What did TRIUMPH-2 and TRIUMPH-3 report?

On 23 July 2026 Eli Lilly reported topline results from both trials. In TRIUMPH-2, average weight loss at 80 weeks was 12.7%, 19.1% and 20.8% on retatrutide 4, 9 and 12 mg versus 4.0% on placebo, with A1C reductions of up to 1.6%. In TRIUMPH-3, it was 21.6% and 22.6% on 9 and 12 mg versus 3.2% on placebo.

Who took part in TRIUMPH-2?

1,152 adults with type 2 diabetes and obesity or overweight, randomised 1:1:1:1 to retatrutide 4 mg, 9 mg, 12 mg or placebo for 80 weeks. Average baseline weight was 106.4 kg, BMI 38.2 and A1C 7.7%.

Who took part in TRIUMPH-3?

1,949 adults with severe obesity, defined as a BMI of at least 35, plus established cardiovascular disease, with or without type 2 diabetes. They were randomised 1:1:2 to retatrutide 9 mg, 12 mg or placebo for 80 weeks. Average baseline weight was 111.4 kg and BMI 40.4.

Why are these percentages lower than the 28.3% from TRIUMPH-1?

Because the populations differ. TRIUMPH-2 studied people with type 2 diabetes, who consistently lose less weight on incretin-based compounds across the whole drug class, and TRIUMPH-3 studied people with severe obesity plus established heart disease. TRIUMPH-1 studied a broad obesity population without diabetes. Percentages from different populations are not directly comparable.

Did TRIUMPH-3 show that retatrutide reduces cardiovascular events?

No. Events were rarer than the trial anticipated in both arms, so the analysis was underpowered. The five-component MACE endpoint gave a hazard ratio of 0.82 with a 95% confidence interval of 0.55 to 1.22 (44 events on retatrutide versus 52 on placebo), and the three-component endpoint gave 1.12 with an interval of 0.64 to 1.96 (27 versus 23 events). Both intervals include 1.0, so neither benefit nor harm was demonstrated.

What were the most common side effects?

Gastrointestinal effects dominated and were dose-dependent. In TRIUMPH-2, diarrhea occurred in 27.4 to 33.6% versus 13.2% on placebo, nausea in 13.7 to 28.0% versus 8.0% and vomiting in 5.5%, 10.2% and 15.7% on 4, 9 and 12 mg versus 4.2% on placebo. In TRIUMPH-3, diarrhea occurred in 24.4 to 30.1% versus 8.7% and nausea in 21.7 to 22.4% versus 5.8%; hyperglycemia was also among the most common events there, at 3.9% and 3.1% on 9 and 12 mg versus 13.4% on placebo, the one listed event that was more frequent on placebo than on retatrutide. Vomiting was not listed among the most common events in TRIUMPH-3, and hyperglycemia was not listed in TRIUMPH-2.

How many participants stopped because of side effects?

In TRIUMPH-2, 3.8% (4 mg), 11.6% (9 mg) and 7.7% (12 mg) versus 4.9% on placebo. In TRIUMPH-3, 9.8% (9 mg) and 13.5% (12 mg) versus 4.8% on placebo. The TRIUMPH-2 pattern is notable because the 9 mg arm dropped more participants than the 12 mg arm, which a topline release does not explain.

What is dysesthesia and how often did it occur?

Dysesthesia is an altered or unpleasant skin sensation. It occurred in 4.5%, 5.6% and 7.3% of participants on 4, 9 and 12 mg in TRIUMPH-2 versus 0.7% on placebo, and in 6.4% on both doses in TRIUMPH-3 versus 1.3% on placebo. It is the adverse event that separates most clearly from placebo in this programme.

Is there a urinary tract infection signal with retatrutide?

It is unresolved. TRIUMPH-1 reported 7.5%, 8.8% and 8.4% against 5.3% on placebo, TRIUMPH-2 reported 3.8%, 6.3% and 8.0% against a placebo rate of 6.6%, so the two lower doses came in below placebo, and TRIUMPH-3 reported 6.1% and 7.0% against 5.3%. A signal that separates in one trial and overlaps placebo in another is not a settled finding. A clinicians' letter on the question appeared in the European Journal of Internal Medicine on 23 July 2026 (PMID 42493254), but it is paywalled and has no abstract, so we do not summarise its argument.

