Full Transcript for Michael Blyumin: Can you trust compounded GLP-1s?

00:03:09,900 three years, you could not get them at the pharmacy. 84 00:03:09,900 --> 00:03:10,733 They were backordered. 85 00:03:10,733 --> 00:03:12,233 They could not make enough of them. 86 00:03:13,000 --> 00:03:16,500 And when that happens, even if the drug is patented, 87 00:03:16,800 --> 00:03:19,033 there is exemptions made where you can compound, 88 00:03:19,033 --> 00:03:21,100 or a compounding pharmacy can compound it, 89 00:03:21,133 --> 00:03:23,166 to alleviate the shortage. 90 00:03:23,200 --> 00:03:24,966 When the shortage ends, though, 91 00:03:25,066 --> 00:03:27,400 that is no longer, no longer legal, 92 00:03:27,400 --> 00:03:31,033 which is why a lot of those processes have winded down. 93 00:03:31,866 --> 00:03:34,466 That's the short of it in terms of how... 94 00:03:34,466 --> 00:03:35,266 That's... Absolutely. 95 00:03:35,500 --> 00:03:39,266 So why do you think we still see so many compounded 96 00:03:39,266 --> 00:03:40,800 GLP-1s, you know, 97 00:03:40,800 --> 00:03:42,266 being made available? Is, uh, 98 00:03:42,266 --> 00:03:43,833 is there a, is there a, 99 00:03:43,833 --> 00:03:45,733 a cost difference? Uh, 100 00:03:45,733 --> 00:03:48,266 is it an access issue? Insurance? 101 00:03:48,266 --> 00:03:50,733 What is the, what is the reason why this is, 102 00:03:50,733 --> 00:03:53,233 is still happening, apart from capitalism? 103 00:03:53,433 --> 00:03:55,133 Yeah, I'm glad you brought up the last point. 104 00:03:55,133 --> 00:03:56,000 That was definitely part of it. 105 00:03:56,000 --> 00:03:57,866 I think it's a confluence of all of those things. 106 00:03:57,866 --> 00:04:00,200 So historically, people feel that these medications 107 00:04:00,200 --> 00:04:02,333 are very unaffordable. The reality is they also are 108 00:04:02,333 --> 00:04:05,633 very expensive in the US. This is very true. Historically, 109 00:04:05,633 --> 00:04:07,700 they've been hard to get, though that's eased now, 110 00:04:07,700 --> 00:04:09,900 especially with supply 111 00:04:09,933 --> 00:04:11,866 sort of catching up somewhat to demand. 112 00:04:11,866 --> 00:04:14,100 So all of that access component is true. 113 00:04:14,100 --> 00:04:16,500 That's what led to the formation of these companies, 114 00:04:16,500 --> 00:04:17,600 right? There was a huge demand. 115 00:04:17,600 --> 00:04:18,466 There's no supply. 116 00:04:18,466 --> 00:04:21,233 There's a legal way to do it outside of, you know, 117 00:04:21,233 --> 00:04:24,433 paying Eli Lilly or Novo Nordisk for their compounds. 118 00:04:24,533 --> 00:04:26,500 And so naturally, with capitalism, 119 00:04:26,500 --> 00:04:27,600 you form a company: 120 00:04:28,233 --> 00:04:29,233 "We're gonna compound GLP-1s, 121 00:04:29,233 --> 00:04:30,633 and we'll give it to you." 122 00:04:30,633 --> 00:04:31,900 Because you're compounding, 123 00:04:31,900 --> 00:04:33,633 you probably can do it at a more affordable rate 124 00:04:33,633

--> 00:04:34,900 than paying, you know, 125 00:04:34,900 --> 00:04:36,300 the, the drug manufacturers. 126 00:04:36,300 --> 00:04:37,666 And so also, 127 00:04:37,666 --> 00:04:40,533 you could potentially, depends on the company, 128 00:04:40,533 --> 00:04:42,333 offer someone a good price for it. 129 00:04:42,866 --> 00:04:44,366 I would say recently, 130 00:04:45,333 --> 00:04:48,033 that's not really the same equation anymore. 131 00:04:48,033 --> 00:04:50,300 They've hung on because, you know, 132 00:04:50,300 --> 00:04:52,600 they've been able to accumulate a customer base. 133 00:04:52,933 --> 00:04:55,433 People feel like they can trust them. Why? 134 00:04:55,433 --> 00:04:56,000 I don't know. 135 00:04:56,000 --> 00:04:58,400 More than, like, a drug company or a pharmacy. 136 00:04:58,500 --> 00:05:00,400 And so they hang on. In reality, 137 00:05:00,400 --> 00:05:03,633 most of these compounding pharmacies, companies, 138 00:05:03,633 --> 00:05:04,633 whatever you want to call them, 139 00:05:04,633 --> 00:05:07,700 have actually winded down offering compounded products. 140 00:05:07,700 --> 00:05:09,300 Most of them are now offering commercially 141 00:05:09,300 --> 00:05:11,233 available products. I think 142 00:05:11,233 --> 00:05:13,000 Hims & Hers is what it's called, 143 00:05:13,000 --> 00:05:15,300 is probably the only one still fighting 144 00:05:15,300 --> 00:05:17,033 for compounding GLP-1s. 145 00:05:17,100 --> 00:05:18,300 And the reason they've wound down 146 00:05:18,300 --> 00:05:20,133 is because the FDA is sending cease 147 00:05:20,133 --> 00:05:21,466 and desist letters. It's, 148 00:05:21,466 --> 00:05:24,133 it's not legal to compound a patented drug. 149 00:05:24,133 --> 00:05:25,466 The reason drugs are patented 150 00:05:25,466 --> 00:05:27,266 is so that there is an incentive 151 00:05:27,266 --> 00:05:28,700 to spend billions of dollars 152 00:05:28,800 --> 00:05:30,666 to research the drugs, to bring them to market. 153 00:05:30,666 --> 00:05:32,433 If there's no incentive, then no one's gonna do it. 154 00:05:32,433 --> 00:05:35,266 And so the theory is innovation will stop. 155 00:05:35,266 --> 00:05:36,333 Now, obviously, 156 00:05:36,433 --> 00:05:38,800 we know that pharma companies make a lot of money 157 00:05:39,033 --> 00:05:40,333 with this. So, 158 00:05:40,900 --> 00:05:43,400 you know, that's not a reason to charge people more 159 00:05:43,400 --> 00:05:44,466 than they should, 160 00:05:44,466 --> 00:05:46,500 but that is a reason why these things are expensive 161 00:05:46,500 --> 00:05:48,733 and why patent exclusivity exists. 