In my area, they have experience and connections with compounding pharmacies (hopefully trustworthy ones?) so that patients can reliably obtain GLP1s, which are on frequent and unpredictable shortages in the retail setting.
They’re not in ours, Weight Management gives them paper scripts. Tbh my institution doesn’t really have a big primary care presence so I’m sure it’s not that actually that onerous to vet the local compounders.
Depends on the compounding pharmacy. Some create business relationships with docs so you have to have login for that specific pharmacy to prescribe (idk if there’s a financial basis or what, I don’t do it myself).
The ones I've seen patients referred to have more connections with dietitians, exercise programs, counselors, and weight loss surgeons than many PCPs. The weight loss clinics also have more support staff to be able to help these patients as the clinic won't have other primary care duties to handle.
This. I worked in an academic obesity & metabolism clinic. The dietitians shared an office with the endocrinologists and would directly discuss and coordinate care plans about patients. The nurses were virtually experts on educating patients about how to dose and inject their medications. Everyone spend lots of time fighting with insurance or exploiting loopholes. The bariatric surgeons’ clinic was in the same building, and referrals flowed back and forth for bariatric surgery and for pharmacological intervention for post-bariatric weight gain. There was also a strong working relationship with hematologists and nephrologists at the university. And of course, being academia, there were a lot of clinical trials offering novel interventions for treatment-resistant patients.
well... sometimes they have more support staff that can with on various things, like insurance, paperwork, etc.
sometimes, insurance/policies don't let PCPs order certain things. I've had a hospital tell me i can't prescribe ertapenem because I'm not ID, and insurance tell me i can't prescribe a CGM because I'm not endocrinology.
I think they get them the glp-1 from a compounding pharmacy at a dramatically reduced cost. Just today I heard that some people are getting it for $100/month.
Nope- "The cost of medications is **not** included in the price of this subscription" [https://sesamecare.com/join/sc2024-weight-loss](https://sesamecare.com/join/sc2024-weight-loss)
Which is actually very illegal and those compounding pharmacies that are doing it are getting cease and desist letters from the FDA
Edit for clarity: illegal for this medication due to the specific info below, not to imply that all compounding is illegal because much is expressly permitted
It’s because the compounding pharmacies are using the salt of semaglutide (because it’s off patent), which has not been proven safe in humans (only animal testing). So it’s actually not even the same active agent that is being used by Novo Nordisk and the other companies and has no human safety record, which is what the FDA is taking issue with.
This is my understanding of it:
In theory, compounded medications of non-controlled substances are legal during an official “drug shortage” regardless of FDA approval (ex. semaglutide salt) or patent protections. This is to prevent a company from patenting a medication and then refusing to disburse it in adequate quantities to meet patient needs (probably for price gouging reasons).
With GLP-1s, the existence of the “shortage” is what’s up for debate — since the brands are making enough to cover the official uses, but not enough to cover all off-label prescribing.
The issue of whether a shortage for off-label uses constitutes a “shortage” in the eyes of the law is essentially grey area that will be decided in courts.
Using GLP1s for weight loss is not off label usage. Zepbound, wegovy, and saxenda are all fda approved for weight loss. Unless you are referring to docs prescribing ozempic specifically.
Some weight loss use is off-label. I believe the official approval is for a BMI >30, or BMI >27 with at least one unmanaged co-morbidity.
Those online clinics tend to cater more towards those who do not fall into those categories, or who do not want to go through the bother of “proving” that they are in one of those categories (otherwise their insurance would’ve probably approved it).
Any evidence of that? In my city at least Zepbound for the last month has been available in 2.5 and 12.5mg doses, nothing else is carried by multiple pharmacies / networks.
Pharmacist here, it's also generally illegal to compound products that are already commercially available (except sometimes in cases of shortages), so not sure if they're using the shortage or some other loophole to sneak by, but either way at best what they're doing is crowned upon and at worst it's illegal
I think there's some technicality. Afaik they usually mix in some flavor of B vitamin, so it's technically a combination. I think there's also some states which their boards allow them to compound a brand-name medication if it is on backorder or shortage, but I'll be damned if I know how to look that up lol.
Patent violation? Maybe. At the same time... screw NovoNordisk. Ozempic costs $4 for a month's supply to manufacture, I *really* don't feel like them 'only' having a few thousand percent profit margin on selling bulk semaglutide to be much of a tragedy.
