Dr Thomas So On What You Need To Know Before You Consider Taking Weight Loss Drugs

An Interview With Maria Angelova

Weight loss drugs don’t cause the same side effects for everyone, but people who often have strong reactions to medications should review the most common side effects before commencing weight loss through medication.

The pursuit of healthy weight management is a journey many of us embark on. In a world where quick fixes are often sought after, weight loss drugs have found a notable presence. However, like any medical intervention, there’s a need for understanding, caution, and professional guidance before considering such options. In this interview series, we are talking to doctors and medical and wellness professionals about the science, safety, efficacy, and ethical considerations surrounding weight loss drugs. As a part of this series, I had the distinct pleasure of interviewing Thomas So.

Thomas So, PharmD, is Senior Manager of the Consumer Drug Information Group at FDB (First Databank, Inc.). He brings over 20 years of experience curating, editing and maintaining FDB’s drug resources and patient drug education materials. FDB offers Meducation, a cloud-based solution embedded directly in electronic health record (HER) or pharmacy management system workflows that delivers simplified medication instructions to all patients. Dr. So has a clinical pharmacist background and brings a depth of industry knowledge to FDB’s editorial team.

Thank you so much for joining us! Our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’?

As I was growing up, I always thought I would be a pharmacist at Walgreens — it just seemed like such a good job that was connected to the community and the customers you serve. Before I became a licensed pharmacist in 1991, I worked at a pediatric hospital in the central processing department on the graveyard shift removing dirty trays and other reusable items for cleaning and restocking.

When I became a full-time pharmacist, I worked in multiple hospitals in the San Francisco Bay Area. I advanced from staff positions involved with drug dispensing to clinical management positions where I monitored patient drug regimens, including Total Parenteral Nutrition and antibiotic plans, while supervising technicians. In the late 1990s, I also led the completion of an extensive and successful survey for our hospital pharmacy’s Joint Commission accreditation, which is the gold standard across the industry in terms of complying with safety and quality standards.

After the accreditation project, I wanted to explore more — to find a way to merge my passions for pharmacy and patient education. Fortunately, a colleague of mine at the time told me that FDB (First Databank, Inc.) was looking for someone with my background. That was in 1999, and I’ve been a part of the FDB family ever since.

Outside of my career, I have a wonderful adult daughter and son. In my spare time, I practice kung fu, a hobby I initially took up with my children when they were younger. I’m a 6th-degree black belt and have competed in kung fu tournaments in the U.S. and internationally, including in Brazil.

Can you share with us the most interesting story from your career? Can you tell us what lessons or ‘takeaways’ you learned from that?

The most interesting and instructive story from my career would have to be completing the Joint Commission accreditation process for the hospital’s pharmacy. I took home several lessons from the experience that have benefited my career since then.

• Preparation and process are everything. Understanding the significance of preparation and systematic processes is essential, especially in highly regulated industries like healthcare. This sector is subject to rigorous state and federal laws, along with stringent quality measures set by various public and private entities. During the Joint Commission accreditation, I filled in for another clinical coordinator who typically handled the process. What I discovered was that the hospital was not well prepared, and its current processes needed modifications to comply with the Joint Commission’s requirements.

In contrast, at FDB, where I lead the patient education team, we have established a robust process for content development. When there’s a change in drug information or regulations, we’re immediately ready to update the information patients receive with their prescriptions. Granted, this important task can be demanding, but we’re able to keep stress levels in check because we have a roadmap to follow.

• Building personal connections is vital. During the accreditation process, I interacted with various departments and colleagues. At first, some individuals, particularly doctors and nurses, might appear tough or unapproachable due to the intense demands of their shifts. However, I found that making personal contact — through face-to-face conversations — often led to warmer, more receptive interactions even when on the phone. Colleagues became more willing to provide their assistance and time. In today’s tech-driven world, where communication predominantly takes place via email, text messages, and virtual meetings, the power of a one-on-one conversation cannot be underestimated. Such relationships serve to greatly enhance your professional network and collaboration.
• Embrace continual improvement. This concept primarily stems from my kung fu training, but it’s applicable universally. Over time, I’ve found greater enjoyment in honing my skills and training than in participating in actual competitions. This is because win or lose, my performance in tournaments reflects the time and dedication I’ve invested in training and heeding my Sifu’s (coach’s) advice.

