I've had some patients that benefitted from bupropion/naltrexone for weight loss. I got to wondering about my ADHD patients that are on methylphenidate or amphetamine (but not bupropion) if adding naltrexone to their regimen would be helpful for weight loss. Does anyone have experience with, or thoughts about, this?
Stimulant/Naltrexone for Weight
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I've seen benefits from naltrexone alone for folks who struggle with very impulsive, classic binge-eating, like "leave the house, drive to the store, buy six packages of cookies, come home and eat them all" sort of binging. Less so the slow creep of a bit too many calories every day for months to years.
Certainly. This would be more of a relatively easy, straightforward trial (of adding a cheap, quite safe, oral drug) that may be of benefit.
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I've tried adding naltrexone like that without much luck. I've had more luck when it was associated with binge episodes like @clausewitz2, especially when there's another indication for naltrexone, like alcohol cravings, and the patients lose some weight with that (admittedly, alcohol has a lot of calories, so weight loss isn't far fetched for those folks).
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psych medications for weight loss generally arent that great. One of the biggest issues is people confuse binge eating and just generalized overeating. Overeating requires dietary modifications, education, etc. Medications for binge eating sometimes work in my strong insight individuals, as i have a few people on vyvanse and its been very successful for their binge eating, but as a whole the efficacy isnt that great for many people. Often once the vyvanse wears off at night people binge.
my understanding is naltrexone reduces the rewarding effect from food which would in theory help overeating but ive never been blown away by it.
The problem with overeating is multifactorial. My spouse is a registered dietician and fairly knowledgeable about this and we talk about it sometimes but its a combination of access to healthy foods (food desserts), convenience (time spent cooking a healthy meal vs buying a cheeseburger), calorie education (most people have no idea how many calories theyre eating with each meals or what BMR is), portion sizes, etc. People swear up and down "but doc im only eating this!" without realize that the foods they're choosing are abundanly high in calories. Its about providing calorie education so people understand what theyre eating, beacause without understanding, no medication will be a miracle cure. I recommend myfitnesspal to a lot of my patients.
my understanding is naltrexone reduces the rewarding effect from food which would in theory help overeating but ive never been blown away by it.
The problem with overeating is multifactorial. My spouse is a registered dietician and fairly knowledgeable about this and we talk about it sometimes but its a combination of access to healthy foods (food desserts), convenience (time spent cooking a healthy meal vs buying a cheeseburger), calorie education (most people have no idea how many calories theyre eating with each meals or what BMR is), portion sizes, etc. People swear up and down "but doc im only eating this!" without realize that the foods they're choosing are abundanly high in calories. Its about providing calorie education so people understand what theyre eating, beacause without understanding, no medication will be a miracle cure. I recommend myfitnesspal to a lot of my patients.
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Food desserts are nice. Food deserts not so much.
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hey i write posts in between patients in fairness or early in the morning
Are you a psychiatrist prescribing these? Sure these work great in the short term, but from what ive read once people stop taking these medications they just have rebound weight gain again. People would have to take it indefinitely if solely used for weight loss and the overall cause of the cause isnt being addressed.
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it looks like about half of people have the rebound weight gain. So while generally true that a lot of people will need it forever, it's also a lot like antipsychotics where after the first year or two of stability about half of the people who have a first-episode psychosis really won't need antipsychotics for life.
Well I guess there's no risk of rebound weight gain with naltrexone since you just won't lose any in the first place. 🙂 Seriously, we should get more comfortable with the FDA approved meds to manage side-effects we are creating.
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Some patients are not comfortable going to injections straight away. Also insurance can throw up rather a lot of roadblocks when the prescription comes from a psychiatrist. What I'm saying is let's not pretend there aren't legitimate practical reasons not to necessarily prescribe GLP-agonists right off the bat.