When could retatrutide be approved?

Lilly says it is completing the Chemistry, Manufacturing and Controls data package and plans to submit a Biologics License Application in the US in Q1 2027. A submission is the start of a review, not an approval, and any European process would run separately and later through the EMA. Retatrutide currently has no marketing authorisation anywhere.

How was retatrutide dosed in these trials?

Once weekly by subcutaneous injection, with stepwise titration. Participants randomised to retatrutide started at 2 mg once weekly and increased every four weeks until reaching their target dose, via steps at 2, 4, 6 and 9 mg depending on the arm. This is a description of the trial protocol, not a usage instruction.

How does retatrutide differ from tirzepatide and semaglutide?

Semaglutide acts on the GLP-1 receptor, tirzepatide on GLP-1 and GIP, and retatrutide adds a third target, the glucagon receptor, which increases energy expenditure rather than only reducing appetite. That third arm is the usual mechanistic explanation for the larger weight changes seen in its trials.

What were the six Australian liver injury cases about?

On 19 June 2026 the Victorian Department of Health reported six cases of acute liver injury in Victoria since January 2026 in people who had used an unapproved product labelled Retatrutide, bought online, through friends and via social media accounts. The alert states that additional contaminants may be contributing, that product analysis was ongoing, and that similar cases may have been reported in some other Australian jurisdictions. No regulator has published a confirmed causal link to the retatrutide molecule itself.

How can the identity and purity of a research peptide be checked?

Through a batch-specific certificate of analysis from a third-party laboratory, which reports the identity of the substance, its purity and the measured quantity per vial, and which can be verified against the issuing laboratory's own records. Our supplier lab reports are published per batch on our CoA page, and our supplier vetting guide explains how to read one.

Is retatrutide approved or sold as a weight-loss medicine?

No. Retatrutide is an investigational molecule that cannot legally be sold or marketed for human use. This article reports trial data only. We supply it as a research compound, not for human consumption, and give no dosing or usage recommendations.

Retatrutide TRIUMPH-2 and TRIUMPH-3: 20.8 % and 22.6 % Weight Loss, and the Numbers Behind the Headline (July 2026)

Q: What cardiovascular risk factors changed in TRIUMPH-3?

At the highest dose, Lilly reported average reductions of 37.0% in triglycerides, 16.5% in non-HDL cholesterol, 9.3 mmHg in systolic blood pressure, 19.0 cm in waist circumference and 51.2% in high-sensitivity C-reactive protein. These are risk-factor changes, not event outcomes.

Important note: This article serves scientific information and research purposes only. Retatrutide is an investigational compound that is not approved as a medicine anywhere in the world, and we supply it strictly as a research chemical, not for human consumption. Nothing here is a dosing recommendation, a protocol, or medical advice.

TL;DR: what Lilly reported on 23 July 2026

The event: Eli Lilly published topline results from two further pivotal Phase 3 trials of retatrutide, its GIP, GLP-1 and glucagon triple receptor agonist. TRIUMPH-2 (n = 1,152, type 2 diabetes plus obesity or overweight): average weight loss of 12.7 %, 19.1 % and 20.8 % on 4 mg, 9 mg and 12 mg after 80 weeks, versus 4.0 % on placebo, with A1C reductions of up to 1.6 %. TRIUMPH-3 (n = 1,949, severe obesity plus established cardiovascular disease): 21.6 % and 22.6 % on 9 mg and 12 mg after 80 weeks, versus 3.2 % on placebo. The part the headlines skipped: cardiovascular events were rarer than the trial had anticipated, so the MACE confidence intervals cross 1 and prove nothing either way, and discontinuation because of side effects reached 13.5 % in the 12 mg arm of TRIUMPH-3. What happens next: Lilly is completing its manufacturing data package and plans a US submission in Q1 2027. Retatrutide remains unapproved, in the US and in the EU.

Retatrutidemetabolic

First-ever triple-action weight management peptide targeting three receptors at once: GLP-1, GIP, and glucagon. Shown exceptional results in Phase 2 trials - up to 24% weight reduction. The most advanced metabolic peptide available.

Two trials, two populations that had not been tested before

Retatrutide is the molecule that activates three receptors at once: GLP-1 and GIP, which mainly act on appetite and insulin signalling, plus glucagon, which raises energy expenditure. Its Phase 3 programme has been reporting in instalments since December 2025, and each instalment covers a different population. Mixing them up is the single most common error in coverage of this compound.