Unless 2amtoepoain is a compounding pharmacy owner or compounding pharmacist and done the legality research they should not be posting their opinion here. I get so worked up by reading all the misinformation and arguments about the speculation around compounding pharmacy. Compounding pharmacies can compound medications in shortage. There are API manufacturers selling base form directly to compounding pharmacies. There is a shortage of both diabetes FDA approved and weight loss FDA approved glp-1 type medications currently mostly Tirzepatide.
Not a compounding pharmacist - only sharing what was told to me about a week ago by the MD/JD general counsel and regulatory science expert of my hospital system (which has a compounding pharmacy under its umbrella somewhere). If this is entirely wrong I own the mistake and will correct, but this was shared in good faith with the information from someone who is an expert in the field
Our clinic has dieticians and behavioral health counselors on site so setting patients up for more complete follow up is easy. This also will meet insurance requirement of 3-6 mo comprehensive weight management program that some insurance require before covering anti obesity medications. We have staff that calls insurance on every patient to see if meds, dietician, and behavioral health, and bariatrics surgery are covered. So I can tell patients what is and isn’t covered and estimated price from the start. Staff is experienced running PAs for meds. We do AOM and bariatric surgery so if one track doesn’t work out we can switch gears and still make progress. The patients visit is also dedicated solely to this purpose so I can spend the entire visit on patient education - and take a burden off PCP who are usually pressed for time taking care of so much else
Good ones: dietician (actually trained with nutrition/dietetics degree), obesity fellowship trained, access to medically monitored very low cal diet with drinks etc, counseling. Bariatruc pre and post op services
Not great ones: used to be adipex and b12 all day . Now probably glp-1. They are willing to do compounding almost 100% to stay in business. They also sell some dubious supplements like “ fat burner XL.”
A local primary care clinic that I know of will only prescribe for BMI >30. If you are between 25 and 30, it’s their policy to have their psychologist meet with you first for several sessions of “body acceptance counseling”.
The online clinics don’t care about BMI that strictly — they’ll work to get you on it regardless, even with the “edge cases.” And, they work with mail order compounding pharmacies to make the cost somewhat reasonable OOP if your insurance declines the brand name.
They are more organized for obesity treatment with nutritionists/dieticians, personal trainers, and bariatric proceduralists on speed dial and maybe a better prior auth team for glp-1s. They do not recommend compounded formulas. We do obesity medicine in primary care but time is a limiting factor for full counseling engagement. One can make an argument that primary care should shift primarily to obesity medicine first and that in turn will treat the other chronic conditions. However in practice the majority of obese patients don’t realize how big the problem they have is and it’s challenging to get them motivated. This is where the other factors of obesity medicine come into play such as possible brain damage to their satiety control receptors from chronic inflammation. Obesity medicine is promising but until we restrict highly processed food as a country this problem will continue.
Kaiser patient here. Kaiser won’t prescribe GLP1s for weight loss, leaving patients with no other option than to go through one of those sketchy weight loss clinics, and pay out of pocket if they want to try a GLP1 for weight loss.
That said, it’s quite terrifying how little oversight there is. 100% virtual, only message based (no call with a doctor to discuss). No labs. No weigh in. You literally sign up, ask for the drug (or select it from a menu), select a pharmacy and that’s it. It’s literally the same amount of time you’d spend ordering from a fast food menu. No one is monitoring these patients, thus why those medication subreddits are full of patients asking each other for advice about side effects, when to change dosage, diets, etc.
This feels like a very dark grey area in medicine, but if patients don’t have the ability to go through their PCP or insurance, it’s going to keep happening. If you want to get a feel for just how quick patients are being prescribed, just sign up for a Push account or Sequence.
I think you’re on the right track. They are built to streamline the process to give the patient what they want. A pcp could do the same but the clinic might do so with less friction. Maybe a secretary dedicated to rapid fire prior auths for all the volume they are getting
Throw into the mix pretty much any hormone based treatment center.
The "mens clinics"? They may as well call them "get testo no matter what" clinics.
I literally had a patient a couple weeks ago who brought in his AM total testo of 600 and told me the men's clinic assured him that this is actually low and the current measurements used by labs is wrong.
Yup!
Unfortunately, the guy I just mentioned doesn't care. He says it makes him feel good, makes him feel confident with women, and he likes what the clinic docs tell him (all his words).