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note that the wegovy approval for weight loss is in addition to diet and exercise, and from what I see wegovy is often prescribed as a replacement, rather than addition, to diet and exercise. medications may give people a jump start into a healthier lifestyle, but I think if someone is using these medicaitons purely for weight loss than we should provide adequate counseling on dietary modifications and living a healthier lifestyle. I think the approach should be more of an all encompassing approach. Im not against GLP agonist by any means, my fear is that we start to see this as a replacement to lifestyle changes, rather than addition.
Similiar to: not getting all As? Take Adderall. Had a bad day at work? Take xanax. Terrible diet for 10 years and need to lose weight? Wegovy
Obviously things like SGAs can cause weight and have metabolic effects and I recognize that, and in those patients weight gain can become unavoidable and medications to treat this make clear sense.
Personally I would live to integrate a clinic with a psychiatrist, outpatient registered dietician for meal planning/education, and psychologists for the therapy aspect.
Similiar to: not getting all As? Take Adderall. Had a bad day at work? Take xanax. Terrible diet for 10 years and need to lose weight? Wegovy
Obviously things like SGAs can cause weight and have metabolic effects and I recognize that, and in those patients weight gain can become unavoidable and medications to treat this make clear sense.
Personally I would live to integrate a clinic with a psychiatrist, outpatient registered dietician for meal planning/education, and psychologists for the therapy aspect.
Pretty much everything should be done with diet and exercise. Depressed? Diet and exercise. Back pain? Diet and exercise. Diabetes? Diet and exercise. If we actually made lifestyle changes a requirement for treatments, we would do almost nothing. The question for a given treatment should be is it better than no change for a given patient. It sure does seem like GLP agonists are a heck of a lot better than nothing, which is the actual option. Lifestyle changes were always available and rarely used.
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I think that is a bit different. Poor diet/exercise isnt always the cause of back pain/depression, whereas a poor diet/exercise quite frequently causes weight gain.
Do we treat symptoms or disorders? If lifestyle changes are rarely used than perhaps we should work on identifying barriers to those changes, which could be something simple as providing education. The average American has no idea the calorie content of the food they eat. I would argue that many think they do, but would be way off.
Again, never said GLP agonists were bad. Im saying perhaps theyre not a blanket cure
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Majority of patients I've tred on Naltrexone for being overweight most don't notice a benefit. I've seen it benefit some, but this was a small minority.
Replace excess food intake/addiction with any other substance use disorder and we use meds for those disorders regularly. Plus recommend all the behavioral lifestyle changes as well.
Biggest difference seems to be glp1s are more akin to Suboxone as far as results are concerned, compared to the other meds for substance use disorders. So why not combine it with lifestyle recommendations and help someone drop 50-100lbs. Then maybe they can actually start exercising. Maybe they can actually learn what a reasonable amount of food/calorie intake is.
Biggest difference seems to be glp1s are more akin to Suboxone as far as results are concerned, compared to the other meds for substance use disorders. So why not combine it with lifestyle recommendations and help someone drop 50-100lbs. Then maybe they can actually start exercising. Maybe they can actually learn what a reasonable amount of food/calorie intake is.
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yes i was thinking of that analogy the other day. Though one argument could be made that the immediate risk of OUD is much more severe, than overeating, of course the longterm risk of overeating has it own negative health outcomes of course. Ultimately yes it is harm reduction.
Though again, thats why i said above, im not against wegovy and all that, im just saying it should be an addition, not replacement, for education/lifestyle changes. Wegovy could be the catalyst some people need to start living healthier.
Lets be honest how many physicians actually sit down and talk to their patients about nutrition, or even have the knowledge to do this? Nutrition was such a weakly taught topic in medical school ironically, yet we were always trained to promote lifestyle changes. Perhaps its why i like my current job and 30 minute f/us. I actually have time to talk with my patients about interventions
I would argue that conceptually it's more realistic to say that diet and excise should be in addition to glp agonists with them being the default for most obese people. And sure, it's very similar to suboxone. Some people go off suboxone, a lot (most?) don't. Again, we've always had diet and exercise. For whatever systemic, evolutionary, genetic, racist, capitalist, sexist, other type of ist cause...preaching them hasn't worked and that isn't likely to change in the short or medium term before our obese patients are long dead.