TRIUMPH-4 (December 2025): obesity with knee osteoarthritis. See our TRIUMPH-4 write-up.
TRANSCEND-T2D-1 (topline March 2026, full data published in The Lancet in June 2026): type 2 diabetes. See the TRANSCEND-T2D-1 article.
TRIUMPH-1 (May 2026): the broad obesity population without diabetes, up to 28.3 % weight loss. See the TRIUMPH-1 article.
TRIUMPH-2 and TRIUMPH-3 (23 July 2026): the two trials covered here.

The two new readouts fill the gaps that mattered most for a regulatory file: people whose obesity comes with type 2 diabetes, and people whose obesity comes with established heart disease. Lilly now describes retatrutide as having five positive Phase 3 studies, and says it has the clinical data package to support submissions in obesity, knee osteoarthritis pain and obstructive sleep apnea.

TRIUMPH-2: type 2 diabetes and obesity

TRIUMPH-2 randomised 1,152 adults 1:1:1:1 to retatrutide 4 mg, 9 mg, 12 mg or placebo for 80 weeks. Everyone in the three retatrutide arms started at 2 mg once weekly and stepped up every four weeks until reaching the target dose. Average baseline weight was 106.4 kg, average BMI 38.2, average A1C 7.7 %.

Group	Weight change at week 80	A1C change	Discontinued due to adverse events
Retatrutide 4 mg	-12.7 % (-13.5 kg)	-1.4 %	3.8 %
Retatrutide 9 mg	-19.1 % (-20.6 kg)	-1.6 %	11.6 %
Retatrutide 12 mg	-20.8 % (-22.5 kg)	-1.5 %	7.7 %
Placebo	-4.0 % (-4.2 kg)	-0.2 %	4.9 %

Retatrutide 4 mg

Weight change at week 80: -12.7 % (-13.5 kg)
A1C change: -1.4 %
Discontinued due to adverse events: 3.8 %

Retatrutide 9 mg

Weight change at week 80: -19.1 % (-20.6 kg)
A1C change: -1.6 %
Discontinued due to adverse events: 11.6 %

Retatrutide 12 mg

Weight change at week 80: -20.8 % (-22.5 kg)
A1C change: -1.5 %
Discontinued due to adverse events: 7.7 %

Placebo

Weight change at week 80: -4.0 % (-4.2 kg)
A1C change: -0.2 %
Discontinued due to adverse events: 4.9 %

Two details in that table are worth more attention than the headline percentage. The A1C column does not rise with dose: 9 mg produced the largest reduction, and 12 mg slightly less. The discontinuation column does not rise with dose either, with 9 mg dropping more participants than 12 mg. Neither pattern is explained in a topline release, and neither can be interpreted without the full dataset.

Trial design in brief

Phase 3, randomised, double-blind, placebo-controlled, basket design, 80 weeks (NCT05929079). 1,152 adults with type 2 diabetes and obesity or overweight. Doses of 4, 9 and 12 mg once weekly subcutaneous, each reached by stepwise titration from 2 mg every four weeks, followed by a four-week post-treatment period. Primary endpoint: percentage change in body weight. The figures below come from a company topline release, not from a peer-reviewed publication.

TRIUMPH-3: severe obesity with established cardiovascular disease

TRIUMPH-3 is the more ambitious of the two. It randomised 1,949 adults with a BMI of at least 35 and established cardiovascular disease, 1:1:2, to retatrutide 9 mg, 12 mg or placebo, again over 80 weeks. Average baseline weight was 111.4 kg, average BMI 40.4.

Group	Weight change at week 80	Discontinued due to adverse events
Retatrutide 9 mg	-21.6 % (-23.9 kg)	9.8 %
Retatrutide 12 mg	-22.6 % (-25.3 kg)	13.5 %
Placebo	-3.2 % (-3.5 kg)	4.8 %

Retatrutide 9 mg

Weight change at week 80: -21.6 % (-23.9 kg)
Discontinued due to adverse events: 9.8 %

Retatrutide 12 mg

Weight change at week 80: -22.6 % (-25.3 kg)
Discontinued due to adverse events: 13.5 %

Placebo

Weight change at week 80: -3.2 % (-3.5 kg)
Discontinued due to adverse events: 4.8 %

Alongside weight, the 12 mg arm showed average reductions of 37.0 % in triglycerides, 16.5 % in non-HDL cholesterol, 9.3 mmHg in systolic blood pressure, 19.0 cm in waist circumference and 51.2 % in high-sensitivity C-reactive protein.