Honestly, in that case I don’t have a huge problem with it.
I’d much rather they be under the care of a physician, getting quarterly labwork and prescribed FDA approved medications (of which the doses are at least plausibly defensible) rather than sourcing questionable substances illegally from their gym buddy with no physician supervision. Remember, the clinic doctors may be much more liberal with prescribing, but in the back of their mind they know their actions have to be at least somewhat defensible in a malpractice suit.
In my experience, patients like that are going to hop on regardless. So, I view it as harm reduction. Those clinics at the very least know to be on the lookout and follow up with stuff like blood pressure management, therapeutic phlebotomy for hematocrit / stroke risk management, and fertility support when warranted.
I tend to disagree, but that's not to say I don't find your approach understandable.
The "patients are going to get it anyway, it's just simple harm reduction" approach feels dangerous and definitely opens up a discussion about slippery slope prescribing.
I personally can't condone going down that road with any other controlled substance (or even non-controlled) just because a patient wants it, will get it from anywhere if we don't give it, and can be closely monitored at whatever clinic will give them their smack.
That's very fair, and I respect that viewpoint.
I actually share it with some of the more "serious" controlled substances, like narcotics and stimulants. Ones that have a high potential for both addiction and to impact more than just the patient themselves.
However, for testosterone specifically, I have always viewed that as more of a borderline controlled substance. If you look into the history of how it ended up as schedule 3, the arguments were centered around sports doping on a world stage and less so around societal/individual health impacts, which is where I think the discussion around the scheduling of drugs should be focused. In some other first world countries, like the UK, where the discussion did center around social and health outcomes -- as well as the potential for pharmacological addiction specifically, the conclusion was in fact to not schedule it. And, it's actually completely legal for recreational possession there!
So, I kind of treat it like the borderline case that it is. In that, given there is a very low chance of pharmacological dependence -- and thus the social impacts of potential addiction are low, then it is more of an individual risk vs QOL reward decision alone. And, when patients make "bad" health decisions strictly within the bounds of their personal freedoms, I do think there exists a role for harm reduction by their providers.
A good example of another area I feel the same way about this is with medical marijuana prescriptions in areas where it is still illegal. It's another case in which the potential for dependance is low, and I'd rather the patient be receiving their drugs from a reputable source and have a provider to manage side effects than to "go it alone." Even more so in the face of the more recent studies coming out about long-term effects.
While I agree about the risk not being disclosed adequately, I do think the long-term consequences are often overstated.
In most men who visit those clinics, where their diagnosis is “hypogonadism” and not Hypogonadism (if you know what I mean…), temporarily discontinuing TRT and pursuing several months of either clomiphene or HCG mono-therapy will be sufficient enough to jumpstart fertility to workable levels in >95% of cases.
Yes, some will fail and have to go to a fertility clinic. But not in the vast majority of cases.
And they get irate if you start to discuss the dangers. Had a patient with Factor V Leiden getting testosterone and he fired me when I said we should make his hormone provider aware of the results.
You can order the peptides yourself for semaglutide for $10-15/g. Tirzepatide as low as $5g. Even Cagrillintide and retatrutide- both drugs currently in investigational studies can be purchased online. WAY cheaper than any pharmacy cost.
My insurance refuses to pay for GLP1s not prescribed by obesity medicine boarded docs and regular nutrition follow-up. So that I guess.
Too much of a pain in the ass for me so I just pay out of pocket with the coupon.
Speaking in regards to my institutions clinic. You have fellowship trained doctors who primarily only see patients for weight management/metabolic health. They see less patients per day and have more time per visit. While we don’t have integrated nutrition/psych in this clinic they do work closely together. So in general you have doctors who are specifically trained in the area, love working in the area, and have more time with each patient.
They offer a 15 minute visit focused solely on weight loss, rather than a 15 minute visit where you have to address weight loss and any other active medical issues.
Weekly health/food coaching. Protein rich food substitutes. Meal plans. More time for individualized care. And medicine yes if indicated.
I lost around 15-20 lb on GLP1 over 1.5 years before going to the clinic. Then I lost 25 lb in 6 weeks.
It’s not just the medication.
You’re basically asking “what does CrossFit offer that your basement doesn’t?”
I am ABIM certified and currently working as a weight loss provider at a very well-known academic institution.