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Forgot to add this and I want my post to be evidenced based. Out of the few dozen I've tried I'd say less than 20% felt an actual benefit with Naltrexone for weight loss. So this is about what you'd see with a placebo. Also when I've done pubmed searches on it, I never saw anything highly convincing. From memory, and last time I checked was years ago, it was on the order of only a few subjects per test so they weren't highly convincing.
I've had success with Metformin and weight loss on the order of about 50%. Nice thing is it's cheap, safe, and good data that even off label could add to longevity. Only problems are side effects, but the one worrisome side effect is possible but unlikely B12 deficiency.
I always offer Metformin first to anyone who wants a GLP-1 agonist.
I've had success with Metformin and weight loss on the order of about 50%. Nice thing is it's cheap, safe, and good data that even off label could add to longevity. Only problems are side effects, but the one worrisome side effect is possible but unlikely B12 deficiency.
I always offer Metformin first to anyone who wants a GLP-1 agonist.
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To further your point - the data from the olanzapine-samidorphan combo (essentially a naltrexone analog) seemed to show decline in olanzapine related weight gain, but not really much de novo weight loss
I had only one patient on the expensive combo drug, and they experienced a modest (5 lb in 5 month) weight loss. They had had 0 weight change for months doing significant exercise and diet alone on olanzapine mono therapy prior to that.
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ive had some people on lybalvi in the past and some of the people didnt like how they felt on it, compared to just zyprexa. When i tried it a year ago sporadically i wasnt super impressed. In my opinion the only benefit of lybalvi vs just using metformin/zyprexa was less pills.
also the coverage and manufacture programs for it used to be terrible but maybe they have improved
ive have some people stabilize weight gain and lose a few pounds if i recall, on caplyta
Yes I am a psychiatrist and yes I am prescribing GLP1s with great success.
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Some "medical spa" in my area is selling Semglutide shots for $300 a pop. Now how the eff they are affording this >$1000/month med for $300 without using insurance to pay for it, which included the evaluation and injection, someone explain that to me.
Pharmacies are compounding it. Which is allowed apparently if the drug is deemed to be in shortage by the FDA. As in you don’t get patent protection on your drug if you’re not making enough to satisfy demand.
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These medical spas, I don't know whether to hate them to love them for their ingenuity.
Since Samidrophan is similar to Naltrexone I've had a few patients try Naltrexone-Olanzapine but so far with no success. My sample size is only 3, but none of them worked so far. All had weight gain as bad as Olanzapine by itself.
Since Samidrophan is similar to Naltrexone I've had a few patients try Naltrexone-Olanzapine but so far with no success. My sample size is only 3, but none of them worked so far. All had weight gain as bad as Olanzapine by itself.
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Someone mentioned Suboxone.
I don't recommend it due to several concerning issues associated with its use. There have been numerous lawsuits against Indivior, the manufacturer of Suboxone, alleging that it causes severe dental problems, including tooth decay. As it's shown on this law firm's site, these lawsuits suggest that Indivior may have been aware of these risks but failed to adequately warn patients and healthcare providers. So that's a big no for me.
I don't recommend it due to several concerning issues associated with its use. There have been numerous lawsuits against Indivior, the manufacturer of Suboxone, alleging that it causes severe dental problems, including tooth decay. As it's shown on this law firm's site, these lawsuits suggest that Indivior may have been aware of these risks but failed to adequately warn patients and healthcare providers. So that's a big no for me.
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its like south park said though..."rich people get ozempic, poor people get lizzo/body positivity"
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I practice in this area quite a bit:
1. stimulant/bupropion + naltrexone is fundamentally a psychiatric drug combo. It deals with a psychiatric complaint that has a big behavioral component, namely Binge Eating Disorder in the classic sense. Check DSM-5 if you want it spelled out clearly.
It DOES seem to work for this indication, especially in combination with high quality behavioral modification program.
However, this combo is NOT all that effective for WEIGHT LOSS per se.
