November 15, 2006 • www.familypracticenews.com Obesity 47 Shared Decision Making Is Best Approach to Obesity

BY NANCY WALSH therapy for obese patients with hyperten- long-term studies and potential for abuse. strated before insurers would be more New York Bureau sion, cardiovascular disease, or dyslipi- Nonetheless, it is still the most common- willing to reimburse for treatment. Dr. demia, he said. ly prescribed weight-loss drug, largely be- Arterburn replied that most payers are not B OSTON — The decision to embark on Sibutramine is associated with small in- cause of its lower cost, said Dr. Arterburn, so much interested in the amount of a weight management program that incor- creases in both systolic and diastolic blood also of the department of internal medi- weight lost as in a reduction in disease in- porates pharmacotherapy is one that should pressure and so would be more appropri- cine, University of Washington, Seattle. cidence, reduced hospitalizations, and be shared by patient and clinician, based on ate for the otherwise healthy patient with- And the cost of treatment can be a bar- overall lower costs. “Until we can get stud- reasonable goals, and must take into ac- out cardiovascular risk factors. Sibutramine rier for some patients, with a 30-day supply ies far enough along to demonstrate the count the patient’s cardiovascular risk fac- also might be preferable for a patient who of 120-mg orlistat and 15-mg sibutramine harder outcomes that impact patient tors, according to Dr. David Arterburn. is unable or unwilling to tolerate the gas- costing $140 and $115, respectively. health care, we’re not going to see wide- “Selecting the right drug for the right pa- trointestinal side effects of orlistat, he said. An audience member asked how much spread adoption of these medications by tient in primary care is a process of shared Phentermine is limited by a lack of weight loss would have to be demon- large organizations.” ■ decision making, which is a nonpaternal- istic approach that is particularly useful when there are no clear best options for the patient,” Dr. Arterburn said at the annual meeting of NAASO, the Obesity Society. “And arguably, in weight management it’s safe to say we can’t come to the table knowing that there is one clear best option today,” he said. Visit The role of the caregiver is to provide the patient with the best available infor- mation on benefits, risks, and likely out- comes, and to help set an achievable goal, www.sleepleaders.org which generally is a 5%-10% weight loss over 6 months. Many patients want to lose more than that, but they are more likely to succeed with a modest initial goal that can later be renegotiated, explained Dr. for the latest in sleep disorder information Arterburn, an internist at the Center for Health Studies, Seattle, Wash. Also, even a relatively small 5% reduc- tion in body weight is an amount that is associated with significantly reduced long- term health risks, he said. Two agents, orlistat and sibutramine, have been approved for long-term use in obesity. Orlistat is a lipase inhibitor that blocks the absorption of approximately 30% of ingested fat, while sibutramine is Sleep leaders is an online educational resource for health care professionals, a norepinephrine, serotonin, and dopamine reuptake inhibitor. offering multimedia CME programs that include video webcasts, panel A third agent, phentermine, is a sym- pathomimetic amine similar to the am- discussions, case studies and audio commentaries with experts phetamines and is recommended only for short-term use of 12 weeks or less. in the field of sleep. To be eligible for drug treatment, pa- tients generally must have a body mass in- dex of 30 kg/m2 or greater, or a BMI be- tween 27 and 29.9 kg/m2 and two or more obesity-related morbidities. Both orlistat and sibutramine have been shown to be more effective than placebo in clinical trials with patients who were also dieting and exercising. Patients re- ceiving orlistat averaged a 2.89-kg greater weight loss than did those receiving place- bo, and in one study, patients on this drug Coming soon to Sleepleaders.org: Journal Club to Go plus diet and exercise were 15% more likely to achieve a 5% weight loss than The premier series release features moderator, David N. Neubauer, MD and were those on diet and exercise alone (Di- abetes Care 2004;27:155-61). Gary Richardson, MD, discussing the NIH State-of-the-Science Conference The effect size has been larger in stud- Statement on Manifestations and Management of Chronic Insomnia in Adults ies of sibutramine, with patients losing an average of 4.5 kg. “Adults taking sibu- tramine plus diet and exercise for 1 year were 19%-34% more likely to achieve a 5% weight loss than were those taking place- bo,” Dr. Arterburn said. While both drugs do aid in weight loss, they differ in impact on attendant obesity risk factors. Orlistat has an excellent car- diovascular safety profile, typically show- ing small improvements in blood pres- sure, lipids, and glycemic control, and therefore would be a suitable first-line