87: Listener Q&A: Does It Make Sense to Titrate Up When You’re Seeing Results?
Oct 07, 2024Since launching our new fan mail feature, we've been excited to receive many thought-provoking questions, including this listener’s concern around increasing their dosage of anti-obesity medication, even when it seems to be effective:
“I’m on day 14 of Zepbound, down 5.8 pounds and one inch in waist circumference. I haven’t experienced any side effects, and I was prescribed five milligrams at week five. If it’s effective at this dose, why increase? The answer I received from my nurse practitioner was that it’s a manufacturer's recommendation, but I need a better explanation.”
Navigating the Nuances of Medication Management in Weight Loss
This is an excellent question that highlights the complexities of medication management in the context of weight loss. While it may seem sensible to raise your dosage for better results—especially when you're seeing weight loss and improved health markers—there are several critical factors to consider.
The reality is that when it comes to prescribing medications, especially in weight management, there’s a significant amount of nuance involved—what I like to refer to as “the art of medicine”. Often, people focus solely on the prescribing recommendations without considering the broader picture.
For example, with antibiotics, we follow strict regimens because we know the organism won’t respond if the treatment isn’t completed. However, weight management is different. Our understanding of obesity medications has rapidly evolved, particularly since the introduction of newer options like Zepbound (also known as Tirzepatide) just a few years ago.
Initially, the protocol was to titrate up every month based on clinical trials. But over time, experienced practitioners noticed a more tailored approach was necessary. If a patient is achieving healthy fat loss—say, 2-3%—and feeling great without cravings or urges, there’s little reason to increase the dosage. Why risk under-eating or feeling overly suppressed if the current dose is working well?
Using Data and Personal Experience for Informed Decisions
Within the weight management community, people often find themselves shamed for either increasing their medication dosage or choosing not to. This creates an environment where the focus shifts away from what truly matters: the data and your personal experience.
When making medication decisions, it's crucial to consider a few key questions. How are you feeling? What symptoms are you experiencing? The answers to these questions are what should guide your approach.
When the nurse practitioner referenced the manufacturer’s recommendation, it wasn’t incorrect, but it hints at a lack of nuance in understanding the individual’s situation. It’s perfectly valid to decide not to increase your dosage if you’re already seeing positive results. The key is whether you feel comfortable with your healthcare team and confident in the direction they're taking you.
Ultimately, the best path forward involves a collaborative approach that weighs your experiences and preferences alongside clinical guidelines.
The Impact of Insurance Companies on Medication Decisions
A significant factor that often complicates medication management is the role of insurance companies. Many insurance providers in the U.S. impose strict policies that require patients to increase their dosage after only one or two months, regardless of how well they’re responding to their current regimen. For instance, I have a patient who’s thriving on her existing dose, yet her insurance insists she titrate up monthly.
Insurance companies often base their decisions on studies rather than the real-life experiences of patients and healthcare providers. While these studies provide valuable data, they don’t always reflect the nuances of individual care. We need to consider how a patient feels, their responses to medication, and any side effects they may encounter. Unfortunately, the guidelines from these studies don’t always fit every patient’s unique situation.
It’s disheartening to see patients being pushed into unnecessary dosage increases simply because an insurance policy mandates it. Many individuals achieve great results without needing to escalate their dosage, sometimes for extended periods. Yet, due to rigid insurance regulations, they often don’t have the flexibility to make the best choice for their health.
Finding Your Balance
If you are experiencing great results with your current medication, increasing your dosage may not be necessary. In fact, I’ve seen instances where patients who are thriving can inadvertently undermine their progress by titrating up too quickly. When you push the dosage higher, there’s a real risk of becoming overly suppressed, leading to under-eating rather than the desired weight loss.
It’s crucial to strike that fine balance between maintaining a calorie deficit and ensuring you’re getting the nutrients your body needs. If you find yourself avoiding healthy foods like fruits, vegetables, nuts, and seeds because of feeling too full or suppressed, then that’s not a sustainable approach for the long term. Remember, the goal is to foster a healthy relationship with food while supporting your weight management journey.
The key takeaway is to communicate openly with your healthcare team. Consider how you're feeling, what your body is telling you, and make decisions based on a combination of your personal experiences and the data available. Your health journey is unique, and finding the right balance for you is what truly matters.
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