162 00:05:49,433 --> 00:05:51,433 Now, in terms of cost, 163 00:05:51,933 --> 00:05:55,000 because the manufacturers are offering self-pay 164 00:05:55,000 --> 00:05:57,166 cash options directly to consumers, 165 00:05:57,466 --> 00:06:00,400 you can basically get the same thing with the FDA 166 00:06:00,400 --> 00:06:03,166 approved medication without a middleman, 167 00:06:04,066 --> 00:06:05,666 without using, like, Ro, for example, 168 00:06:05,666 --> 00:06:06,800 or something like that. 169 00:06:07,466 --> 00:06:09,766 Those prices are becoming pretty equal, 170 00:06:09,933 --> 00:06:10,500 especially 171 00:06:10,500 --> 00:06:13,300 because those other companies can't compound anymore. 172 00:06:13,300 --> 00:06:15,133 And they actually may charge you more in the end, 173 00:06:15,133 --> 00:06:17,233 'cause you might have to pay for a membership fee, 174 00:06:17,633 --> 00:06:21,466 et cetera. And people also have this innate trust in that: 175 00:06:21,466 --> 00:06:23,033 "Oh, this is an alternative. 176 00:06:23,233 --> 00:06:24,300 I think, you know, 177 00:06:24,300 --> 00:06:25,866 it's, it's expanding market access. 178 00:06:25,866 --> 00:06:28,333 This is a good thing." The reality is, 179 00:06:28,333 --> 00:06:29,666 these companies are after the same thing 180 00:06:29,666 --> 00:06:31,533 everybody's after. They're after profit. 181 00:06:31,533 --> 00:06:34,200 They are just as profit-motivated as any pharma company. 182 00:06:34,200 --> 00:06:35,633 They're not here for the good of the people. 183 00:06:35,633 --> 00:06:37,600 They're here to exploit an opportunity. 184 00:06:37,733 --> 00:06:40,133 That's what capitalism is. So, 185 00:06:40,133 --> 00:06:42,933 I, I don't place any more sort of 186 00:06:42,933 --> 00:06:46,133 good faith in any of those companies than I do 187 00:06:46,133 --> 00:06:47,200 like a drug manufacturer. And, 188 00:06:47,200 --> 00:06:49,933 in fact, it becomes a little bit the opposite way 189 00:06:49,933 --> 00:06:51,433 when you're compounding illegally, 190 00:06:51,433 --> 00:06:53,233 because then there's a whole question on: 191 00:06:53,266 --> 00:06:54,500 Who's overseeing the process? 192 00:06:54,500 --> 00:06:55,800 Is the product clean? 193 00:06:56,033 --> 00:06:58,533 Is it being introduced with other compounds 194 00:06:58,533 --> 00:07:00,533 to make them novel? But those 195 00:07:00,933 --> 00:07:03,300 style of compounds have never been truly validated 196 00:07:03,300 --> 00:07:05,600 to be absorbed properly or effective. 197 00:07:05,600 --> 00:07:07,700 It leads to a whole separate discussion. 198 00:07:08,500 --> 00:07:09,300 Absolutely. And, 199 00:07:09,300 --> 00:07:10,733 and you must have, you know, 200 00:07:10,733 --> 00:07:12,900 you must have seen some sort of horror stories. 201 00:07:12,900 --> 00:07:14,033 What, what are some of the sort of 202 00:07:14,033 --> 00:07:16,333 most egregious things that you've seen happening in, 203 00:07:16,333 --> 00:07:17,633 in that space? 204 00:07:18,666 --> 00:07:19,600 Yeah, for one, 205 00:07:19,600 --> 00:07:22,100 it's, the, the marketing is a little bit predatory, 206 00:07:22,100 --> 00:07:23,400 in my opinion, right? 207 00:07:23,400 --> 00:07:25,000 We're marketing people's health, 208

00:07:25,000 --> 00:07:27,033 and promises are made without sort of 209 00:07:27,033 --> 00:07:30,300 fully having that benefit 210 00:07:30,300 --> 00:07:32,900 risk discussion that you have at the doctor's office, 211 00:07:32,900 --> 00:07:34,333 or you should have at the doctor's office. 212 00:07:34,333 --> 00:07:36,500 Like, with my patients, when we start new medicines, 213 00:07:36,700 --> 00:07:39,166 whether it's weight loss or diabetes or something else, 214 00:07:39,433 --> 00:07:41,066 you know, there is a lot of discussion that happens 215 00:07:41,066 --> 00:07:42,233 about why we should do it. 216 00:07:42,233 --> 00:07:44,433 And if we do it, what are the risks we're incurring? 217 00:07:44,500 --> 00:07:46,366 And these companies, 218 00:07:47,266 --> 00:07:48,133 they're, they're marketing. 219 00:07:48,133 --> 00:07:49,233 They're not doctors' offices. 220 00:07:49,233 --> 00:07:51,233 Like, they're pharmacy, compounding pharmacies, 221 00:07:51,233 --> 00:07:52,566 or whatever you want to call them. 222 00:07:52,666 --> 00:07:54,533 They're marketing to get people in there. 223 00:07:54,533 --> 00:07:56,100 So that marketing, in my opinion, 224 00:07:56,100 --> 00:07:57,033 is a bit predatory. 225 00:07:57,033 --> 00:07:59,066 The formulations that they are promising people 226 00:07:59,066 --> 00:08:02,166 may not necessarily be approved formulations. 227 00:08:02,733 --> 00:08:04,866 Novel formulations give me particular pause, 228 00:08:04,866 --> 00:08:06,900 because if you haven't ran sort of 229 00:08:06,900 --> 00:08:08,433 a larger trial 230 00:08:08,433 --> 00:08:10,333 to understand if they're absorbed the same way, 231 00:08:10,333 --> 00:08:12,033 if the doses are equivalent, 232 00:08:12,033 --> 00:08:13,133 if they aren't absorbed at all, 233 00:08:13,700 --> 00:08:14,233 and you're 234 00:08:14,233 --> 00:08:16,300 making people pay for something that doesn't work, 235 00:08:16,700 --> 00:08:18,433 that's a potential problem. 236 00:08:18,666 --> 00:08:21,000 The other problem that exists is essentially, 237 00:08:21,000 --> 00:08:22,300 to get around the compounding law, 238 00:08:22,300 --> 00:08:23,533 you would have to claim 239 00:08:23,800 --> 00:08:26,266 you are making a totally new compound, right? 