Obesity
Obesity Medication
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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
Vitamin
s (
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,
Paresthesia
s,
Tachycardia
,
Ureteral Stone
s (intolerable in 8%)
Must be tapered gradually (due to risk of
Seizure
)
Significant
Teratogen
icity 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
Opioid
s, 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
Vitamin
s (
Vitamin
s 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
Arrhythmia
s
Hyperthyroidism
Narrow-Angle
Glaucoma
Substance Abuse
history
Drug Interactions
Orlistat
Cyclosporine
Fat soluble
Vitamin
s (see above)
Serotonin Syndrome
risk
Lorcaserin
(
Belviq
) when combined with other serotonergic agents
Noradrenergic agents (all except
Orlistat
)
MAO inhibitor
s
Guanethidine
Tricyclic Antidepressant
s
Alcohol
Centrally acting stimulants or
Anorexia
nts
Adjunctive Therapies
Ursodeoxycholic Acid
600mg qd
Prevention of
Gallstone
s 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 Receptor
s
Elevates
Blood Pressure
Preparations
Research Drugs (not approved)
Selective
Cannabinoid
Type I Blocker
Acomplia (Rimonabant) is first in class
Decreases appetite by blocking
Cannabinoid Receptor
s
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]
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