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Interview with Richard Rothman, M.D., Ph.D. about Phentermine-5-HTP
Wednesday, September 10, 2003 2:29 pm Email this article
"We wouldn't be in business without 5-HTP," says Richard B. Rothman, M.D., Ph.D., Medical Director of BE-LITE Medical Centers located in Virginia and Maryland.
This interview was originally published in Obesity Research Update, September 1999, Volume 4 Number 9 Page 65.
Dr. Rothman, who is Board Certified in Psychiatry, also conducts and publishes pre-clinical and clinical research in psychopharmacology. He received his M.D. degree and his Ph.D. degree in Pharmacology from the University of Virginia.
Dr. Rothman has published over two hundred scientific papers in peer-reviewed scientific journals and has presented over 390 scientific abstracts at national and international scientific meetings including published work on appetite suppressants.
Dr. Rothman has received numerous awards recognizing his work, including the Joseph Cochin Young Investigator Award awarded by the Committee on Problems of Drug Dependence, Inc., The Scientific Achievement Award in Biological Sciences for contributions in the field of opioid pharmacology by the Washington Academy of Sciences, and the A. E. Bennett Award (basic science) by the Society for Biological Psychiatry.
In addition to his extensive experience in the treatment of obesity, Dr. Rothman also has extensive clinical experience in the psychopharmacological treatment of psychiatric disorders. Dr. Rothman is a member of several professional groups, including the Society for Neuroscience, the Society of Biological Psychiatry, the American Society for Pharmacology and Experimental Therapeutics, the Medical Society of the District of Columbia and the American Psychiatric Association.
Larry Hobbs spoke to Dr. Rothman by phone.
Hobbs: What drugs are you using for weight loss?
Rothman: Most patients take phentermine plus 5-hydroxytryptophan (5-HTP) plus carbidopa plus pindolol.
Hobbs: Is the Phen-5-HTP combination better than phentermine alone?
Rothman: Yes. We wouldn’t be in business without 5-HTP. The average weight loss during the first month for our patients on Phen-5-HTP is approximately 17 pounds compared to 10 pounds for those taking phentermine alone. But of course there are some patients that don’t respond.
Hobbs: Why do you say “we wouldn’t be in business without 5-HTP?”
Rothman: We stopped prescribing fenfluramine in July 1997. Afterwards, as former Fen-Phen patients returned for treatment, they were treated with phentermine alone. Most dropped out because phentermine alone was not anywhere near as effective as the Fen-Phen combination. The introduction of 5-HTP into our practice led to a more effective treatment, better results, and an improved patient census.
Hobbs: How does Phen-5-HTP compare to Fen-Phen?
Rothman: Phen-5-HTP works as well as Fen-Phen in approximately 60 percent of patients who previously took Fen-Phen; another 30 percent say that Phen-5-HTP doesn’t work quite as well as Fen-Phen but it works better than phentermine alone; and in the remaining 10 percent of patients Phen-5-HTP doesn’t seem to work at all.
Hobbs: Does carbidopa increase the effectiveness of 5-HTP?
Rothman: Yes. 5-HTP is rapidly metabolized into serotonin in the intestine and blood stream. Carbidopa prevents metabolism of 5-HTP in the body so that more can be transported into the brain. Without the carbidopa I would estimate that you would have to use 500 to 1000 mg of 5-HTPa dose that I do not recommendin order to raise brain levels of serotonin.
Hobbs: What is the pindolol for?
Rothman: Pindolol is a beta blocker used mainly for the treatment of hypertension. Typical doses for this use are 10 to 40 mg per day. The dose we use2 mg per capsule for a total of 4 to 6 mg per dayreduces the stimulant side effects of phentermine. But it also helps in another way.
Hobbs: How’s that?
Rothman: Pindolol also helps to maintain serotonin release by blocking serotonin 1A (5-HT1A) receptors in the brain. These receptors act as part of a negative feedback mechanism which when stimulated by serotonin release decrease the firing rate of serotonergic nerves, which reduces serotonin release. The pindolol blocks this negative feedback loop leading to increased synaptic levels of serotonin which further increases the effectiveness of the 5-HTP.
Hobbs: How about side effects?
Rothman: A few patients develop nausea or increased sweating from 5-HTP as would be expected for a serotonergic medication. However, diarrhea is uncommon with our 5-HTP which is probably because most of it is converted to serotonin in the brain, and not the intestine. Stimulant side effects are not a problem for most patients since the pindolol and 5-HTP reduce the stimulant effects of phentermine. Fatigue, sedation and orthostatic hypotension are also uncommon with Phen-5-HTP. The Phen-5-HTP causes fewer side effects than Fen-Phen.
Hobbs: Is fatigue or sexual dysfunction a problem with the use of the beta blocker or 5-HTP?
Rothman: No, I’m not aware of any reports of sexual dysfunction associated with our use of either pindolol which is not surprising since we are using a very small doseor our 5-HTP. However, a few patientsmaybe 1 percenthave developed fatigue and/or sedation from the pindolol.
Hobbs: What doses do you use?
