An increase in weight is associated with a linear increase in systemic inflammation . Recent data from large-scale studies indicate that only a moderate weight loss is sufficient to provide substantial health benefits . Therefore, regardless of the perceived issue of vanity, weight control has profound health benefits. Helping the patient maintain weight loss, also maintains the health benefit!
The goals of my program (as printed in the new patient pamphlet given to each patient) are:● Achieve an optimum level of health, including dropping excess fat stores● To maintain weight loss indefinitely
The following 6 techniques are utilized to achieve these goals:● Weekly monitoring to drop weight efficiently, provide patient safety, and educate. Monthly monitoring indefinitely to maintain weight loss. No charge is made for either of type of these visits.● High-protein, low-carbohydrate nutrition.● Hydration adequate to promote diuresis of fat break-down products.● Cardiovascular exercise daily.● Resistance training twice weekly.● Weight-loss medications, amino acid supplements, and hormone supplementation as indicated and appropriate.
The Role Of Phentermine
Phentermine acts to release the neurotransmitter, norepinephrine, from neuronal stores . Norepinephrine is synthesized from tyrosine at nerve terminations, stored in granules and released in the synaptic cleft to act on post-ganglionic receptors. After they act on those receptors, the monoamines may be deactivated through catechol-O-methyltransferase or to undergo reuptake by the same granules . One major effect of saturation of norepinephrine nerves by norepinephrine is appetite suppression . As well, phentermine causes an outpouring of epinephrine from the adrenal glands resulting in an increase of peripheral energy expenditure . Included in this effect is a breakdown of fat stores .
To repeat: Two phentermine effects resulting in weight loss are appetite suppression and breakdown of fat stores.
Because of the above-described effects, a long-term result of the daily use of Phentermine is the relative depletion of norepinephrine stores. L-Tyrosine is taken daily to replete norepinephrine stores and L-Cysteine is utilized to create a more efficient conversion of L-Tyrosine into norepinephrine . Norepinephrine and serotonin are in dynamic balance. Thus, 5-HTP is utilized to create serotonin, since giving L-Tyrosine alone can cause a depletion of serotonin .
Typically, L-Tyrosine and L-Cysteine are each administered in 500 mg capsules 3 x per day. However, Tyrosine can be delivered in larger doses, up to 1500 mg 3 x per day to produce norepinephrine stores. Cysteine on the other hand acts as a catalyst and doses need not be increased. In fact, smaller doses of Cysteine work just as well, but are not commercially available . The use of these amino acids allows the weight loss benefits of Phentermine to become extended over time.
Another technique to be used in tandem to extend the weight loss benefits of phentermine is to cycle its use, taking a 4-week break periodically. The weight maintenance use of phentermine does not require cycling.
How is phentermine used and in what doses? Patients are initially given mild to moderate doses on a BID schedule and adjusted according to patient response. Again, patients are to monitor weekly but are encouraged to immediately report side effects or any concern whatsoever. Doses typically range from 15 mg once or twice daily to 30 mg twice daily, as tolerated and benefit noted. However, I have patients who do not take phentermine at all due to either preference or intolerance. Since the 8 mg tablet has been unavailable for almost 10 years, I have several patients who will subdivide a 15 mg capsule to create a tolerable dose. On the other hand, I have two patients (out of hundreds) who take 37.5 mg tablets 3 x per day. The dose varies according to patient benefit and tolerance. One dose does not fit all regardless of what you read in the product insert.
Regarding doses of phentermine prescribed, the American Society of Bariatric Physicians conducted a survey of its members in the Fall of 2007 and the Spring of 2008. The results were published in the Journal, Obesity in March of 2009 with a detailed report also published in the Jan-Feb, 2009 issue of the ASBP News [40,41].
97% of respondents used phentermine in their practice. Only 16% limited phentermine to 12 weeks or less. 52% of respondents used phentermine with patients for an unlimited period of time. The average low dose used was 15 mg, and the average high dose was 56.25 mg. About 20% of respondents stated that their highest dose is 75 mg daily. (Emphasis mine)
The issue of “Short-term; Adjunct” and “short-term monotherapy” have been dealt with earlier in this document. (top of page 5) Also: “Advances in medication discovery suggest that novel molecular entities that target 2 different neurochemical mechanisms, that is, “combination pharmacotherapy,” will yield efficacious antiobesity medications with reduced adverse side effects.” [50,52]
An example of a combination therapy that does not cause heart valve injury nor PPH is the use of Phentermine along with Fluoxetine . As well, the amino acid 5-HTP is a precursor of serotonin, and the use of it does not cause valvulopathy. The new 5-HT2C receptor agonist, Lorcaserin (trade name Belviq), has not caused valve injury.
Back in the 1990s, Fenfluramine caused valvular injury via activation of the numerous valvular “serotonin 2B (5-HT2B) receptors by norfenfluramine, the major metabolite of fenfluramine.” 
So, Fenfluramine was removed from the market. Phentermine was not associated with valve injury, and it remains today the most popular weight loss medicine, as well as the safest.
“The use of sympathomimetic appetite suppressants and serotonin-selective reuptake inhibitors (SSRIs) has been questioned due to anecdotal reports of serotonin syndrome. A survey of bariatric physicians using these medications in clinical practice did not find any cases of serotonin syndrome among 1174 patients. The monitored use of the combination of these medicines by trained practitioners is justifiable.” 
In fact, there are no studies that directly link phentermine only usage to Primary Pulmonary Hypertension or valvular heart disease . “There is no evidence that phentermine causes valvulopathy. Phentermine is the most widely used anti-obesity drug. In view of the serious cardiovascular risks associated with obesity, it is important to clarify that phentermine is a safe and effective anti-obesity medication.” 
Phentermine does not release serotonin in therapeutic doses. Phentermine acts to release the neurotransmitter, norepinephrine, from neuronal stores .
Inappropriate condemnation of Phentermine has occurred saying that “tolerance” to its effects occurs after a relatively short period of time, at which point, naysayers state that use of the medicine should be abandoned in such patients.
Response: Tolerance to weight loss maintenance effect of phentermine does not occur (See “Barrier 5", pages 3-4; middle of page 7). When tolerance to weight loss production occurs, and further weight loss is sought, I agree, discontinue phentermine while simultaneously continuing the restoration of norepinephrine neuronal stores via supplementation of L-Tyrosine.54 The motivated patient may re-start phentermine with the production of weight loss in 4 to 8 weeks. Effective dose varies from patient to patient as described on page 7, the last 2 paragraphs.
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