BED can enter into remission in a matter of months. I have patients who have 5 binge episodes a week to ZERO in 2 months. It also follows a very classic psychiatric disorder pattern, chronic, relapse remitting, strongly comorbid with mood/anxiety upticks, etc. etc.
2. Weight loss is a much longer-term program that's metabolic/steady state in nature. This works much better with GLP1 agonists. GLP1 agonists have some psychiatric properties, but they are not nearly as pronounced. In particular, GLP1s work much better for ALCOHOL, and NOT all that well with things like cluster B traits/impulsivity-related symptoms. In general, obesity does not feel particularly "psychiatric" but one could make a case that it's primary a behavioral conditions. Nevertheless, even on the behavioral side, treatment is utterly different. It's not really about impulse control as much as modification of baseline.
Obesity do NOT resolve in a matter of months. Typically the timeline is something 72 weeks of continuous intervention with both meds and lifestyle changes to drop someone's BMI from 30+ to below 25.
I would say these are almost orthogonal issues. Many patients are obese without BED, and they don't respond well to stimulant+naltrexone combo.
1. stimulant/bupropion + naltrexone is fundamentally a psychiatric drug combo. It deals with a psychiatric complaint that has a big behavioral component, namely Binge Eating Disorder in the classic sense. Check DSM-5 if you want it spelled out clearly.
It DOES seem to work for this indication, especially in combination with high quality behavioral modification program.
However, this combo is NOT all that effective for WEIGHT LOSS per se.
BED can enter into remission in a matter of months. I have patients who have 5 binge episodes a week to ZERO in 2 months. It also follows a very classic psychiatric disorder pattern, chronic, relapse remitting, strongly comorbid with mood/anxiety upticks, etc. etc.
2. Weight loss is a much longer-term program that's metabolic/steady state in nature. This works much better with GLP1 agonists. GLP1 agonists have some psychiatric properties, but they are not nearly as pronounced. In particular, GLP1s work much better for ALCOHOL, and NOT all that well with things like cluster B traits/impulsivity-related symptoms. In general, obesity does not feel particularly "psychiatric" but one could make a case that it's primary a behavioral conditions. Nevertheless, even on the behavioral side, treatment is utterly different. It's not really about impulse control as much as modification of baseline.
Obesity do NOT resolve in a matter of months. Typically the timeline is something 72 weeks of continuous intervention with both meds and lifestyle changes to drop someone's BMI from 30+ to below 25.
I would say these are almost orthogonal issues. Many patients are obese without BED, and they don't respond well to stimulant+naltrexone combo.
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I mean it takes 17 weeks alone to get to the dose they used in studies (2.4mg), but I have seen an appreciable difference in body weight (10-15%) of body weight) within 3 months of starting it even before we get to that dose. I've been seeing about 20-25% body weight loss in my patients, especially because I'm pretty firm in my recommendations for physical exercise and calorie tracking. I refer to a local nutritionist and will have them start an exercise regimen with a personal trainer.
It's lifechanging for patients. I've gotten several patients off of antidepressants because their self-esteem, social anxiety, and overall physical health parameters of depression (sleep, energy, appetite, concentration) are much better. I wonder if it should be studied as an antidepressant for certain patients because we do know that those other lifestyle factors can have a similar effect size to an SSRI.
It hasn't worked for everyone though as I've had some people not respond at all even at the higher dosages, which is disappointing. You're telling me it takes 72 weeks of continuous intervention makes me feel like I should persist even though it's been about 6-8 months of using it.
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I also have pts that don’t respond. I’m not sure why. Seems like they just don't control themselves. So this becomes a weird psych issue again.
I am almost certain that a mono therapy for depression for BMI > 35 will be positive. But this study doesn’t even need to be done as it’s sold well as is without needing comorbidity. I personally would just go ahead and treat. Most of pt in my practice in this scenario are young patients with predominant psych issues and hence don’t even have a primary care so cannot even meet cv risk comorbidity.
It would be interesting for combo treatment for the GLP1 NONRESPONDERS. But nobody will focus on this group for now in trials.