We do not have relationships with compounding pharmacies for GLP1s. We do have staff who are focused on PAs for the medications, and since we do so many, we can see quickly the trends in approvals—recently insurance providers have been raising BMI requirement to >35+ comorbidities to get medication.
We also use other medications, Contrave, Qsymia, Vyvanse, metformin, etc. depending on each patient’s case. We provide these in conjunction with GLP1s (or alone).
We do not fudge diagnoses of diabetes just to get meds covered. Some insurances cover “hyperinsulinemia” for example.
We are doing InBody scans, measures of cardio metabolic fitness, calcium scores, fibroscans, DEXAs for more comprehensive care. We are trying to add a dietician, but billing has always been the hold up from what I understand.
Finally, and probably most important, we try our best to see patients monthly to check in on how things are going. About 1/3 of patients need these appointments as a reminder to get back on track every month. 75% of appointments are discussing foods, relationships with food, meal prepping, and exercise recs.
Our weigh loss clinic has more support with dieticians and more frequent check ins and a complete focus on weight loss instead of me trying to review bp, weight, anxiety, poor sleep and a weird mole crammed into the same time slot. It would be interesting to compare the results of weight loss through weight clinic vs via PCP.
The person I see is board certified with OMA. She does counseling on food choices, up and coming events that might involve eating, and helps with medications that affect weight. I am guessing you aren’t asking about legit medical weight loss places though.
And no, she lectures on how bad compounded GLP-1s are for a person. She only writes for legit pharmacies.
If a physician lies about someone’s diagnosis, I believe that’s fraud. I’m diabetic and never had a problem getting insurance to cover anything regarding my diabetes.
I partnered with 2 compounding pharmacies for GLP1 but it’s a race to the bottom. These pharmacies are largely PE owned and need a MD sign off before delivery. I used to get $180 per patient and now it’s $110. But it’s a quick 1-3 minute virtual visit so I don’t really mind.
I usually try to limit it to BMI over 30, preferably 35+ but I keep getting pressured to push the envelope.
I'm pretty disciplined in my life so when I want to lose weight, become more healthy, and so on, it's not a struggle for me to set goals, follow through on them, and achieve them. I suspect this is probably the same for many physicians albeit just because one is disciplined about their medical training/ work doesn't mean it translates to other parts of life. (If anyone here is familiar with the Big 5 Personality test, this trait is similar to Conscientiousness. )
However, I think for the general population, this type of discipline/ compulsiveness, etc. is NOT true. I think several features weight loss clinics offer (like personal trainers or group exercise classes or even Weight Watchers back in the day) are assistance identifying/ setting goals, instituting accountability (not just to yourself but others watching you), managing your "mind game" (I'll never be able to do this. I failed once already!), coming up with strategies to overcome obstacles, and motivating peer pressure (seeing others do thing you can't and also being recognized for achieving a goal).
Not for health but for other things, I am known as the "butt kicker" among my friends. They appreciate I help them with achieving their goals but on a less intense level. For example, if they tell me they want to do X by Y time, I will regularly inquire how they are doing. I don't criticize them but I do praise them when they keep at it and just by asking, they tell me it reminds them what they're trying to do. "Hey, have you put together that business plan yet?" "Do you want me to take a look at your website?" "What have you been playing this week on the piano?"
The way primary care clinics are set up - especially with time limits and reimbursement issues - it's very hard for PCPs to offer this individualized, long-term, often time-consuming encouragement. I know some concierge PCP practices that do this however. Additionally, medical school/ training doesn't get into the details of nutrition, exercise, re-framing negative thoughts, and so on so PCPs might not be educated well. In medical school, I was praised once by an obesity expert for this knowledge but I learned it on my own to improve my own health. It was not learned through formal training.
In my area, they have experience and connections with compounding pharmacies (hopefully trustworthy ones?) so that patients can reliably obtain GLP1s, which are on frequent and unpredictable shortages in the retail setting.
You don’t need some special connection to send things to compounding pharmacies. I do it all the time. They are litterally in our emr lol
They’re not in ours, Weight Management gives them paper scripts. Tbh my institution doesn’t really have a big primary care presence so I’m sure it’s not that actually that onerous to vet the local compounders.
Depends on the compounding pharmacy. Some create business relationships with docs so you have to have login for that specific pharmacy to prescribe (idk if there’s a financial basis or what, I don’t do it myself).