Rothman: Fifteen mg of phentermine taken with a capsule containing 10 mg of 5-HTP plus 5 mg of carbidopa plus 2 mg of pindolol. This is taken twice a daybefore breakfast and before lunch. Over time, most patients progress to a daily dose of 45 to 60 mg phentermine. Along with phentermine, I use three strengths of 5-HTP 5 mg, 10 mg or 15 mg combined with the carbidopa and pindolol taken two or three times per day. About sixty percent of patients use the 10 mg of 5-HTP plus carbidopa plus pindolol two or three times per day, thirty percent use 15 mg of 5-HTP and the other ten percent use the 5 mg dose.
Hobbs: Are you concerned about the peak X contaminant in the 5-HTP?
Rothman: No, not in the product that I’m using. It’s pharmaceutical grade and manufactured in FDA approved laboratories. The certificate of analysis indicates that it is free of contaminants.
Hobbs: Do you every use 5-HTP alone?
Rothman: In the few patients who can not take a stimulant because of a medical contraindication, I’ll used 5-HTP alone. It works, but not as well as the Phen-5-HTP combination. In addition, I’ve successfully used 5-HTP5 to 10 mg of 5-HTP with carbidopa and pindolol two or three times per dayin a few non-obese patients to control craving for sweets and chocolate.
Hobbs: Do you ever give phentermine alone?
Rothman: Not very often. It’s usually only when a patient has used it before and knows that it works. With phentermine alone I add a small dose of propanolol, another beta blocker 10 to 40 mg in order to reduce the stimulant side effects of phentermine such as nervousness and anxiety.
Hobbs: Do the beta blockersthe pindolol or propanololreduce the effectiveness of the phentermine?
Hobbs: Do you ever use Tenuate or phendimetrazine?
Rothman: Sometimes. Sometimes I’ll add 25 mg of immediate-release Tenuate or 35 mg of phendimetrazine to the Phen-5-HTP taken two or three times per day in patients whose weight loss has plateaued or who continue to experience hunger and/or craving. Some patients take 35 mg of phendimetrazine at 4 or 5 o’clock to control their evening hunger. I also have a few patients on phendimetrazine-5-HTP/carbidopa/pindolol who found that phentermine caused unacceptable side effects.
Hobbs: Do phendimetrazine taken at 4 or 5 o’clock cause sleep problems?
Rothman: No, not usually. Phendimetrazine is shorter-acting than phentermine.
Hobbs: Do you use any serotonin reuptake inhibitors (SSRIs) in combination with phentermine such as Phen-Prozac, Phen-Zoloft, Phen-Effexor, etc.?
Rothman: Yes, but I don’t start patients on SSRIs with phentermine unless they specifically request it and there is no contraindication. I’ve added 20 mg of Prozac once or twice a day to patients who are already taking the Phen-5-HTP and whose weight loss has plateaued or who continue to experience significant hunger and/or craving. Adding Prozac often helps these patients.
Hobbs: Have you observed adverse effects in patients taking antidepressants plus Phen-5-HTP?
Rothman: No. I’m not aware of any significant adverse effects in our patients resulting from these combinations. It is not uncommon that patients who come in for treatment are already taking a variety of antidepressants such as Zoloft, Prozac, Wellbutrin or Effexor. I do not ask these patients to discontinue their antidepressants and I’m not aware of any significant adverse effects resulting from our treatment of these patients.
Hobbs: Do you ever use the combination of ephedrine and caffeine?
Rothman: Yes. I use a combination of 20 mg of ephedrine plus 100 mg of caffeine plus 20 mg of propranolol and 200 mg of the amino acid L-histidine. A few patients have taken it alone and done very well, but most of the time I have added it to the Phen-5-HTP when a patient stops losing weight.
Hobbs: Do patients say that ephedrine/caffeine is helpful?
Rothman: About 70 percent of patients say that it is beneficial and 30 percent say that it is not.
Hobbs: What dose do you use?
Rothman: I typically have patients take one capsule twice a day.
Hobbs: What is the histidine for?
Rothman: Histidine is the precursor to histamine which is involved in suppressing appetite.
Hobbs: What about side effects with ephedrine/caffeine?
Rothman: I’ve had very few. A few people complain of an upset stomach and a few experience stimulant side effects. The inclusion of propranolol in the capsule minimizes the occurrence of stimulant side effects and taking the medication with food minimizes nausea.
Hobbs: How often do you see patients and how do you monitor their progress?
Rothman: New patients return one week after their initial visit. Most patients are seen monthly. The longest time between visits is four weeks. At each visit, patients are weighed, vital signs measured, and medication side effects and compliance with the prescribed diet and exercise program are accessed. Patients receive nutritional counseling and see a medical professional at each visit. Three lead EKGs are run at the initial visit and every three months while the patients are taking medications.
Hobbs: Being that you are a psychiatrist have you found Phen-5-HTP effective for treating depression or other psychiatric disorders?
Rothman: I do not offer Phen-5-HTP as a primary treatment of psychiatric disorders. However, I’ve collected a number of cases of depression, seasonal affective disorder (SAD), obsessive compulsive disorder, fibromyalgia and bulimia which appeared to respond to treatment with Fen-Phen. These patients were treated for obesity and it happened that their other problems were helped. Some obese patients with depression seem to become less depressed but it isn’t clear whether or not this is due to an effect of the medication or as a result of the weight loss. One patient with SAD is taking Phen-5-HTP as a preventative. She says that it works better for her than Prozac.
Hobbs: Do you sell your formulas?
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