240 00:08:26,266 --> 00:08:28,300 Like, some people can't take an oral medicine, 241 00:08:28,333 --> 00:08:29,500 and so you have to compound, like, a, 242 00:08:29,500 --> 00:08:30,633 like a big tablet, 243 00:08:30,633 --> 00:08:32,133 but there's no other product available. 244 00:08:32,133 --> 00:08:34,266 You have to compound a liquid. That makes sense. 245 00:08:34,266 --> 00:08:35,333 That person needs the medicine. 246 00:08:35,333 --> 00:08:37,200 They can't swallow the tablet, or they have a G-tube, 247 00:08:37,200 --> 00:08:39,166 et cetera. They need an alternate form. 248 00:08:39,900 --> 00:08:42,566 What compounding GLP-1 companies are doing is saying, 249 00:08:43,200 --> 00:08:45,066 "Let's make a whole different formulation," 250 00:08:45,066 --> 00:08:47,000 but it may not be equivalent. 251 00:08:47,000 --> 00:08:48,500 Peptides are hard to absorb. 252 00:08:48,533 --> 00:08:50,400 And when they do make a similar formulation, 253 00:08:50,400 --> 00:08:52,366 like an injectable subcutaneously, 254 00:08:52,800 --> 00:08:53,433 they say, "Oh, 255 00:08:53,433 --> 00:08:54,666 we'll put other things in it. 256 00:08:54,666 --> 00:08:57,033 Maybe vitamin B12, or maybe something else." 257 00:08:57,800 --> 00:08:59,400 Things can affect absorbability. 258 00:08:59,400 --> 00:09:00,833 Compatibility between different products 259 00:09:00,833 --> 00:09:01,900 is not always guaranteed. 260 00:09:01,900 --> 00:09:04,433 And if you're just willy-nilly making a new compound 261 00:09:04,433 --> 00:09:06,833 so that you can say that it's a new compound and legal, 262 00:09:06,900 --> 00:09:08,166 but not testing 263 00:09:08,333 --> 00:09:10,933 the true efficacy and safety of that combination, 264 00:09:11,700 --> 00:09:12,733 that gives me pause. 265 00:09:12,733 --> 00:09:14,800 I can't tell my patients anything about 266 00:09:14,800 --> 00:09:17,833 the safety of that because it's not been studied, right? 267 00:09:18,400 --> 00:09:19,433 Absolutely. I mean, 268 00:09:19,433 --> 00:09:21,100 and, and not a day goes by, 269 00:09:21,100 --> 00:09:21,500 I mean, well, 270 00:09:21,500 --> 00:09:23,933 not a second goes by on social media without, 271 00:09:23,933 --> 00:09:27,133 you know, somebody talking about peptides and GLP-1s. 272 00:09:27,133 --> 00:09:28,700 But let's just home in on the media 273 00:09:28,700 --> 00:09:30,133 and sort of mainstream media. 274 00:09:30,133 --> 00:09:32,333 What do you think they could possibly cover? 275 00:09:32,333 --> 00:09:34,100 So we need an entire series. 276 00:09:34,100 --> 00:09:35,800 What, what do you think are the sort of, 277 00:09:35,800 --> 00:09:38,733 the main things that mainstream media 278 00:09:38,733 --> 00:09:41,766 get wrong about GLP-1s? And, you know, 279 00:09:42,200 --> 00:09:43,400 we've obviously seen, uh, 280 00:09:43,400 --> 00:09:45,500 you know, the adoption of the term GLP-1s. 281 00:09:45,500 --> 00:09:46,000 I think, you know, 282 00:09:46,000 --> 00:09:48,000 really didn't even pop into, 283 00:09:48,000 --> 00:09:50,733 you know, sort of conversation until, oh, 284 00:09:50,733 --> 00:09:53,200 well, a couple of years ago. It was very much Ozempic 285 00:09:53,200 --> 00:09:55,000 and an "Ozempic face." And, 286 00:09:55,000 --> 00:09:55,333 you know, what, 287 00:09:55,333 --> 00:09:57,266 what are the, what are the common 288 00:09:57,266 --> 00:09:59,400 sort of media mistakes that you see? 289 00:10:00,000 --> 00:10:00,333 Yeah, I, 290 00:10:00,333 --> 00:10:02,600 I think it's just not treating this medication 291 00:10:02,600 --> 00:10:03,600 like a

medication. I mean, 292 00:10:03,600 --> 00:10:05,333 we really don't talk about any other medication 293 00:10:05,333 --> 00:10:06,333 this way, right? 294 00:10:06,333 --> 00:10:10,066 We're treating it, like, on one hand, like a miracle drug, 295 00:10:10,066 --> 00:10:10,733 on the other hand, 296 00:10:10,733 --> 00:10:12,433 like something you can just easily take 297 00:10:12,433 --> 00:10:14,100 to get a few little benefits out of. 298 00:10:14,100 --> 00:10:16,333 And I would just say we need to treat it with the same 299 00:10:16,333 --> 00:10:19,566 sort of a caution that we treat any 300 00:10:19,666 --> 00:10:22,233 public discussion about the use of medication 301 00:10:22,300 --> 00:10:24,466 and its effects and safety. You know, 302 00:10:24,466 --> 00:10:27,666 if you're not someone that has credentials to do that, 303 00:10:27,666 --> 00:10:29,900 you, you might want to be careful about 304 00:10:30,066 --> 00:10:31,000 how you speak about it, 305 00:10:31,000 --> 00:10:33,133 to not give people the false impression about what 306 00:10:33,133 --> 00:10:34,666 and what not the drug is. 307 00:10:34,666 --> 00:10:38,900 So, like, more concretely, I think it needs to... 308 00:10:39,100 --> 00:10:41,000 People that really, truly need the medication, 309 00:10:41,000 --> 00:10:42,100 or fit the profile 310 00:10:42,100 --> 00:10:43,733 of getting benefit from the medication, 311 00:10:43,733 --> 00:10:45,533 are the people that should be taking it. 312 00:10:45,533 --> 00:10:47,833 We should not be posing this as an option 313 00:10:47,833 --> 00:10:51,000 for just anybody. That, that's one thing to consider. 314 00:10:51,000 --> 00:10:51,500 Second thing, 315 00:10:51,500 --> 00:10:53,333 there's a lot of discussion from my patients, like, "Oh, 316 00:10:53,333 --> 00:10:54,866 I heard this new side effect. 317 00:10:54,866 --> 00:10:57,433 I heard there's this new issue with the medicine." 