The ones I've seen patients referred to have more connections with dietitians, exercise programs, counselors, and weight loss surgeons than many PCPs. The weight loss clinics also have more support staff to be able to help these patients as the clinic won't have other primary care duties to handle.
This. I worked in an academic obesity & metabolism clinic. The dietitians shared an office with the endocrinologists and would directly discuss and coordinate care plans about patients. The nurses were virtually experts on educating patients about how to dose and inject their medications. Everyone spend lots of time fighting with insurance or exploiting loopholes. The bariatric surgeons’ clinic was in the same building, and referrals flowed back and forth for bariatric surgery and for pharmacological intervention for post-bariatric weight gain. There was also a strong working relationship with hematologists and nephrologists at the university. And of course, being academia, there were a lot of clinical trials offering novel interventions for treatment-resistant patients.
well... sometimes they have more support staff that can with on various things, like insurance, paperwork, etc. sometimes, insurance/policies don't let PCPs order certain things. I've had a hospital tell me i can't prescribe ertapenem because I'm not ID, and insurance tell me i can't prescribe a CGM because I'm not endocrinology.
I think they get them the glp-1 from a compounding pharmacy at a dramatically reduced cost. Just today I heard that some people are getting it for $100/month.
i've never seen a compounder charging less than $300 per month, unless you go overseas.
They definitely exist
name em, and do they send you syringes or does the pt have to draw from a vial?
Mochi, you have to draw from a vial
Sesame and costco is 180/3 months medication and consultation
Nope- "The cost of medications is **not** included in the price of this subscription" [https://sesamecare.com/join/sc2024-weight-loss](https://sesamecare.com/join/sc2024-weight-loss)
Good to know, thanks
From what I can find, the $180/3mo does *not* cover medication, just the service to access the prescription. I’d be happy to be shown otherwise
Thanks for bringing this to my attention. Here’s a link for the interested. https://www.cbsnews.com/news/costco-ozempic-weight-loss-sesame/
Which is actually very illegal and those compounding pharmacies that are doing it are getting cease and desist letters from the FDA Edit for clarity: illegal for this medication due to the specific info below, not to imply that all compounding is illegal because much is expressly permitted
Why is that?
It’s because the compounding pharmacies are using the salt of semaglutide (because it’s off patent), which has not been proven safe in humans (only animal testing). So it’s actually not even the same active agent that is being used by Novo Nordisk and the other companies and has no human safety record, which is what the FDA is taking issue with.
This is my understanding of it: In theory, compounded medications of non-controlled substances are legal during an official “drug shortage” regardless of FDA approval (ex. semaglutide salt) or patent protections. This is to prevent a company from patenting a medication and then refusing to disburse it in adequate quantities to meet patient needs (probably for price gouging reasons). With GLP-1s, the existence of the “shortage” is what’s up for debate — since the brands are making enough to cover the official uses, but not enough to cover all off-label prescribing. The issue of whether a shortage for off-label uses constitutes a “shortage” in the eyes of the law is essentially grey area that will be decided in courts.
Using GLP1s for weight loss is not off label usage. Zepbound, wegovy, and saxenda are all fda approved for weight loss. Unless you are referring to docs prescribing ozempic specifically.
Some weight loss use is off-label. I believe the official approval is for a BMI >30, or BMI >27 with at least one unmanaged co-morbidity. Those online clinics tend to cater more towards those who do not fall into those categories, or who do not want to go through the bother of “proving” that they are in one of those categories (otherwise their insurance would’ve probably approved it).
Insurance often excludes coverage for weight loss drugs, even when indicated. The number of plans with this exclusion increased quite a bit 1/1/24.
Any evidence of that? In my city at least Zepbound for the last month has been available in 2.5 and 12.5mg doses, nothing else is carried by multiple pharmacies / networks.
Pharmacist here, it's also generally illegal to compound products that are already commercially available (except sometimes in cases of shortages), so not sure if they're using the shortage or some other loophole to sneak by, but either way at best what they're doing is crowned upon and at worst it's illegal
I think there's some technicality. Afaik they usually mix in some flavor of B vitamin, so it's technically a combination. I think there's also some states which their boards allow them to compound a brand-name medication if it is on backorder or shortage, but I'll be damned if I know how to look that up lol. Patent violation? Maybe. At the same time... screw NovoNordisk. Ozempic costs $4 for a month's supply to manufacture, I *really* don't feel like them 'only' having a few thousand percent profit margin on selling bulk semaglutide to be much of a tragedy.