The same principle can be applied to any endeavor. If you’re passionate about your career, seek continuous improvement either through training or by tackling new responsibilities. Such challenges will make your work more rewarding and may even lead to greater compensation. However, while a higher income is great, you can’t put a price tag on the incomparable feeling of achievement you get when you set a challenging goal for yourself and succeed.

During the Joint Commission accreditation process, for instance, it wasn’t an easy journey, and there were moments of anguish. However, knowing that I had put in my best effort and had contributed to the hospital’s achievement of this accreditation presented me with an immense sense of accomplishment.

You are a successful leader. Which three character traits do you think were most instrumental to your success? Can you please share a story or example for each?

Earlier in my career, I took the CliftonStrengths® personality test from Gallup®. After answering hundreds of questions, my top three traits were found to be ‘learner,’ ‘woo,’ and ‘individualization’. Each of these traits has played a critical role in my professional success.

Learner: Let’s start with ‘learner.’ Being designated a learner wasn’t at all surprising to me. Whatever the subject, I’ve always been eager to learn, and I appreciate the process of learning. This ties back to my kung fu experiences, where physical maneuvers, known as ‘forms,’ need to be executed flawlessly and without showing fatigue. I’ve had instances where I felt like I was on the brink of a heart attack while performing these ‘forms.’ Nevertheless, by following my Sifu’s guidance and through continuous practice, I mastered them, a process that has been incredibly gratifying for me.

At FDB, the same principle applies. We put significant effort into researching and creating content that educates patients about their medications. When customers and patients appreciate our final product, it makes all the hard work we put in at the beginning worthwhile.

Woo: Next up is ‘woo’. This is a funny way to say that someone is likable, or that they have a knack for winning people over. I can’t say that I’ve ever consciously worked on this trait, but in my professional and personal interactions, I strive to connect with the other person on a human level.

This trait was evident when I was gathering data for the Joint Commission accreditation, as well as during a kung fu tournament in Brazil. I was competing against local Brazilian students. After my turn, one student took a liking to my towel, which I’d bought in Japan. The towel featured her favorite Anime character. She was so enamored with the towel that I felt compelled to give it to her. This simple and spontaneous act of generosity won her heart despite our varying cultures, backgrounds, and other differences. Since then, we’ve become good friends. I enjoy following her kung fu achievements on Facebook.

Individualization: Similarly, the ‘individualization’ trait leads me to be intrigued by the unique qualities of each person that I meet and work with. Rather than focusing on differences between individuals, I try to draw out each person’s strengths or the best in each person.

When hiring pharmacists in our group, for example, I focus on attracting candidates from diverse backgrounds and practice areas. The individual experience of each pharmacist on our team is vital to ensuring that we can produce patient education content that covers all the different drugs in FDB’s highly curated and trusted databases.

At the same time, we nurture lifelong learning by offering projects to pharmacists who may be less experienced in a specialty but have a genuine desire to learn more about the area and strengthen their knowledge base.

Ok, thank you for all that. Now let’s shift to the main focus of our interview about health and longevity. To begin, can you share with our readers a bit about why you are an authority in the fields of health, obesity, or weight loss? In your opinion, what is your unique contribution to the world of wellness?

I have more than 24 years of experience researching consumer drug information at FDB. Our team of pharmacists and content experts is responsible for crafting the patient education materials that are attached to prescriptions when you leave the pharmacy. We are tasked with learning about the drugs and producing patient information at a 5th- to 8th-grade reading level, so that it can be easily understood by the patient, regardless of reading skills or medical knowledge. My work involves analyzing the information we receive from pharmaceutical companies and at times using peer-reviewed journal research. Through these activities, I have gained a deep knowledge base about the medications and other treatments used for weight loss or obesity.

When should a person consider using weight loss drugs to lose weight?

If a person has tried lifestyle changes (diet and exercise) without adequate weight loss, drug therapies may be tried along with lifestyle changes. In cases when weight loss has been achieved with diet and exercise alone, but the patient is struggling to maintain the weight loss, a physician may prescribe weight loss drugs to help these patients support long-term change.

Weight loss drugs should be considered when a person meets specific criteria, such as a Body Mass Index (BMI) of 30 or greater, after evaluation by a healthcare professional. Another criterion can be a BMI of 27 or higher with obesity-related health issues such as hypertension or type 2 diabetes.

What are common examples of effective weight loss medications?