318 00:10:57,433 --> 00:10:58,733 Treating this medicine like it's new. 319 00:10:58,733 --> 00:11:01,033 I mean, a lot of the newer formulations are new. 320 00:11:01,033 --> 00:11:03,033 Mounjaro is new. Zepbound is new, 321 00:11:03,033 --> 00:11:05,233 relatively speaking. It's like four years now. 322 00:11:05,500 --> 00:11:07,300 But this class of medications 323 00:11:07,300 --> 00:11:09,133 has been around like 20 years or so, 324 00:11:09,133 --> 00:11:11,533 studied since the '90s, initially used for diabetes. 325 00:11:11,533 --> 00:11:13,766 It wasn't popular because they weren't potent. 326 00:11:14,133 --> 00:11:15,866 They didn't have a lot of weight loss. 327 00:11:15,866 --> 00:11:17,266 They had a little bit, but not a lot. 328 00:11:17,266 --> 00:11:19,200 But as we got more potent and potent versions, 329 00:11:19,200 --> 00:11:20,833 or higher doses were approved, 330 00:11:20,933 --> 00:11:22,633 people noticed the weight loss. 331 00:11:22,633 --> 00:11:26,333 That got into sort of

the use of it for weight loss. 332 00:11:26,633 --> 00:11:28,733 The weight loss versions got more potent, 333 00:11:28,933 --> 00:11:30,900 and that's how we ended up here today. 334 00:11:31,000 --> 00:11:31,666 And so, so you, 335 00:11:31,666 --> 00:11:33,666 you've seen a sort of a gradual increasing, 336 00:11:33,666 --> 00:11:34,200 I guess, then, 337 00:11:34,200 --> 00:11:36,333 of the sort of the dosing and the strength in the, 338 00:11:36,333 --> 00:11:38,100 in the time that you've been working in the space. 339 00:11:38,100 --> 00:11:39,433 What does that sort of look like? 340 00:11:39,433 --> 00:11:40,000 So, you know, 341 00:11:40,000 --> 00:11:42,400 for the people who are not familiar with where, 342 00:11:42,400 --> 00:11:45,200 where it started and kind of where it's at now, and, 343 00:11:45,200 --> 00:11:48,000 and is that something that somebody needs to do? 344 00:11:48,000 --> 00:11:49,333 And, and also, just to sort of, 345 00:11:49,333 --> 00:11:51,733 to sort of wrap that up in a little bow, 346 00:11:51,866 --> 00:11:53,466 what happens when somebody says, 347 00:11:53,466 --> 00:11:55,033 "I don't want to take this anymore. 348 00:11:55,033 --> 00:11:57,400 I don't think I need to take this anymore"? 349 00:11:57,400 --> 00:11:59,333 What, what should they be looking at, 350 00:11:59,333 --> 00:12:02,233 or what should their medical provider be looking at? 351 00:12:02,333 --> 00:12:03,033 Yeah, yeah. 352 00:12:03,033 --> 00:12:05,933 So the, the point of that is that these are not new 353 00:12:05,933 --> 00:12:06,600 miracle drugs. 354 00:12:06,600 --> 00:12:08,600 These are drugs that have been sort of long available, 355 00:12:08,600 --> 00:12:10,633 long studied. They're just newer versions of it. 356 00:12:10,633 --> 00:12:13,933 And so people need not to think this is some new, 357 00:12:13,933 --> 00:12:16,333 unproven thing. We've known about this for a long time, 358 00:12:16,333 --> 00:12:18,233 and it's been studied for a decent amount of time. 359 00:12:18,233 --> 00:12:18,833 So when people say, "Oh, 360 00:12:18,833 --> 00:12:20,433 I have some new side effects," or they're 361 00:12:20,433 --> 00:12:21,300 reporting these new things, 362 00:12:21,300 --> 00:12:22,666 I mean, it's always a possibility 363 00:12:22,666 --> 00:12:23,333 we learn something new 364 00:12:23,333 --> 00:12:25,333 as we gain more time with a certain medicine. 365 00:12:25,333 --> 00:12:27,466 But a lot of these things are things we knew about, 366 00:12:27,466 --> 00:12:29,333 and it's seeming new because 367 00:12:29,666 --> 00:12:31,066 people may be getting medication 368 00:12:31,066 --> 00:12:32,233 from people that are not explaining 369 00:12:32,233 --> 00:12:33,700 the full benefits and risks. 370 00:12:34,100 --> 00:12:36,700 These medications started, like, early 2000s. 371 00:12:36,700 --> 00:12:38,133 They were, potency-wise, 372 00:12:38,133 --> 00:12:40,066 which is basically, you can say, like, 373 00:12:40,066 --> 00:12:41,733 how much sugar can they lower? 374 00:12:41,733 --> 00:12:43,033 How much weight loss can they cause? 375 00:12:43,033 --> 00:12:44,633 Those go hand in hand, typically. 376 00:12:45,066 --> 00:12:46,600 They were not as strong as they are today. 377 00:12:46,600 --> 00:12:48,033 For, like, an A1C result, 378 00:12:48,033 --> 00:12:51,300 maybe 1% or so in reduction, versus, like, high-dose 379 00:12:51,300 --> 00:12:55,133 Mounjaro now is 2.3%. Weight loss, maybe 5 to 10%. 380 00:12:55,133 --> 00:12:58,100 Now it's, on some of them, like 15 to 20%. 381 00:12:58,200 --> 00:13:00,266 And before, they were daily injectables, 382 00:13:00,266 --> 00:13:02,000 another reason they weren't super popular. 383 00:13:02,000 --> 00:13:03,666 People don't love injecting every day. 384 00:13:03,666 --> 00:13:05,600 And then they became weekly injectables. 385 00:13:05,600 --> 00:13:07,400 Now we even have oral versions. 386 00:13:07,733 --> 00:13:10,733 So that's sort of been the progression. 387 00:13:10,733 --> 00:13:13,600 And the point is that this development has been take, 388 00:13:13,600 --> 00:13:16,500 taken a long time. Certainly, they've gotten better. 389 00:13:16,533 --> 00:13:18,200 In terms of getting off of the medicine, 390 00:13:18,200 --> 00:13:19,600 it depends on what you're using it for. 391 00:13:19,600 --> 00:13:21,400 If you're someone who's using it for blood sugar, 392 00:13:21,400 --> 00:13:22,200 for example, 393 00:13:23,466 --> 00:13:25,433 it's unlikely you will fully get off the medicine, 394 00:13:25,433 --> 00:13:26,700 because we don't cure diabetes. 