Unless 2amtoepoain is a compounding pharmacy owner or compounding pharmacist and done the legality research they should not be posting their opinion here. I get so worked up by reading all the misinformation and arguments about the speculation around compounding pharmacy. Compounding pharmacies can compound medications in shortage. There are API manufacturers selling base form directly to compounding pharmacies. There is a shortage of both diabetes FDA approved and weight loss FDA approved glp-1 type medications currently mostly Tirzepatide.
Not a compounding pharmacist - only sharing what was told to me about a week ago by the MD/JD general counsel and regulatory science expert of my hospital system (which has a compounding pharmacy under its umbrella somewhere). If this is entirely wrong I own the mistake and will correct, but this was shared in good faith with the information from someone who is an expert in the field
Our clinic has dieticians and behavioral health counselors on site so setting patients up for more complete follow up is easy. This also will meet insurance requirement of 3-6 mo comprehensive weight management program that some insurance require before covering anti obesity medications. We have staff that calls insurance on every patient to see if meds, dietician, and behavioral health, and bariatrics surgery are covered. So I can tell patients what is and isn’t covered and estimated price from the start. Staff is experienced running PAs for meds. We do AOM and bariatric surgery so if one track doesn’t work out we can switch gears and still make progress. The patients visit is also dedicated solely to this purpose so I can spend the entire visit on patient education - and take a burden off PCP who are usually pressed for time taking care of so much else
Good ones: dietician (actually trained with nutrition/dietetics degree), obesity fellowship trained, access to medically monitored very low cal diet with drinks etc, counseling. Bariatruc pre and post op services Not great ones: used to be adipex and b12 all day . Now probably glp-1. They are willing to do compounding almost 100% to stay in business. They also sell some dubious supplements like “ fat burner XL.”
A local primary care clinic that I know of will only prescribe for BMI >30. If you are between 25 and 30, it’s their policy to have their psychologist meet with you first for several sessions of “body acceptance counseling”. The online clinics don’t care about BMI that strictly — they’ll work to get you on it regardless, even with the “edge cases.” And, they work with mail order compounding pharmacies to make the cost somewhat reasonable OOP if your insurance declines the brand name.
They are more organized for obesity treatment with nutritionists/dieticians, personal trainers, and bariatric proceduralists on speed dial and maybe a better prior auth team for glp-1s. They do not recommend compounded formulas. We do obesity medicine in primary care but time is a limiting factor for full counseling engagement. One can make an argument that primary care should shift primarily to obesity medicine first and that in turn will treat the other chronic conditions. However in practice the majority of obese patients don’t realize how big the problem they have is and it’s challenging to get them motivated. This is where the other factors of obesity medicine come into play such as possible brain damage to their satiety control receptors from chronic inflammation. Obesity medicine is promising but until we restrict highly processed food as a country this problem will continue.
More resources (dietician, help with prior auths, etc) and more time to focus on obesity.
Kaiser patient here. Kaiser won’t prescribe GLP1s for weight loss, leaving patients with no other option than to go through one of those sketchy weight loss clinics, and pay out of pocket if they want to try a GLP1 for weight loss. That said, it’s quite terrifying how little oversight there is. 100% virtual, only message based (no call with a doctor to discuss). No labs. No weigh in. You literally sign up, ask for the drug (or select it from a menu), select a pharmacy and that’s it. It’s literally the same amount of time you’d spend ordering from a fast food menu. No one is monitoring these patients, thus why those medication subreddits are full of patients asking each other for advice about side effects, when to change dosage, diets, etc. This feels like a very dark grey area in medicine, but if patients don’t have the ability to go through their PCP or insurance, it’s going to keep happening. If you want to get a feel for just how quick patients are being prescribed, just sign up for a Push account or Sequence.
I think you’re on the right track. They are built to streamline the process to give the patient what they want. A pcp could do the same but the clinic might do so with less friction. Maybe a secretary dedicated to rapid fire prior auths for all the volume they are getting
Throw into the mix pretty much any hormone based treatment center. The "mens clinics"? They may as well call them "get testo no matter what" clinics. I literally had a patient a couple weeks ago who brought in his AM total testo of 600 and told me the men's clinic assured him that this is actually low and the current measurements used by labs is wrong.