The cardiovascular numbers do not show what the headlines implied

Because this cohort had established heart disease, the obvious question was whether retatrutide reduces cardiovascular events. The honest answer from this topline is that the trial cannot say. Events occurred less frequently than anticipated in both arms, which leaves the analysis underpowered. For the five-component MACE endpoint there were 44 events on retatrutide (9 mg and 12 mg pooled) against 52 on placebo, a hazard ratio of 0.82 with a 95 % confidence interval of 0.55 to 1.22. For the three-component endpoint there were 27 events against 23, a hazard ratio of 1.12 with an interval of 0.64 to 1.96. The release also reports a second, not pre-specified on-treatment analysis, which excludes events more than 35 days after discontinuation: a MACE-5 hazard ratio of 0.73 (95.0 % CI 0.47 to 1.12) and a MACE-3 hazard ratio of 0.92 (95.0 % CI 0.51 to 1.65), and both of those intervals cross 1.0 as well. Both pre-specified intervals comfortably include 1.0, which means neither benefit nor harm was demonstrated. A dedicated cardiovascular outcomes trial is a separate, still-running part of the programme.

Why 20.8 % and 22.6 % sit below TRIUMPH-1's 28.3 %

At first glance the new numbers look like a step backwards from the 28.3 % reported in TRIUMPH-1 in May. They are not directly comparable, and the reason is the population rather than the molecule.

People with type 2 diabetes consistently lose less weight on incretin-based compounds than people without it, across every drug in this class, and TRIUMPH-2 was a diabetes trial. TRIUMPH-3 enrolled people with severe obesity and established cardiovascular disease, a group that is older, sicker and on more concomitant medication than a TRIUMPH-1 participant. A cross-trial comparison of percentages between different populations is exactly the kind of arithmetic that produces confident and wrong conclusions.

How to compare trial percentages honestly

Compare within a trial, against that trial's own placebo arm. TRIUMPH-2 delivered a 16.8 percentage-point separation from placebo at 12 mg, TRIUMPH-3 a 19.4 point separation, and TRIUMPH-1 roughly 26 points. That framing tells you something real. Comparing 20.8 % against 28.3 % across different populations does not.

The side-effect numbers, in full

Gastrointestinal effects dominated, they were dose-dependent, and they were consistently higher than placebo. The first six rows below are the events Lilly listed as most common in each trial, which is why two cells read "not listed": the event did not appear in that trial's most-common list, which is not the same as it never occurring. The last two rows, dysesthesia and urinary tract infection, come from a separate incidence sentence in the same release.

Adverse event	TRIUMPH-2 (4/9/12 mg vs placebo)	TRIUMPH-3 (9/12 mg vs placebo)
Diarrhea	27.4 / 33.5 / 33.6 % vs 13.2 %	30.1 / 24.4 % vs 8.7 %
Nausea	13.7 / 20.8 / 28.0 % vs 8.0 %	21.7 / 22.4 % vs 5.8 %
Constipation	14.0 / 16.2 / 16.8 % vs 9.4 %	18.0 / 15.7 % vs 7.1 %
Decreased appetite	5.8 / 12.3 / 17.1 % vs 4.5 %	13.5 / 14.5 % vs 3.0 %
Vomiting	5.5 / 10.2 / 15.7 % vs 4.2 %	not listed
Hyperglycemia	not listed	3.9 / 3.1 % vs 13.4 %
Dysesthesia	4.5 / 5.6 / 7.3 % vs 0.7 %	6.4 / 6.4 % vs 1.3 %
Urinary tract infection	3.8 / 6.3 / 8.0 % vs 6.6 %	6.1 / 7.0 % vs 5.3 %

Diarrhea

TRIUMPH-2 (4/9/12 mg vs placebo): 27.4 / 33.5 / 33.6 % vs 13.2 %
TRIUMPH-3 (9/12 mg vs placebo): 30.1 / 24.4 % vs 8.7 %