395 00:13:26,700 --> 00:13:27,800 We can only manage it. 396 00:13:27,800 --> 00:13:30,900 We can't reverse insulin resistance in 99% of the cases, 397 00:13:30,900 --> 00:13:33,000 right? So that's a whole different discussion. 398 00:13:33,000 --> 00:13:34,700 From a weight loss perspective, 399 00:13:34,866 --> 00:13:36,300 when you're on the medicine, 400 00:13:36,633 --> 00:13:38,700 you will lose weight. A lot of the weight loss 401 00:13:38,700 --> 00:13:41,100 mechanism is related to caloric deficits, 402 00:13:41,100 --> 00:13:43,100 because you have appetite suppression. 403 00:13:43,666 --> 00:13:46,766 Those caloric deficits are very difficult to maintain 404 00:13:46,900 --> 00:13:50,366 without the medicine because of things like food noise, 405 00:13:50,733 --> 00:13:52,500 because of the, you know, 406 00:13:52,500 --> 00:13:54,333 sort of the taking off of that mask 407 00:13:54,333 --> 00:13:58,433 of getting full faster. Your old appetite will return. 408 00:13:58,633 --> 00:14:02,033 So that's what makes it difficult to keep weight off 409 00:14:02,033 --> 00:14:04,533 after discontinuing the medicine. 410 00:14:04,533 --> 00:14:07,066 So that is something you should think about as a, 411 00:14:07,066 --> 00:14:09,733 definitely a possibility when you

stop the medicine. 412 00:14:09,733 --> 00:14:14,433 And not only are you losing fat when you're on a GLP-1, 413 00:14:14,833 --> 00:14:18,566 most studies point to about 25% loss of lean muscle. 414 00:14:19,233 --> 00:14:20,633 That was gonna be my next question. 415 00:14:20,633 --> 00:14:22,300 So, in terms of, you know, 416 00:14:22,300 --> 00:14:24,833 diet changes, lifestyle changes, 417 00:14:24,833 --> 00:14:26,233 what would you be saying to somebody 418 00:14:26,233 --> 00:14:27,533 that they need to do from a 419 00:14:27,533 --> 00:14:29,566 sort of an augmentation perspective? 420 00:14:30,200 --> 00:14:31,700 Yeah, if you're on a GLP-1, 421 00:14:31,700 --> 00:14:33,733 it's very important to be physically active, 422 00:14:33,733 --> 00:14:36,833 use your muscles, both cardio-type activities, 423 00:14:36,833 --> 00:14:38,366 but also resistance training. 424 00:14:38,666 --> 00:14:41,233 That obviously helps not atrophy our muscles 425 00:14:41,233 --> 00:14:42,233 if we're going to use them, 426 00:14:42,233 --> 00:14:44,800 and they're already at risk of that with the GLP-1. 427 00:14:45,066 --> 00:14:47,533 And then protein intake is important. 428 00:14:47,533 --> 00:14:48,633 That's a bit of a tough one 429 00:14:48,633 --> 00:14:50,633 when you're feeling full all the time, 'cause 430 00:14:50,633 --> 00:14:51,733 protein makes us full. 431 00:14:51,800 --> 00:14:54,000 But protein has a number of benefits, 432 00:14:54,000 --> 00:14:57,533 in the sense that you'll need it for muscle retention 433 00:14:57,533 --> 00:14:59,300 or growth, depending what you're looking for. 434 00:14:59,300 --> 00:15:02,133 And it keeps you full, so that it helps, 435 00:15:02,133 --> 00:15:03,466 if you're lowering the dose 436 00:15:03,466 --> 00:15:06,000 or coming off of it completely, to again 437 00:15:06,000 --> 00:15:08,133 curb the food noise while being able to maintain 438 00:15:08,133 --> 00:15:10,000 some level of calorie deficit. 439 00:15:10,333 --> 00:15:12,633 Fats and carbs are more calorically dense. 440 00:15:12,933 --> 00:15:14,333 So, you know, 441 00:15:14,333 --> 00:15:15,933 the more we have of those, 442 00:15:15,933 --> 00:15:17,433 the higher calories intake, 443 00:15:17,466 --> 00:15:19,033 the less weight loss you get, 444 00:15:19,033 --> 00:15:22,366 or more weight gain upon discontinuation you'll get. 445 00:15:22,366 --> 00:15:23,733 So people need to be aware of that, 446 00:15:23,733 --> 00:15:25,100 that you may have lost muscle, 447 00:15:25,100 --> 00:15:27,200 or you may lose muscle on the GLP-1, 448 00:15:27,200 --> 00:15:29,100 and when you discontinue, and if you have weight regain, 449 00:15:29,100 --> 00:15:31,266 it's not like you just magically gain back muscle, right? 450 00:15:31,266 --> 00:15:31,833 Most of that... So, 451 00:15:31,833 --> 00:15:32,833 so looking, yeah, 452 00:15:32,833 --> 00:15:33,933 looking at it as a, as a, 453 00:15:33,933 --> 00:15:37,466 as a wonder pill or a wonder jab in a standalone, 454 00:15:37,466 --> 00:15:40,533 in a standalone way is, is not particularly helpful for, 455 00:15:40,533 --> 00:15:42,266 for the patient. Yeah. 456 00:15:42,266 --> 00:15:43,233 I mean, there are no, 457 00:15:43,233 --> 00:15:45,500 there's no magic in, in this world. 458 00:15:45,533 --> 00:15:46,700 It's, it's science. 459 00:15:46,700 --> 00:15:48,333 It's, everything has a risk and benefit. 460 00:15:48,333 --> 00:15:49,633 Everything we put in our mouths, 461 00:15:49,633 --> 00:15:51,600 food-wise, has a risk and benefit. Supplements, 462 00:15:51,600 --> 00:15:52,633 vitamins, medicines, 463 00:15:52,633 --> 00:15:54,166 everything has a risk and benefit. 464 00:15:54,433 --> 00:15:55,866 It is certainly very good, 465 00:15:55,866 --> 00:15:57,200 and much better at what it does 466 00:15:57,200 --> 00:15:58,900 than anything we had before. 467 00:15:58,900 --> 00:15:59,100 You know, 468 00:15:59,100 --> 00:16:01,400 if you think about weight loss medications from before, 469 00:16:01,400 --> 00:16:02,966 largely based on stimulants, 470 00:16:03,200 --> 00:16:03,933 that has a, 471 00:16:03,933 --> 00:16:07,033 not a great profile from a cardiovascular standpoint, 472 00:16:07,066 --> 00:16:07,466 which is 473 00:16:07,466 --> 00:16:08,933 a lot of the reason why you want to lose weight, 474 00:16:08,933 --> 00:16:10,700 to improve your cardiovascular health. 