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Obesity Medication
Aka: Obesity Medication, Appetite Suppressants, Appetite Depressants, Anti-Obesity Agents
- See Also
- Obesity
- Obesity in Children
- Obesity Evaluation
- Obesity Measurement (or Obesity Screening)
- Obesity Risk (or Obesity Comorbid Conditions)
- Obesity Management
- Dietary Supplements in Obesity
- Exercise in Obesity
- Obesity Resources
- Medications Associated with Weight Gain
- Indications
- Follow indications strictly!!
- Morbid Obesity (BMI>30)
- Moderate Obesity (BMI 27) with comorbidity
- Approach
- Employ all other weight loss strategies concurrently
- See Obesity Management
- See Exercise in Obesity
- Avoid Medications Associated with Weight Gain
- First-line agents
- Orlistat
- Preferred among the Obesity Medications as first -line
- Reevaluate efficacy, compliance and adverse effects on a schedule
- Stop weight loss medications if patient fails to lose 5% body weight after 12 weeks at maximal dose
- Document BMI and treatment plan at a minimum of every 6 months
- Most Obesity Medications are expensive
- Most agents are $200 per month
- Phentermine and Orlistat are least expensive at $30 and $45/month respectively
- Saxenda is most expensive at >$1000/month
- Management: Medications (most are DEA Controlled agents)
- FDA Schedule 4 Medications
- Phentermine (Fastin, Adipex-P, Lonamin)
- Diethylpropion (Tenuate)
- Lorcaserin (Belviq)
- FDA Schedule 3 Medications
- Benzphetamine (Didrex)
- Phendimetrazine (Bontril)
- Non-FDA-Scheduled medications
- Orlistat (Xenical)
- Liraglutide (Saxenda)
- Management: Combination Protocols
- Phentermine and Prozac
- Phentermine 30 mg orally daily
- Prozac 20 mg orally daily
- Phentermine and Topiramate (Qsymia, previously Qnexa)
- See Qysmia
- Bupropion and Naltrexone
- Contrave (90 mg Bupropion with 8 mg Naltrexone) tablet orally daily, gradually advanced to 2 tablets twice daily
- Management: Dietary Supplements
- See Dietary Supplements in Obesity
- Patients on Orlistat should take a daily MVI with the fat soluble Vitamins (Vitamin A, Vitamin D, Vitamin E and Vitamin K)
- Preparations
- Qsymia (Phentermine and Topiramate)
- Results in 19-20 pound weight loss more than Placebo at 1 year
- May cause decreased cognition, Paresthesias, Tachycardia, Ureteral Stones (intolerable in 8%)
- Must be tapered gradually (due to risk of Seizure)
- Significant Teratogenicity risk (requires Informed Consent, reliable Contraception and monitoring with UPT)
- Semaglutide Injection (Ozempic, Wegovy up to 2.4 mg/week)
- Incretin Mimetic (GLP-1 Analog) used in Type II Diabetes Mellitus
- Titrated to 2.4 mg (instead of the 1 mg used in Type II Diabetes Mellitus alone)
- Start at 0.25 mg injected weekly, and slowly titrate over 16 weeks to maximum of 2.4 mg weekly
- Expect 10-12% weight loss at one year (twice the weight loss of Saxenda)
- Stop medication if inadequate weight loss (<5% at 12 weeks of 2.5 mg/week)
- Costs $1400/month in 2021
- Increased risk of Retinopathy complications (esp. if pre-existing Retinopathy)
- Saxenda Injection (Liraglutide up to 3 mg/day)
- Incretin Mimetic (GLP-1 Analog) used in Type II Diabetes Mellitus
- Titrated to 3 mg (instead of the 1.8 mg used in Type II Diabetes Mellitus alone)
- Results in 10-12 pound weight loss more than Placebo in one year
- May cause Nausea and rare Hypoglycemia (intolerable in 5%)
- Most expensive Obesity Medication (>$1000/month)
- Contrave (Bupropion and Naltrexone)
- Results in 9 to 10.8 lb (up to 4.9 kg) weight loss more than Placebo in one year
- May cause Nausea (intolerable in 12%)
- Contraindicated with concurrent Opioids, or Seizure Disorder, Uncontrolled Hypertension