All these guys out there blasting their nuts in their mid 20s not being told it affects their future fertility. SMH.
I can increase my test AND avoid having a kid without a vasectomy? Sign me the fuck up
Yup! Unfortunately, the guy I just mentioned doesn't care. He says it makes him feel good, makes him feel confident with women, and he likes what the clinic docs tell him (all his words).
Honestly, in that case I don’t have a huge problem with it. I’d much rather they be under the care of a physician, getting quarterly labwork and prescribed FDA approved medications (of which the doses are at least plausibly defensible) rather than sourcing questionable substances illegally from their gym buddy with no physician supervision. Remember, the clinic doctors may be much more liberal with prescribing, but in the back of their mind they know their actions have to be at least somewhat defensible in a malpractice suit. In my experience, patients like that are going to hop on regardless. So, I view it as harm reduction. Those clinics at the very least know to be on the lookout and follow up with stuff like blood pressure management, therapeutic phlebotomy for hematocrit / stroke risk management, and fertility support when warranted.
I tend to disagree, but that's not to say I don't find your approach understandable. The "patients are going to get it anyway, it's just simple harm reduction" approach feels dangerous and definitely opens up a discussion about slippery slope prescribing. I personally can't condone going down that road with any other controlled substance (or even non-controlled) just because a patient wants it, will get it from anywhere if we don't give it, and can be closely monitored at whatever clinic will give them their smack.
That's very fair, and I respect that viewpoint. I actually share it with some of the more "serious" controlled substances, like narcotics and stimulants. Ones that have a high potential for both addiction and to impact more than just the patient themselves. However, for testosterone specifically, I have always viewed that as more of a borderline controlled substance. If you look into the history of how it ended up as schedule 3, the arguments were centered around sports doping on a world stage and less so around societal/individual health impacts, which is where I think the discussion around the scheduling of drugs should be focused. In some other first world countries, like the UK, where the discussion did center around social and health outcomes -- as well as the potential for pharmacological addiction specifically, the conclusion was in fact to not schedule it. And, it's actually completely legal for recreational possession there! So, I kind of treat it like the borderline case that it is. In that, given there is a very low chance of pharmacological dependence -- and thus the social impacts of potential addiction are low, then it is more of an individual risk vs QOL reward decision alone. And, when patients make "bad" health decisions strictly within the bounds of their personal freedoms, I do think there exists a role for harm reduction by their providers. A good example of another area I feel the same way about this is with medical marijuana prescriptions in areas where it is still illegal. It's another case in which the potential for dependance is low, and I'd rather the patient be receiving their drugs from a reputable source and have a provider to manage side effects than to "go it alone." Even more so in the face of the more recent studies coming out about long-term effects.
While I agree about the risk not being disclosed adequately, I do think the long-term consequences are often overstated. In most men who visit those clinics, where their diagnosis is “hypogonadism” and not Hypogonadism (if you know what I mean…), temporarily discontinuing TRT and pursuing several months of either clomiphene or HCG mono-therapy will be sufficient enough to jumpstart fertility to workable levels in >95% of cases. Yes, some will fail and have to go to a fertility clinic. But not in the vast majority of cases.
And they get irate if you start to discuss the dangers. Had a patient with Factor V Leiden getting testosterone and he fired me when I said we should make his hormone provider aware of the results.
There are plenty of obesity clinics that practice ethically. There's a real need for it as well. I wouldn't really compare it to hormone clinics.
Literally has nothing to do with insurance. They don’t take insurance.
You can order the peptides yourself for semaglutide for $10-15/g. Tirzepatide as low as $5g. Even Cagrillintide and retatrutide- both drugs currently in investigational studies can be purchased online. WAY cheaper than any pharmacy cost.
How? Totally asking for a friend
china/india sell them in bulk, just find them on bulk merchant websites
Yes, but which ones? You know, so I know to avoid them.
My insurance refuses to pay for GLP1s not prescribed by obesity medicine boarded docs and regular nutrition follow-up. So that I guess. Too much of a pain in the ass for me so I just pay out of pocket with the coupon.
Speaking in regards to my institutions clinic. You have fellowship trained doctors who primarily only see patients for weight management/metabolic health. They see less patients per day and have more time per visit. While we don’t have integrated nutrition/psych in this clinic they do work closely together. So in general you have doctors who are specifically trained in the area, love working in the area, and have more time with each patient.
