A patient arrives having read about a peptide. They are enthusiastic, they have a source, and they want to know whether you will prescribe it. You need an answer in about ten seconds, and “let me look into that” is not one.
Dr. Stephen Cosentino, Empire's founder and president, uses a three-bucket sort that does the work quickly. It is the most portable thing in this field, and it applies equally to peptides, to exosomes, to anything else arriving faster than its evidence.
The Three Buckets: Proven, Plausible, Promoted
“I usually try to think of peptides in three categories,” Cosentino says.
- Proven. “It's the proven — what we know is going to work.” His example is the GLP-1 class. Approved products, labelled indications, real trials.
- Plausible. “The newer peptides and things that are coming out. They're not quite FDA approved, but we can still use them if we're following correct medical necessity.” Mechanism is credible, human data is thin, and use is a considered clinical judgment rather than a default.
- Promoted. “This is what you see on Instagram. And these are a little bit too maybe too aggressive.” Marketed ahead of the evidence.
The sort takes seconds and it changes what you say next: “What category, what bucket is it falling into? And it's something that maybe we want to pass on to the patient so they understand, okay, this one is FDA approved, I'm safer with this. This one is not. But what is the purpose? Why are we using this? And does the benefit outweigh the risk?”
Why the Buckets Beat a Yes or No
The instinct with an over-enthusiastic patient is to shut the conversation down. Cosentino argues against it, and the reasoning is commercial as much as clinical.
“We don't want to suppress their hype,” he says. “They're coming in so excited about peptides. We don't want to tell them, okay, hold on, we've got to be careful of this, we can't do this. We don't want to suppress this, but we do want to give them the correct education.”
A flat no ends the conversation and sends the patient somewhere with a lower standard. Sorting the request instead keeps you in the conversation, demonstrates that you know the category, and moves the discussion to indication and risk — which is where you wanted it. A patient told “that one is in the promoted bucket, here is what we actually know, and here is what I would use instead” has been educated rather than refused.
Applying the Sort: What Sits Where
Proven is a short list, and honesty about its shortness is the point. Insulin is a peptide. The GLP-1 receptor agonists are peptides with approved indications and substantial trial data. That is a very different evidentiary position from a compound with animal data and a Reddit following.
Plausible is the largest and most demanding bucket, because it is where clinical judgment actually lives. Dr. Chris Croley, Empire's Chief Medical Officer, notes there are over 200 active clinical trials in this space worldwide — an enormous amount of work in progress, which is precisely why the bucket is full and why its contents move.
The obligation in this bucket is to know both sides. Croley's worked example is BPC-157: genuinely interesting for inflammatory and gut conditions, and it promotes neoangiogenesis. “What if this patient has an undiagnosed malignancy? Will this promote new blood vessel growth to that tumor? Is it going to make it worse? When we read and only select out the positive effects, that's what our patients are doing. As providers, we actually need to be educated enough that we understand the good and the bad.”
Promoted is not a synonym for useless — some of it will migrate to plausible as data arrives. It means the marketing has outrun the evidence today.
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You Need This Even If You Do Not Prescribe Peptides
This is the part clinicians in aesthetics most often resist, and Croley is blunt about it.
“Even if you decide, hey, peptides aren't really for me, I'm not into it, as a provider you still need to understand it. It is a point in time that it's no longer acceptable to be like, I'm just going to put my head in the sand and pretend this is not out there.”
The practical reason is interaction. Your patients are already sourcing these compounds independently, often from unapproved suppliers, and they are arriving in your chair with them on board. If you do not know what they are taking, you cannot reason about how it affects your treatment plan, your healing timelines or your complication risk.
A Script for the Request You Cannot Fill
- Acknowledge the interest. They have done reading. Say so.
- Name the bucket, out loud. “That one is not approved, and here is what we do and do not know about it.”
- Ask what they are trying to achieve. The goal behind the request is usually addressable, and often by something in a better bucket.
- State what you would use instead, and why.
- Ask what they are already taking. This is the question that protects your treatment plan.
- Document the conversation.
Related reading: peptides are the last 10 percent on where they sit in a wellness plan, and what NAD is and why it is not a peptide, which is the most common category error in this space.
Empire teaches the underlying receptor science and clinical application across the anti-aging and regenerative medicine academy, and covers the regulatory layer in Aesthetic Practice Legal & Licensing.
Frequently Asked Questions
Are peptides safe?
The question cannot be answered for the category, only for a specific compound, in a specific patient, from a specific source. Some peptides are approved drugs with large safety datasets. Others have little or no human data. Sorting the specific compound into proven, plausible or promoted is the first step toward an answer.
What does “not FDA approved” mean for a peptide?
It means the compound has not been approved for a labelled indication. It does not automatically mean use is unlawful — a licensed prescriber may use an approved drug off-label where clinically justified — but unapproved status affects what may be compounded, what may be claimed in advertising, and what must be disclosed in consent.
How do I answer a patient asking for a peptide I will not prescribe?
Do not simply refuse. Name which bucket it sits in, explain what is known and unknown, ask what outcome they are chasing, and offer the better-supported alternative. Then ask what they are already taking, because that answer affects your treatment plan.
Do I need to understand peptides if I only do aesthetics?
Yes. Patients are obtaining these compounds independently and arriving with them on board. Whatever they are taking can affect healing, inflammation and complication risk, so it belongs in your history-taking whether or not you prescribe.
Disclaimer
This article is educational and intended for licensed clinicians. It is not medical advice and does not establish a clinician-patient relationship. Regulatory status for individual peptides changes, and nothing here should be relied on as a current statement of approval or compounding eligibility for any specific compound. Verify the current status of any agent before prescribing, and make treatment decisions on an individual patient basis.
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