475 00:16:10,733 --> 00:16:12,700 So, in that context, 476 00:16:12,866 --> 00:16:13,633 these have certainly 477 00:16:13,633 --> 00:16:14,433 changed the game 478 00:16:14,433 --> 00:16:16,066 and are very helpful for a lot of people. 479 00:16:16,066 --> 00:16:17,933 They've changed the lives of my diabetes patients. 480 00:16:17,933 --> 00:16:19,733 They lower cardiovascular risk, 481 00:16:19,733 --> 00:16:20,833 fatty liver, sleep 482 00:16:20,833 --> 00:16:23,600 apnea. But there's contexts for them. 483 00:16:23,600 --> 00:16:25,533 There are certain people that are better fits for them, 484 00:16:25,533 --> 00:16:26,733 certain people that are not. 485 00:16:26,733 --> 00:16:28,666 If you wanna lose, you know, 486 00:16:28,666 --> 00:16:30,400 just 5% of your body weight, 487 00:16:30,400 --> 00:16:32,933 take the medicine for two months and stop, 488 00:16:32,933 --> 00:16:34,633 yeah, it might help you achieve that. 489 00:16:34,733 --> 00:16:36,033 But you have to ask yourself: 490 00:16:36,033 --> 00:16:38,800 Is the risk worth the benefit for such a small benefit, 491 00:16:38,800 --> 00:16:40,566 potentially, or if that's all you're looking for? 492 00:16:41,733 --> 00:16:43,800 And as we sort of look towards the future, 493 00:16:43,800 --> 00:16:45,133 you know, we started off with, 494 00:16:45,133 --> 00:16:47,233 with GLP-1s. GLP-2's 495 00:16:47,233 --> 00:16:50,533 now a thing. A lot of speculation of the first, 496 00:16:50,533 --> 00:16:53,066 or one

of the very first trillion-dollar drugs. 497 00:16:53,066 --> 00:16:55,566 And GLP-3s. For our audience, 498 00:16:55,800 --> 00:16:56,800 what is the sort of the, 499 00:16:56,800 --> 00:16:58,800 what is the difference between the, 500 00:16:58,800 --> 00:17:01,000 the, the GLP family? And, 501 00:17:01,000 --> 00:17:03,500 you know, when will we get to GLP-49? 502 00:17:04,233 --> 00:17:04,900 Yeah, yeah. 503 00:17:04,900 --> 00:17:07,066 That's a good question. So they're all GLP-1s. 504 00:17:07,066 --> 00:17:08,833 Just some of them hit multiple pathways. 505 00:17:08,833 --> 00:17:10,733 So some of them are built as a GLP-1. 506 00:17:10,733 --> 00:17:11,200 Some of them are, 507 00:17:11,200 --> 00:17:12,733 are built as a dual-agonist 508 00:17:12,733 --> 00:17:14,433 GLP-1. Some are built, will, 509 00:17:14,433 --> 00:17:16,333 will be triple agonists, 510 00:17:16,500 --> 00:17:19,166 meaning they hit three different receptor pathways. 511 00:17:19,433 --> 00:17:20,933 So GLP-1 is the main one. 512 00:17:20,933 --> 00:17:23,033 The current one that's dual, 513 00:17:23,033 --> 00:17:24,433 the only one of them exists, 514 00:17:24,433 --> 00:17:28,433 it's Mounjaro or Zepbound. Generic name is tirzepatide. 515 00:17:28,700 --> 00:17:32,533 And that's a GLP/GIP, so dual agonism. 516 00:17:33,200 --> 00:17:36,500 Same pathway, though, so, like, same areas of process. 517 00:17:37,466 --> 00:17:38,600 The difference, we, 518 00:17:38,600 --> 00:17:40,333 I don't think we fully understand. Certainly, 519 00:17:40,333 --> 00:17:42,966 I'm not, I don't have any 520 00:17:43,833 --> 00:17:44,633 literature 521 00:17:44,733 --> 00:17:46,500 showing that we fully understand what happened 522 00:17:46,500 --> 00:17:48,666 when we hit only one pathway or both pathways. 523 00:17:48,666 --> 00:17:48,900 I think 524 00:17:48,900 --> 00:17:51,233 we're still learning about the potential effects, 525 00:17:51,233 --> 00:17:53,266 because these receptors are located all over our body, 526 00:17:53,266 --> 00:17:55,800 meaning there can be effects in lots of different ways. 527 00:17:56,100 --> 00:17:58,833 Right now, what it looks like is the dual mechanism, 528 00:17:58,833 --> 00:18:00,100 like Mounjaro and tirzepatide, 529 00:18:00,100 --> 00:18:03,000 tend to be stronger in their effect. 530 00:18:03,133 --> 00:18:05,000 Like the max approved effect, 531 00:18:05,200 --> 00:18:07,400 max approved dose has a larger effect on weight loss 532 00:18:07,400 --> 00:18:08,633 and, and blood sugar. 533 00:18:08,666 --> 00:18:10,666 Maybe a little bit improvement 534 00:18:10,666 --> 00:18:12,300 in how well people tolerate, 535 00:18:12,300 --> 00:18:13,666 from a nausea perspective, 536 00:18:13,666 --> 00:18:15,933 though hard evidence, 537 00:18:16,033 --> 00:18:18,900 in terms of statistics in a clinical trial, 538 00:18:18,900 --> 00:18:21,333 don't prove that. Anecdotally, practicing, 539 00:18:21,333 -->

00:18:23,033 we do see a lot of people 540 00:18:23,466 --> 00:18:25,200 seem to tolerate Mounjaro better. 541 00:18:25,200 --> 00:18:28,000 There is thoughts about that extra pathway 542 00:18:28,000 --> 00:18:29,200 being a little antiemetic, 543 00:18:29,200 --> 00:18:32,033 anti-nausea. There may be effects on bone health 544 00:18:32,033 --> 00:18:34,533 that come out of this. The retatrutide, 545 00:18:34,533 --> 00:18:36,000 which is in studies right now, 546 00:18:36,000 --> 00:18:38,500 is the triple agonist soon to be. 547 00:18:38,833 --> 00:18:39,066 Again, I, 548 00:18:39,066 --> 00:18:41,066 I can't sit here and speculate on, 549 00:18:41,066 --> 00:18:43,400 on exactly what difference that will cause. 550 00:18:44,200 --> 00:18:47,033 We will have to see, 'cause there is also a theory, right? 551 00:18:47,033 --> 00:18:48,633 In theory, these pathways do X, 552 00:18:48,633 --> 00:18:49,433 Y, Z, 553 00:18:49,433 --> 00:18:51,900 but is this drug strong enough in each pathway 554 00:18:51,900 --> 00:18:53,300 to actually produce those results? 555 00:18:53,300 --> 00:18:54,966 That's the point of the clinical trial. Indeed. 