Nausea

TRIUMPH-2 (4/9/12 mg vs placebo): 13.7 / 20.8 / 28.0 % vs 8.0 %
TRIUMPH-3 (9/12 mg vs placebo): 21.7 / 22.4 % vs 5.8 %

Constipation

TRIUMPH-2 (4/9/12 mg vs placebo): 14.0 / 16.2 / 16.8 % vs 9.4 %
TRIUMPH-3 (9/12 mg vs placebo): 18.0 / 15.7 % vs 7.1 %

Decreased appetite

TRIUMPH-2 (4/9/12 mg vs placebo): 5.8 / 12.3 / 17.1 % vs 4.5 %
TRIUMPH-3 (9/12 mg vs placebo): 13.5 / 14.5 % vs 3.0 %

Vomiting

TRIUMPH-2 (4/9/12 mg vs placebo): 5.5 / 10.2 / 15.7 % vs 4.2 %
TRIUMPH-3 (9/12 mg vs placebo): not listed

Hyperglycemia

TRIUMPH-2 (4/9/12 mg vs placebo): not listed
TRIUMPH-3 (9/12 mg vs placebo): 3.9 / 3.1 % vs 13.4 %

Dysesthesia

TRIUMPH-2 (4/9/12 mg vs placebo): 4.5 / 5.6 / 7.3 % vs 0.7 %
TRIUMPH-3 (9/12 mg vs placebo): 6.4 / 6.4 % vs 1.3 %

Urinary tract infection

TRIUMPH-2 (4/9/12 mg vs placebo): 3.8 / 6.3 / 8.0 % vs 6.6 %
TRIUMPH-3 (9/12 mg vs placebo): 6.1 / 7.0 % vs 5.3 %

Hyperglycemia is the one entry that was clearly more frequent on placebo (13.4 %) than on either retatrutide dose (3.9 % and 3.1 %). Lilly's release does not explain that gap, and neither will we beyond the obvious: it appears in the trial whose participants carried the greater burden of established disease, in a compound programme that also reports A1C reductions.

Dysesthesia, an altered or unpleasant skin sensation, is the signal that separates most cleanly from placebo here: roughly six to ten times the placebo rate in TRIUMPH-2, and five times it in TRIUMPH-3. It has been a consistent feature of the retatrutide programme rather than a new finding.

The urinary tract infection debate

The urinary tract infection signal has become the most discussed safety question around this compound, and the same week as these readouts, on 23 July 2026, a group of clinicians published a letter in the European Journal of Internal Medicine titled "Retatrutide and the urinary tract infection signal: Is the answer hidden in timing?" (PMID 42493254). PubMed indexes it as a letter without an abstract and the full text sits behind a paywall, so we report that the debate is happening in the clinical literature and do not summarise an argument we have not read.

What we can put side by side are the reported rates. In TRIUMPH-1, infections occurred in 7.5 %, 8.8 % and 8.4 % of participants on 4, 9 and 12 mg against 5.3 % on placebo. In TRIUMPH-2 the rates were 3.8 %, 6.3 % and 8.0 % against a placebo rate of 6.6 %, meaning the two lower doses came in below placebo. In TRIUMPH-3 they were 6.1 % and 7.0 % against 5.3 %.

What that pattern means, and what it does not

A signal that separates clearly in one trial, overlaps placebo in the next and separates weakly in a third is not a settled finding. It is the normal appearance of a possible low-frequency effect before pooled data exist. Anyone claiming certainty in either direction, whether that retatrutide causes urinary tract infections or that the signal is nothing, is going beyond what has been published. Lilly reports that dysesthesia and urinary tract infection events were generally mild to moderate and that the majority resolved during treatment.

What happens next, and what it means in Europe

Lilly says it is completing the Chemistry, Manufacturing and Controls package required for a Biologics License Application, and plans to submit retatrutide for US approval in Q1 2027. Detailed results are to be presented at future medical meetings and published in peer-reviewed journals.

A Q1 2027 filing is not a 2027 approval

Submission is the start of the review, not the end. Even on a smooth path, a filing in early 2027 puts a possible US decision well into that year at the earliest, and any European process runs separately and later through the EMA. Until then retatrutide has no marketing authorisation anywhere, and every vial in circulation outside a clinical trial is an unapproved compound. Our article on the EU regulatory status covers what that means in practice.

