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Phentermine-Topiramate (Qsymia): What It Is: Combination of appetite suppressant (phentermine) + anticonvulsant (topiramate) Phentermine: Sympathomimetic amine (stimulant) Topiramate: Originally approved for seizures, also affects appetite Effectiveness: Average Weight Loss: 7-9% of body weight CONQUER Trial: 9.3% loss with highest dose vs 1.6% placebo Third most effective after tirzepatide and semaglutide Dosing: Extended-release capsules taken once daily Dose escalation over 14 days Available in 4 dose combinations Highest: Phentermine 15 mg + Topiramate 92 mg Side Effects: Dry mouth Constipation Paresthesia (tingling in hands/feet) Insomnia Increased heart rate Mood changes Cognitive effects (brain fog reported) Contraindications: Pregnancy (topiramate causes birth defects) Glaucoma Hyperthyroidism Cardiovascular disease History of drug abuse (phentermine is controlled substance) Cost: $150-$250/month Generic versions available Some insurance coverage Who Should Consider: Cant use GLP-1s due to contraindications Need oral medication option Want lower cost than GLP-1s Dont mind daily medication No cardiovascular disease or substance abuse history Naltrexone-Bupropion (Contrave): What It Is: Combination of opioid antagonist (naltrexone) + antidepressant (bupropion) Works on brain reward and hunger centers Not a stimulant Effectiveness: Average Weight Loss: 4-5% of body weight COR Trials: 5.4% loss vs 1.3% placebo Among least effective FDA-approved options Dosing: Two tablets twice daily at full dose Gradual dose escalation over 4 weeks Taken with food Side Effects: Nausea (very common, 29-32%) Headache Constipation Dizziness Insomnia Dry mouth Contraindications: Uncontrolled hypertension Seizure disorders Eating disorders (anorexia, bulimia) Opioid use or withdrawal Use of MAO inhibitors Cost: $100-$250/month Limited insurance coverage Who Should Consider: Cant use GLP-1s Prefer oral medication Have depression (may benefit from bupropion component) Moderate weight loss goals Dont need maximum effectiveness Orlistat (Xenical, Alli): What It Is: Lipase inhibitor (blocks fat digestion) Prevents absorption of ~25% of dietary fat Available prescription (Xenical) and OTC (Alli) Effectiveness: Average Weight Loss: 3-5% of body weight Oldest and least effective option Requires strict low-fat diet Mechanism: Blocks enzyme that breaks down fat Undigested fat passes through intestines Must reduce fat intake or experience GI side effects Side Effects: Oily spotting Fecal urgency and incontinence Oily stools Increased bowel movements Flatulence with discharge Fat-soluble vitamin deficiency Side effects worsen with high-fat meals, essentially forcing dietary compliance through negative reinforcement

Patients should be advised to contact their healthcare provider if gastrointestinal symptoms are severe or persistent, as dose adjustment may be necessary

L-carnitine can be found in PhDs Diet Whey, Diet Whey Meal, Burn and Lean Degree

I generally tell people to take like a level teaspoon, which is five grams, either two to three times a day