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[120] In advanced disease, tamoxifen is now only recognized as effective in ER+ patients, but the early trials did not select ER+ patients, and by the mid-1980s the clinical trial picture was not showing a major advantage for tamoxifen

Or it could require a process called step therapy, which involves trying (and failing) other drugs, like metformin, phentermine, or bupropion, before moving on to Zepbound