- Suicidality risk (FDA black box warning)
- Lorcaserin (Belviq or Belviq XR)
- Results in 7-8 pound weight loss more than Placebo in one year
- May cause Dizziness, Fatigue (intolerable in 2%)
- Risk of Serotonin Syndrome when combined with other serotinergic agents (e.g. SSRI)
- Theoretical risk of valvulopathy (similar to Fenfluramine), but short-term studies demonstrated safety
- Orlistat (Xenical, Alli)
- Typically recommended as a first-line agent among the Obesity Medications
- Results in 7 pound weight loss more than Placebo in one year
- May cause Nausea, Diarrhea, fecal urgency (intolerable in 4%)
- Contraindicated in cholestasis, comorbidity causing malabsorption
- One of the least expensive of the Obesity Medications ($45/month)
- Package insert recommends taking MVI with fat soluble Vitamins (Vitamins A, D, E and K)
- Plenity (cellulose hydrogel)
- Cellulose hydrogel taken with water before meals, expands in Stomach and reduces capacity
- Indicated in BMI 27-40 with normal gastrointestinal motility and anatomy
- Plenity 3 capsules with 16 ounces water taken 20-30 min before lunch and before dinner
- Discontinue use if insignificant weight loss at 2 months
- Patients lose 2% more than Placebo in 6 months (similar to Orlistat) at $100 per month
- Side Effects include Flatulence and bloating
- Bupropion (Wellbutrin)
- Results in 6 pound weight loss more than Placebo in one year
- Phentermine (Fastin, Lonamin, Lomira)
- Results in 5 pound weight loss more than Placebo in one year
- May cause Agitation or Insomnia (intolerable in 11%)
- Contraindicated in heart disease or Uncontrolled Hypertension
- References
- (2015) Presc Lett 22(5): 26
- (2015) Presc Lett 22(2): 7-8
- (2014) Presc Lett 21(11): 62
- Contraindications: Noradrenergic agents (all agents other than Orlistat)
- Hypertension
- Advanced cardiovascular disease
- Coronary Artery Disease
- Congestive Heart Failure
- Arrhythmias
- Hyperthyroidism
- Narrow-Angle Glaucoma
- Substance Abuse history
-
Drug Interactions
- Orlistat
- Cyclosporine
- Fat soluble Vitamins (see above)
- Serotonin Syndrome risk
- Lorcaserin (Belviq) when combined with other serotonergic agents
- Noradrenergic agents (all except Orlistat)
- MAO inhibitors
- Guanethidine
- Tricyclic Antidepressants
- Alcohol
- Centrally acting stimulants or Anorexiants
- Adjunctive Therapies
- Ursodeoxycholic Acid 600mg qd
- Prevention of Gallstones in dieting obese patients
- Reference
- Shiffman (1995) Ann Intern Med 122:899-905 [PubMed]
- Preparations: Pharmacologic Therapies recalled by FDA for CV effects
- Fenfluramine
- Dexfenfluramine
- Sibutramine (Meridia)
- Phenylpropanolamine (over-the-counter)
- Decongestant that stimulates Adrenergic Receptors
- Elevates Blood Pressure
- Preparations: Research Drugs (not approved)
- Selective Cannabinoid Type I Blocker
- Acomplia (Rimonabant) is first in class
- Decreases appetite by blocking Cannabinoid Receptors
- May also be effective in Tobacco Cessation
- Fernandez (2004) Curr Opin Investig Drugs 5:430-5 [PubMed]
- Growth Hormone
- No change in body weight
- Decreases Body fat 9.2%
- Decreased visceral fat 18%
- Johanssen (1997) J Clin Endocrinol Metab 82: 727 [PubMed]
- References
- (1998) AOA Treatment Adult Obesity, 2nd edition
- Erlandson (2016) Am Fam Physician 94(5): 361-8 [PubMed]
- Frank (1998) J Am Diet Assoc 98:S44-48 [PubMed]
- Lyznicki (2001) Am Fam Physician 63(11):2185-96 [PubMed]
- Apovian (2015) J Clin Endocrinol Metab 100(2):342–362 [PubMed]
- Rippe (1998) J Am Diet Assoc 98:S9-15 [PubMed]
- Speer (1997) Phys Sportsmed 25:94-107 [PubMed]
- Yanovski (2002) N Engl J Med 346:593 [PubMed]