The biggest blockbuster weight loss drugs that have caused a media and consumer frenzy in recent years are semaglutide, which is marketed as Ozempic® and Wegovy®; and tirzepatide, marketed as Zepbound™ and Mounjaro®. The drugs are known as GLP-1 receptor agonists and were originally developed for patients with diabetes. Although tirzepatide is a dual-agonist, it works similarly to semaglutide by acting like a hormone that regulates appetite and slows stomach emptying, which can help people maintain controlled blood-sugar levels, as well as lose weight.

Earlier weight loss drugs — which were not as effective nor as widely prescribed as the GLP-1 drugs — included orlistat, which is a medication that works by blocking the absorption of dietary fat in the digestive system. It is marketed over-the-counter as Alli™ and by prescription as Xenical™. Another earlier drug was the combination of phentermine, an appetite suppressant, and topiramate, which is used to treat seizures and migraines and has been shown to support weight loss by reducing appetite and increasing the feeling of fullness. It is available by prescription as Qsymia™. Similarly, the combination of bupropion, an antidepressant, and naltrexone, which is used to treat opioid and alcohol dependence, helps weight loss by affecting appetite control and food cravings. It is available by prescription as Contrave™. Lastly, lorcaserin is a serotonin receptor agonist that affects appetite and can help with weight loss. It is available by prescription as Belviq™.

What are the potential side effects of weight loss with medication?

Potential side effects vary based on the medication, but also by each patient since everyone can react to these drugs differently. Some people may experience debilitating side effects while others have no noticeable reaction at all. With the new GLP-1 drugs, the most common side effects that we have been hearing about are nausea, diarrhea, abdominal pain, and constipation. Recently, the FDA has had the manufacturers of GLP-1 drugs add important warnings about post-marketing reports of ileus, which is intestinal blockage. The number of cases is small, but the FDA felt it was important to warn patients of this risk. There is also newer evidence that received a lot of media attention showing semaglutide being associated with higher suicide ideation than other drugs studied, which didn’t include tirzepatide. This, of course, is just the results of one study that will need to be confirmed with future research.

The earlier weight loss drugs also had side effects, which included troubling gastrointestinal symptoms such as oily stools and diarrhea, and less noticeable reactions such as dizziness, dry mouth, change in taste, increased blood pressure, and heart rate. The combination drugs that included psychiatric medications were occasionally associated with serious mood changes, including suicidal thoughts, while others caused gallbladder issues including gallstones as well as heart valve damage and liver damage, all of which can be harmful or even fatal.

Again, these are only a few of the possible side effects that weight loss drugs can cause. That is why anyone taking these drugs should report any side effects they experience to their healthcare provider.

How do weight loss drugs compare to other methods of weight loss in terms of effectiveness and safety?

Diet and exercise are considered the first course of action to take when trying to achieve weight loss, and often are the safest, most sustainable, and financially affordable strategies long term. Weight loss drugs can be effective in those patients who cannot lose enough weight with just diet and exercise, and as we’re seeing so far with the GLP-1 drugs, they can be very effective.

Surgery for weight loss, known as bariatric surgery, is also a highly effective means for weight loss in those with severe obesity and related health problems due to their obesity. Despite the positive results, bariatric surgery is not without risk, as with any invasive procedure. Complications can include infections, nutritional deficiencies, and the need for additional surgeries, so pursuing the procedure is often only considered after other non-invasive treatments have been abandoned.

Are there certain populations or groups of individuals for whom weight loss drugs are particularly beneficial or harmful?

Weight loss drugs are particularly beneficial in those people who cannot achieve enough or sustain weight loss with just diet and exercise. In people who struggle to sustain weight loss from diet and exercise, drugs can be added to help encourage long-term and sustainable changes. These drugs may also be beneficial to those patients with obesity-related health issues such as high blood pressure, type 2 diabetes, or sleep apnea. By losing weight, patients can often improve the management of these chronic conditions and even stop taking the maintenance medications prescribed for them.

Weight loss drugs may not be best for all patients, such as women during pregnancy or while breastfeeding due to the nutritional and developmental risks to the baby. Weight loss drugs may also not be right for patients with certain medical conditions, including heart, liver, or kidney disease. Some of the medications have stimulant properties, so may not be right for those patients who are at risk of substance use disorder. Likewise, other weight loss drugs can cause mood and behavioral changes, so they may not be appropriate for patients with certain mental health conditions.

In your professional opinion, is it ok or not ok to take medications created for alternative health conditions (like diabetes) for weight loss?