556 00:18:55,533 --> 00:18:56,133 And I think 557 00:18:56,133 --> 00:18:58,500 we're so well conditioned to Apple's marketing 558 00:18:58,500 --> 00:19:01,333 with iPhone 14 and 15 and 16, 559 00:19:01,333 --> 00:19:02,233 there's this presumption 560 00:19:02,233 --> 00:19:04,566 that every time a number goes on it, 561 00:19:04,566 --> 00:19:06,133 then surely it's just getting better. 562 00:19:06,133 --> 00:19:07,300 So, you know, 563 00:19:07,400 --> 00:19:10,233 we joked about, I think it was GLP-46, 564 00:19:10,233 --> 00:19:11,866 but do you actually have people now 565 00:19:11,866 --> 00:19:13,200 coming forward and saying, 566 00:19:13,233 --> 00:19:13,600 "You know, I've, 567 00:19:13,600 --> 00:19:15,600 I've tried GLP-1s, but, you know," 568 00:19:15,600 --> 00:19:16,333 is it, is, 569 00:19:16,333 --> 00:19:20,133 "Can you get me some GLP-6? Will that work better for me?" 570 00:19:20,433 --> 00:19:22,033 We do have people that want 571 00:19:22,033 --> 00:19:24,333 maybe more effect than what they're able to get. 572 00:19:24,333 --> 00:19:25,133 Certainly, 573 00:19:25,600 --> 00:19:27,100 there's an individuality to that. 574 00:19:27,100 --> 00:19:28,800 Some people are better responders than others. 575 00:19:28,800 --> 00:19:30,766 That's true of almost any drug. 576 00:19:30,866 --> 00:19:33,166 But yeah, we do have people that 577 00:19:33,300 --> 00:19:34,466 have heard certain things about 578 00:19:34,466 --> 00:19:36,100 certain GLP-1 medications. 579 00:19:36,866 --> 00:19:38,133 Maybe they'll feel like they didn't, 580 00:19:38,133 --> 00:19:40,433 they plateaued very early on their medicine. 581 00:19:40,600 --> 00:19:43,333 They didn't get that blood sugar control or weight loss 582 00:19:43,333 --> 00:19:45,766 they wanted. They want to try something else. 583 00:19:45,833 --> 00:19:47,833 And I guess, from our perspective, 584 00:19:47,833 --> 00:19:48,866 we look to see if, if, 585 00:19:48,866 --> 00:19:51,366 if that's reasonable or not. 586 00:19:51,800 --> 00:19:54,466 It's definitely reasonable to change between GLP-1s. 587 00:19:54,466 --> 00:19:56,833 Again, what these other GLP-1s promise, 588 00:19:56,833 --> 00:19:57,933 I wouldn't, as a practitioner, 589 00:19:57,933 --> 00:19:59,666 I wouldn't speculate. I would want to see hard evidence. 590 00:19:59,666 --> 00:20:01,300 If I'm gonna sit here and recommend something to you, 591 00:20:01,300 --> 00:20:04,266 I need to know that in amongst 10,000 people, 592 00:20:04,266 --> 00:20:04,933 there's a certain 593 00:20:04,933 --> 00:20:07,133 likelihood that certain things will happen. 594 00:20:07,400 --> 00:20:11,000 Like, the triple agonist has supposedly, for current data 595 00:20:11,000 --> 00:20:13,800 that we have, a lot more effect on blood sugar 596 00:20:13,800 --> 00:20:14,833 control and weight loss 597 00:20:15,200 --> 00:20:17,733 than what we have currently approved, 598 00:20:17,733 --> 00:20:18,933 which is the single and dual 599 00:20:18,933 --> 00:20:22,300 agonists. If that's what you're looking for, then that's good. 600 00:20:22,300 --> 00:20:23,733 But not everybody is, right? 601 00:20:23,733 --> 00:20:25,933 So it, it's like another tool in your tool belt. 602 00:20:25,933 --> 00:20:27,066 As more and more come out, 603 00:20:27,066 --> 00:20:27,866 it depends on, like, 604 00:20:27,866 --> 00:20:29,700 what's the benefit you're looking for? 605 00:20:29,700 --> 00:20:30,933 Do I want more weight loss? 606 00:20:30,933 --> 00:20:32,666 Some people actually want less weight loss. 607 00:20:32,666 --> 00:20:34,000 Some people don't want to inject. 608 00:20:34,000 --> 00:20:35,300 They want an oral option. So, 609 00:20:35,300 --> 00:20:37,533 it's more like a certain tool in your tool belt 610 00:20:37,533 --> 00:20:39,633 that will fit a certain patient, 611 00:20:39,733 --> 00:20:41,900 not necessarily it's always better, better, better. 612 00:20:42,500 --> 00:20:43,233 Thank you. 613 00:20:43,233 --> 00:20:46,733 And the final question before we come to a close: 614 00:20:47,466 --> 00:20:49,900 Next 10 years, what do you think it's gonna look like? 615 00:20:49,900 --> 00:20:51,533 This could be in your own practice. 616 00:20:51,533 --> 00:20:53,133 This could be the, the sector. 617 00:20:53,133 --> 00:20:55,733 This could be the advancements in, in science. 618 00:20:55,733 --> 00:20:59,233 You, you could do a bit of cosmic ordering if you like. 619 00:20:59,433 --> 00:21:02,066 Yeah, it doesn't have to be wholly grounded in science. 620 00:21:02,066 --> 00:21:03,800 But what would Michael like to see, 621 00:21:03,933 --> 00:21:06,900 you know, come to fruition in the, in the peptide space? 622 00:21:07,133 --> 00:21:10,033 Yeah, from a GLP-1