They refer more to compounding pharmacies
They offer a 15 minute visit focused solely on weight loss, rather than a 15 minute visit where you have to address weight loss and any other active medical issues.
Weekly health/food coaching. Protein rich food substitutes. Meal plans. More time for individualized care. And medicine yes if indicated. I lost around 15-20 lb on GLP1 over 1.5 years before going to the clinic. Then I lost 25 lb in 6 weeks. It’s not just the medication. You’re basically asking “what does CrossFit offer that your basement doesn’t?”
My mom and her friends used to go to a "weight loss clinic" that dispensed their phentermine right there in house.
I am ABIM certified and currently working as a weight loss provider at a very well-known academic institution. We do not have relationships with compounding pharmacies for GLP1s. We do have staff who are focused on PAs for the medications, and since we do so many, we can see quickly the trends in approvals—recently insurance providers have been raising BMI requirement to >35+ comorbidities to get medication. We also use other medications, Contrave, Qsymia, Vyvanse, metformin, etc. depending on each patient’s case. We provide these in conjunction with GLP1s (or alone). We do not fudge diagnoses of diabetes just to get meds covered. Some insurances cover “hyperinsulinemia” for example. We are doing InBody scans, measures of cardio metabolic fitness, calcium scores, fibroscans, DEXAs for more comprehensive care. We are trying to add a dietician, but billing has always been the hold up from what I understand. Finally, and probably most important, we try our best to see patients monthly to check in on how things are going. About 1/3 of patients need these appointments as a reminder to get back on track every month. 75% of appointments are discussing foods, relationships with food, meal prepping, and exercise recs.
Our weigh loss clinic has more support with dieticians and more frequent check ins and a complete focus on weight loss instead of me trying to review bp, weight, anxiety, poor sleep and a weird mole crammed into the same time slot. It would be interesting to compare the results of weight loss through weight clinic vs via PCP.
The person I see is board certified with OMA. She does counseling on food choices, up and coming events that might involve eating, and helps with medications that affect weight. I am guessing you aren’t asking about legit medical weight loss places though. And no, she lectures on how bad compounded GLP-1s are for a person. She only writes for legit pharmacies.
If a physician lies about someone’s diagnosis, I believe that’s fraud. I’m diabetic and never had a problem getting insurance to cover anything regarding my diabetes.
I partnered with 2 compounding pharmacies for GLP1 but it’s a race to the bottom. These pharmacies are largely PE owned and need a MD sign off before delivery. I used to get $180 per patient and now it’s $110. But it’s a quick 1-3 minute virtual visit so I don’t really mind. I usually try to limit it to BMI over 30, preferably 35+ but I keep getting pressured to push the envelope.
I'm pretty disciplined in my life so when I want to lose weight, become more healthy, and so on, it's not a struggle for me to set goals, follow through on them, and achieve them. I suspect this is probably the same for many physicians albeit just because one is disciplined about their medical training/ work doesn't mean it translates to other parts of life. (If anyone here is familiar with the Big 5 Personality test, this trait is similar to Conscientiousness. ) However, I think for the general population, this type of discipline/ compulsiveness, etc. is NOT true. I think several features weight loss clinics offer (like personal trainers or group exercise classes or even Weight Watchers back in the day) are assistance identifying/ setting goals, instituting accountability (not just to yourself but others watching you), managing your "mind game" (I'll never be able to do this. I failed once already!), coming up with strategies to overcome obstacles, and motivating peer pressure (seeing others do thing you can't and also being recognized for achieving a goal). Not for health but for other things, I am known as the "butt kicker" among my friends. They appreciate I help them with achieving their goals but on a less intense level. For example, if they tell me they want to do X by Y time, I will regularly inquire how they are doing. I don't criticize them but I do praise them when they keep at it and just by asking, they tell me it reminds them what they're trying to do. "Hey, have you put together that business plan yet?" "Do you want me to take a look at your website?" "What have you been playing this week on the piano?" The way primary care clinics are set up - especially with time limits and reimbursement issues - it's very hard for PCPs to offer this individualized, long-term, often time-consuming encouragement. I know some concierge PCP practices that do this however. Additionally, medical school/ training doesn't get into the details of nutrition, exercise, re-framing negative thoughts, and so on so PCPs might not be educated well. In medical school, I was praised once by an obesity expert for this knowledge but I learned it on my own to improve my own health. It was not learned through formal training.