There are certain drugs that are FDA-approved for both diabetes and weight loss, that a physician can prescribe for either or both situations. For example, Ozempic, Wegovy, Mounjaro and Zepbound are all FDA-approved for weight loss; the same drugs, semaglutide and tirzepatide, are approved at lower doses to treat diabetes. There continue to be shortages of semaglutide, and even more so with tirzepatide, so there is some concern that people who need the drugs for diabetes may not have as ready access if too many people who don’t have diabetes are using them for weight loss — even though they are FDA approved for weight loss and can be prescribed for that indication. There is also some concern that only wealthier Americans with generous employer-sponsored drug benefits will be able to access GLP-1s, even though obesity is a more prevalent health problem for economically challenged individuals.

What are the potential side effects or dangers of taking medications aimed at alternative health conditions for weight loss? What are the benefits?

The recent suicidal ideation study aside, a more widely accepted complication of using diabetes medications like Ozempic or Zepbound for weight loss has been reported in patients who need to undergo surgery with anesthesia. Because this medication slows stomach emptying, when undergoing surgery, patients are at risk of a condition known as pulmonary aspiration where liquid or food in the stomach is inhaled into the lungs. This can lead to suffocation and lung damage, as well as lung infections after surgery. The standard fasting of 6 to 8 hours before surgery is not enough time if you are taking GLP-1 or similar drugs for weight loss or diabetes treatment. Patients need to work closely with their medical doctor, surgeon, and anesthesiologist to determine the appropriate amount of time ahead of surgery to stop taking a weight loss drug, with specific guidance on how long to fast.

Based on your research or experience, can you please share your “5 considerations one should take into account before commencing weight loss through medicine?”?

1. The most important question someone should ask themselves before starting down the medication path is: have they made their personal best effort to first lose weight through diet and exercise alone? Although the newest drugs are effective, long-term weight management needs to involve building new dietary and activity habits that are safe and sustainable.
2. Another consideration is whether or not the person has received professional support to build those new habits. Many people attempting to lose weight haven’t changed dietary habits or engaged in an exercise routine in years or even decades. Googling ‘weight loss program’ can be overwhelming, and in some cases risky, depending on the person’s age, weight, and health status. Their primary care physician can recommend registered dietitians and exercise experts who can design plans appropriate to that person’s health and lifestyle needs so that these changes can eventually become habits.
3. For some people, there may also be mental health obstacles that prevent them from building healthy habits with diet and exercise. They may need to talk to a therapist or psychiatrist about their mental health or emotional struggles, in addition to other healthcare professionals who can help with addressing their physical health.
4. Weight loss drugs don’t cause the same side effects for everyone, but people who often have strong reactions to medications should review the most common side effects before commencing weight loss through medication. They should ask themselves if they could tolerate those side effects and for how long. Typically, such drug reactions dissipate, but not always — so everyone has to ask themselves if it is worth their time and effort. They also need to be aware that if they have other health conditions, or if they plan to become pregnant, physicians will likely not prescribe certain drugs.
5. This last consideration could also be the first, but a person considering a weight loss drug should define their reasons for wanting to pursue this course. Is it to have more energy and be more active? Is it to help manage other chronic conditions such as cardiovascular disease or diabetes? Is it to improve self-esteem and overall sense of well-being? All of these and many others are worthy goals, but everyone needs to define them for themselves so they are working toward achieving those outcomes, which will be far more fulfilling than just losing some weight.

Are there any common myths or misconceptions about weight loss drugs that you’d like to address?

There are numerous myths about weight loss drugs. Some are the following:

Myth: All effective weight loss drugs require a prescription.

Reality: While it is true that most weight loss drugs require a prescription, orlistat, with the brand name Alli,™ is available over-the-counter (OTC). Orlistat was originally available by prescription only, but the FDA determined — as they do for all drugs approved for OTC purchase — that it could be safely used as indicated without a prescription. Of course, patients should discuss all OTC drugs and nutritional supplements with their physician because there could be potentially harmful interactions with prescription medications they may be taking.

Myth: Weight loss drugs do all the work.

Reality: Some weight loss drugs are effective without changes to our daily habits, but they are most effective when combined with a sensible diet and exercise regimen. In fact, the new GLP-1 drugs are effective because they help people create new habits by consuming fewer calories without feelings of hunger or deprivation.

Myth: There are no serious side effects to taking weight loss drugs

Reality: As we discussed earlier, all of the prescription and OTC drugs available for weight loss have side effects. While the most common side effects are mild, others can be more serious depending on a person’s health conditions, or if they are taking other medications.

Myth: All weight loss drugs are the same.