perspective, 623 00:21:10,600 --> 00:21:14,066 I, I do think more, more compounds is always beneficial. 624 00:21:14,066 --> 00:21:15,933 Like I said, more tools in your tool belt to, 625 00:21:15,933 --> 00:21:18,933 to help patients that have different preferences 626 00:21:18,933 --> 00:21:20,500 or different circumstances. 627 00:21:20,800 --> 00:21:23,333 I think the biggest barrier to GLP-1s 628 00:21:23,333 --> 00:21:25,566 often is access/cost, 629 00:21:25,733 --> 00:21:29,800 and then tolerability. So it would be nice to see 630 00:21:30,466 --> 00:21:35,033 better insurance coverage and market prices 631 00:21:35,233 --> 00:21:37,600 for these GLP-1s, because they are truly, 632 00:21:37,600 --> 00:21:40,000 really beneficial for patients that, 633 00:21:40,000 --> 00:21:42,033 they truly, you know, 634 00:21:42,200 --> 00:21:43,800 that would benefit for, from them. 635 00:21:43,800 --> 00:21:47,700 And if there were ways to improve the tolerability, 636 00:21:47,700 --> 00:21:49,400 you know, reduce nausea, 637 00:21:49,700 --> 00:21:50,733 constipation, diarrhea, 638 00:21:50,733 --> 00:21:51,700 those are the most common, 639 00:21:51,700 --> 00:21:53,733 reduce that muscle wasting, 640 00:21:54,066 --> 00:21:57,766 that would even enhance further the, 641 00:21:58,133 --> 00:21:58,466 you know, 642 00:21:58,466 --> 00:22:00,500 the amount of people that would be able to tolerate 643 00:22:00,500 --> 00:22:02,833 these medications and get the pros out of it 644 00:22:02,833 --> 00:22:04,433 and avoid some of the cons. 645 00:22:05,033 --> 00:22:06,200 In the future, what will happen? 646 00:22:06,200 --> 00:22:09,666 I think for sure people will target multiple pathways. 647 00:22:09,666 --> 00:22:10,933 They will bring new effects 648 00:22:10,933 --> 00:22:12,600 that will bring new FDA indications, 649 00:22:12,833 --> 00:22:14,000 novel FDA indications. 650 00:22:14,000 --> 00:22:15,733 That's good for business for these companies. 651 00:22:15,800 --> 00:22:18,466 It's also good for people that will now have therapies 652 00:22:18,466 --> 00:22:20,533 for things before they did not have therapies, 653 00:22:20,533 --> 00:22:22,033 or an additional therapy. 654 00:22:22,066 --> 00:22:23,933 And there will be more oral GLP-1s. 655 00:22:23,933 --> 00:22:26,133 Foundayo, or orforglipron, just came out. 656 00:22:26,133 --> 00:22:29,266 It's the first non-peptide small-molecule GLP-1, 657 00:22:29,266 --> 00:22:31,333 which means easier to take, 658 00:22:31,700 --> 00:22:34,233 easy to manufacture, much cheaper. 659 00:22:34,266 --> 00:22:37,066 So I assume a lot of that will start coming out too, and, 660 00:22:37,066 --> 00:22:39,133 and this will be like the statins of our time. 661 00:22:39,133 --> 00:22:41,133 You know, statins, when they came out in the '70s, 662 00:22:41,133 --> 00:22:42,633 huge blockbuster drugs. 663 00:22:43,333 --> 00:22:44,033 And this, 664 00:22:44,033 --> 00:22:46,333 this sort of feels like one of those moments again. 665 00:22:46,800 --> 00:22:48,700 Absolutely. And that kind of... I have 666 00:22:48,700 --> 00:22:50,066 a final question. A final, 667 00:22:50,066 --> 00:22:52,233 final question. What's been the, 668 00:22:52,600 --> 00:22:54,500 the most positive 669 00:22:54,500 --> 00:22:57,600 unexpected outcome that you've seen from, 670 00:22:57,600 --> 00:22:59,566 from, from your work with GLP-1s? 671 00:22:59,833 --> 00:23:00,733 Yeah, I, 672 00:23:00,733 --> 00:23:02,800 I would have to point to the diabetes space. 673 00:23:02,800 --> 00:23:04,833 It's hard to describe, really, 674 00:23:04,833 --> 00:23:07,600 how revolutionary some of these drugs are 675 00:23:07,600 --> 00:23:09,200 for people's blood sugar management, 676 00:23:10,200 --> 00:23:12,266 for a number of reasons. One, their effects on, 677 00:23:12,266 --> 00:23:14,700 on the pathway, pathophysiology of diabetes, 678 00:23:14,700 --> 00:23:16,833 but also the appetite suppression, 679 00:23:16,833 --> 00:23:18,500 food noise control that they have. 680 00:23:19,733 --> 00:23:21,933 The amount of people that we've been able to get off of, 681 00:23:21,933 --> 00:23:23,133 like, insulin, for example, 682 00:23:23,133 --> 00:23:24,333 which, there's nothing wrong with insulin, 683 00:23:24,333 --> 00:23:26,400 but it's difficult. It's difficult to manage. 684 00:23:26,400 --> 00:23:28,166 It's multiple injections a day. 685 00:23:28,233 --> 00:23:31,566 It has risks like low sugar that can be serious. 686 00:23:32,266 --> 00:23:34,066 The improvement in people's quality of lives, 687 00:23:34,066 --> 00:23:36,266 to gain a stable sugar for the first time in their life, 688 00:23:36,266 --> 00:23:37,533 with a once-weekly medicine 689 00:23:37,533 --> 00:23:39,000 they don't have to think about all day long, 690 00:23:39,000 --> 00:23:40,466 they don't have to think about every time they eat, 691 00:23:40,466 --> 00:23:42,566 about injecting, checking their sugar, et cetera, 692 00:23:42,933 --> 00:23:43,833 it's hard to understand 693 00:23:43,833 --> 00:23:45,433 how much that improves people's lives. 694 00:23:45,433 --> 00:23:48,300 And we see it a lot because diabetes is so pervasive in, 695 00:23:48,300 --> 00:23:51,133 in society. And so that is, I, 696 00:23:51,133 --> 00:23:52,833 I don't know how unexpected it is, 697 00:23:52,833 --> 00:23:56,566 but it certainly really highlights the power 698 00:23:56,800 --> 00:23:58,066 of some of these medications 699 00:23:58,066 --> 00:23:59,500 in improving people's health 700 00:23:59,500 --> 00:24:01,500 and just in general, you know, 701 00:24:01,500 --> 00:24:02,600 their quality of life. And, 702 00:24:02,600 --> 00:24:05,466 and to be determined on other places it does that. 703 00:24:05,466 --> 00:24:07,100 I think there are some thoughts about it 704 00:24:07,100 --> 00:24:08,033 in the space of, like, 705 00:24:08,033 --> 00:24:11,933 alcohol use disorder and cravings and addiction. Again, 706 00:24:11,933 --> 00:24:13,900 if, if that ever comes to fruition, 707 00:24:14,266 --> 00:24:16,800 that would change a space that is very difficult to treat 708 00:24:16,800 --> 00:24:19,200 and very detrimental to people's quality of life. 709 00:24:20,133 --> 00:24:20,533 Michael, 710 00:24:20,533 --> 00:24:22,633 thank you very much for joining us on Peptide Show 711 00:24:22,633 --> 00:24:25,033 today. Of course. Thank you for having me.