The other retatrutide story of July: what is actually in the vial

While Lilly was publishing efficacy data, a second retatrutide story was running in parallel, and it is the more relevant one for anyone handling research material.

On 19 June 2026 the Victorian Department of Health in Australia issued an alert about six cases of acute liver injury in Victoria since January 2026 in people who had used an unapproved peptide product labelled "Retatrutide", adding that investigations are ongoing and that similar cases may have been reported in some other Australian jurisdictions. The alert states that the clinical presentation "suggest additional contaminants may be contributing to the observed liver toxicity in the products", that the effects are "possibly associated with a contaminant", and that the products had been "purchased online, through friends and through social media accounts". Analysis of the products was still under way. On 9 July 2026 the BMJ published a fact check by Elisabeth Mahase asking whether a man had died after taking the unapproved compound (PMID 42425580); it is indexed as a citation without an abstract and is subscription-only, so we note its existence without repeating conclusions we cannot read.

Why this is a provenance story, not a pharmacology story

No regulator has published a confirmed causal link between the retatrutide molecule itself and those liver injuries. What is documented is a set of vials of unknown content, bought through social media and personal contacts, in which contaminants are suspected. That is a statement about supply chains and documentation, not about the compound that was studied in more than 5,800 participants enrolled in the initial TRIUMPH programme. It is also precisely the question a per-batch certificate of analysis from a third-party laboratory is meant to answer: which substance, at what purity, in which batch. Our guide to vetting a peptide supplier walks through how to read one, and every batch report we hold from our suppliers' third-party laboratory is published on our CoA page.

How to read a topline release without being misled

Step 1: Separate the company release from the evidence

A topline press release is a selected summary written by the sponsor. It is not peer reviewed, the full dataset is not attached, and subgroup results, dropout patterns and rarer adverse events are not in it. Treat every number as provisional until the presentation and publication land.

Step 2: Read the confidence interval before the point estimate

A hazard ratio of 0.82 sounds like an 18 % risk reduction. With an interval of 0.55 to 1.22 it means the trial could not distinguish benefit from harm. Whenever an interval crosses 1.0, the honest summary is "not demonstrated", regardless of which side the point estimate falls on.

Step 3: Check whether the populations match before comparing

Percentages from a diabetes cohort, a cardiovascular cohort and a general obesity cohort are not interchangeable. Compare each arm against its own placebo group, and only then across trials, and say out loud when the populations differ.

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FAQ

Sources

Eli Lilly and Company. "Lilly's triple agonist, retatrutide, successful in two additional Phase 3 obesity trials, delivering significant improvements in weight and A1C." Press release, 23 July 2026. https://www.prnewswire.com/news-releases/lillys-triple-agonist-retatrutide-successful-in-two-additional-phase-3-obesity-trials-delivering-significant-improvements-in-weight-and-a1c-302832674.html
Eli Lilly and Company. "Lilly's triple agonist, retatrutide, delivered powerful weight loss in pivotal Phase 3 obesity trial." Press release, 21 May 2026. https://www.prnewswire.com/news-releases/lillys-triple-agonist-retatrutide-delivered-powerful-weight-loss-in-pivotal-phase-3-obesity-trial-302778859.html
Koufakis T, Argyrakopoulou G, Kokkinos A, le Roux CW. "Retatrutide and the urinary tract infection signal: Is the answer hidden in timing?" European Journal of Internal Medicine, online 23 July 2026. PMID 42493254. https://pubmed.ncbi.nlm.nih.gov/42493254/
Mahase E. "Retatrutide fact check: Has a man died after taking the unapproved weight loss jab?" BMJ 2026;394:e100245, 9 July 2026. PMID 42425580. https://pubmed.ncbi.nlm.nih.gov/42425580/
Victorian Department of Health. "Toxicity linked to unapproved peptide product labelled Retatrutide." Health alert, 19 June 2026. https://www.health.vic.gov.au/health-alerts/toxicity-linked-to-unapproved-peptide-retatrutide
ClinicalTrials.gov records NCT05929079 (TRIUMPH-2) and NCT05882045 (TRIUMPH-3).

Research disclaimer: All content serves scientific information only. Retatrutide is not intended for human consumption and is not approved as a medicine in any jurisdiction. The figures cited come from a manufacturer topline release and do not replace a peer-reviewed publication.