risk wise) about them, but of course anyone is free to do their own math about this.
I don't have diabetes anymore thank to them. May people in that boat. Risks and benefits to be balanced always.
Totally fair and that is another indication! (I do know the indications overlap not uncommonly). I meant to be speaking about their use for intentional weight loss specifically and only (vs. for DM of any flavor). Did not mean to blanket demonize the class of medication, because you are right - it’s always a risk benefit calculation and my guiding principle is: let’s make sure people have good, full information so they can weigh those risks and benefits for themselves. (I feel that medicine as a field is not actually great at delineating risks when we’re trying to nudge someone to do something we as a field “want” them to do, and I think this is a major issue).
I suppose I also see the twin issues, within psychiatry or medicine more generally, of: let’s push everyone into using metabolic nightmare medications without full information, and then out of the other side of our (collective) mouth, go on about “AAAA OBESITY” such that people feel like absolute shit about themselves. My understanding (as well as clinical experience thus far) with GLP-1 agonists is that when used for weight loss specifically, there will be some initial loss, which depending on your starting weight might seem significant or like a drop in the bucket, and then a plateau. And then you have to take the med for the rest of your life to maintain the weight loss. Which depending on your perspective or experience might seem like a great deal or a pile of crap. I have heard both takes from my patients!
I view this as a real problem. Obesity often contributes to depression and these meds contribute to obesity. We should always pick treatments that are weight neutral or than favor weight loss. Meds that cause weight gain should only be used after a very careful consideration of risks and benefits. I follow this rule in treating cardiometabolic diseases and it definitely helps in that setting.
I couldn't agree more bill. The data keeps getting worse for interventions that don't work well enough as it is! Thanks for the comment and make sure to check out some of the prior pieces about obesity and antipsychotic medicines too :)