Reality: Many of the weight loss drugs we discussed are effective because they suppress appetite by making the person feel fuller longer or not as hungry when it’s time to eat. Yet the drugs accomplish this effect through different physiologic pathways in our body, such as by modifying our blood sugar or controlling hormones that tend to trigger feelings of hunger. The different ways drugs can contribute to weight loss is one of the main reasons there have been so many new medications released in the past 20-plus years, and why combination medications are so popular for weight loss.

Myth: Weight loss drugs are addictive.

Reality: Most weight loss drugs have been shown to be non-addictive so far, but one medication has been shown to cause withdrawal symptoms consistent with addiction. It is the combination of phentermine/topiramate or Qsymia™. If stopped suddenly, Qsymia™ can lead to seizures, debilitating fatigue, or severe depression.

Can you help articulate why it is important to upgrade one’s lifestyle in conjunction with medicated weight loss?

The most important reason to upgrade your lifestyle is that we know it’s good for your overall health. Weight loss has consistently been shown through research and real-world evidence to be good for your heart by helping lower blood pressure and reducing cholesterol. In turn, this reduces the stress on your heart and lowers your risk of developing conditions like heart failure. Similarly, weight loss tends to lower your risk for diabetes and the complications from diabetes such as eye problems, foot circulation problems, and kidney problems. The list goes on: weight loss is associated with fewer joint and muscular aches and pain, better sleep, better mood, improved overall well-being, etc.

That’s why I chose one of my myths above to be the erroneous belief that the drugs do all the work. In reality, the goal of any weight loss drug is to help make lifestyle changes easier. For many people, extra weight does not accumulate in a couple of weeks or months, it’s often over years or decades. Changing habits is difficult both physically and psychologically because we have maintained our habits for so long. Our body tends to want to maintain a status quo, so when we try to change, it may seem like our body fights back by making us feel extra hungry, grouchy, or tired. This is especially true when we add a new exercise routine — or any exercise — to our lives.

Weight loss drugs often help reduce those feelings of hunger, irritability, fatigue, and other symptoms associated with eating less. By better managing those reactions associated with disrupting the status quo, we can establish new habits that, over time, could make taking weight loss drugs unnecessary.

Beyond medication, what supplementary treatments or therapies do you recommend in conjunction with weight loss drugs for the best results?

Forming healthier habits isn’t easy. As I mentioned earlier, typing weight loss into Google can leave someone even more confused and overwhelmed than before. That’s why I tend to recommend nutritional counseling by a registered dietitian to personalize a meal plan that aligns with your weight loss goals. If you have a busy career and personal life, the dietitian can give you a simplified plan. Hate vegetables? They can recommend meals that hide the vegetables or give you a plan to slowly integrate them into your diet.

Along with an endless amount of dietary advice, the World Wide Web offers a seemingly endless amount of exercise plans and conflicting information. Consulting a fitness trainer can help people develop a tailored exercise plan that meets their fitness level, time demands, and preferences. That way, exercise becomes a regular habit you don’t have to think about — or something that could evolve into a passion like I have experienced with kung fu.

Losing weight can be as difficult psychologically as it is physically. Cognitive behavioral therapy or some sort of emotional support program has also been shown to contribute to long-term change. Through therapy or a support group, you can have the guidance, encouragement, and accountability needed to make healthy dietary and exercise choices. Above all, though, it is important to set realistic goals. With or without weight loss drugs, there is no such thing as overnight transformation or turning back the clock to when we were in our 20s.

How do you see the future of medicated weight loss evolving with advances in science and medicine?

Given the blockbuster success of semaglutide and tirzepatide, we can expect many more similar drugs will continue to enter the market for the foreseeable future. A report from earlier this year showed that 116 obesity drugs were in various stages of clinical trials. Some of these new medications will likely be more heavily marketed in their pill form. To date, semaglutide and tirzepatide have been found to be more effective and are marketed mostly in their injectable forms, which may discourage some people from using the drug.

Ongoing research may also find new drug classes that can lead to weight loss, but it remains to be seen whether this research will lead to the development of new drug classes. We should also expect more research into combination drugs based on two or more medications already available on the market, which may be found to be more effective than a single drug. Again, only time will tell.

What is the best way for our readers to continue to follow your work online?

Readers can learn more about my professional life on LinkedIn. If they’re interested my kung fu activities and training, they can check out my YouTube page: PEMdude.

This was very inspiring. Thank you so much for the time you spent on this. We wish you only continued success.