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Obesity: When to Consider Medication

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Obesity: When to Consider Medication Obesity: When to consider medication These 4 cases illustrate how weight loss drugs—including the 4 newest— can be integrated into a treatment plan that includes diet, exercise, and behavior modification Katherine H. Saunders, MD; Alpana P. Shukla, MD, MRCP; Leon I. Igel, MD; and Louis J. Aronne, MD odest weight loss of 5% to 10% Until recently, there were few pharma- among patients who are overweight cologic options approved by the US Food M or obese can result in a clinically and Drug Administration (FDA) for the relevant reduction in cardiovascular (CV) management of obesity. The mainstays of disease risk.1 This amount of weight loss can treatment were phentermine (Adipex-P, Ion- increase insulin sensitivity in adipose tissue, amin, Suprenza) and orlistat (Alli, Xenical). liver, and muscle, and have a positive impact Since 2012, however, 4 agents have been on blood sugar, blood pressure, triglycerides, approved as adjuncts to a reduced-calorie 1,2 and high-density lipoprotein cholesterol. diet and increased physical activity for long- IN THIS All patients who are obese or overweight term weight management.8,9 Phentermine/ ARTICLE with increased CV risk should be counseled topiramate extended-release (ER) (Qsymia) on diet, exercise, and other behavioral inter- and lorcaserin (Belviq) were approved Antiobesity 3 10,11 ventions. Weight loss secondary to lifestyle in 2012, and naltrexone sustained re- medication details modification alone, however, leads to adap- lease (SR)/bupropion SR (Contrave) and page 42 tive physiologic responses, which increase liraglutide 3 mg (Saxenda) were approved appetite and reduce energy expenditure.4–6 in 201412,13 (TABLE9,14–39). These medications Pharmacotherapy can counteract this have the potential to not only limit weight Considerations metabolic adaptation and lead to sustained when choosing weight loss. Antiobesity medication can be a drug considered if a patient has a body mass index Practice recommendations page 44 (BMI) ≥30 kg/m2 or ≥27 kg/m2 with obesity- For patients with a body mass index (BMI) related comorbidities such as hypertension, ≥30 kg/m2 or BMI ≥27 kg/m2 with weight- Prescribing type 2 diabetes, dyslipidemia, or obstructive related comorbidities: cautions 3,7 sleep apnea. • Consider antiobesity pharmacotherapy page 45 when diet, exercise, and behavior Comprehensive Weight Control Center, Division of modification do not produce sufficient Endocrinology, Diabetes and Metabolism, Cornell Medicine, weight loss. A New York, New York. • Continue an antiobesity medication if it is Drs. Saunders, Shukla, and Igel reported no potential conflicts deemed effective and well tolerated. A of interest relevant to this article. Dr. Aronne reported various financial relationships with Aspire Bariatrics, AstraZeneca, Strength of recommendation: BMIQ, Eisai, Gelesis, GI Dynamics, Jamieson Laboratories, A Good-quality patient-oriented evidence Janssen Pharmaceuticals, MYOS RENS Technology Inc., B Inconsistent or limited-quality patient- Novo Nordisk, Pfizer, Real Appeal, UnitedHealth Group Ven- tures, and Zafgen. oriented evidence C Consensus, usual practice, opinion, Adapted from The Journal of Family Practice. 2017;66(10): disease-oriented evidence, case series 608–616. mdedge.com/obgmanagement Vol. 30 No. 8 | August 2018 | OBG Management 41 Obesity: When to consider medication TABLE Antiobesity medications: What to expect and who makes a good candidate9,14–39 Mechanism, Most dosage, and common available Trial and Weight adverse Good Medication formulations duration Trial arms loss (%) effects candidates Poor candidates Phentermine Adrenergic Aronne LJ, et 15 mg/d 6.06a Dry mouth, Younger Patients with 15 19 (Adipex-P, agonist al a insomnia, patients uncontrolled Ionamin,16 28 weeks 7.5 mg/d 5.45 dizziness, who need hypertension, 17 8–37.5 mg/d Lomaira, Placebo 1.71 irritability assistance active or unstable 18 Suprenza ) Capsule, tablet with coronary disease, (topiramate appetite hyperthyroidism, Schedule IV ER and suppression glaucoma, anxiety, controlled phentermine/ insomnia, or substance topiramate ER patients who are NOTE: arms excluded) generally sensitive to Approved for stimulants; patients short-term use with a history of drug abuse or recent MAOI use; patients who are pregnant Orlistat Lipase XENDOS22 120 mg three 9.6 Fecal Patients with Patients with (Alli,20 inhibitor 208 weeks times per day (Week 52)a urgency, hyper- malabsorption Xenical21) oily stool, cholesterolemia syndromes or other 60–120 mg 5.25 a flatus with and/or GI conditions that three times per (Week 208) discharge, constipation predispose to GI day with meals Placebo 5.61 fecal who can limit upset/diarrhea; Capsule (Week 52) incontinence their intake of patients who cannot FAST dietary fat modify the fat content TRACK 2.71 of their diets; patients (Week 208) who are pregnant TKPhentermine/ Adrenergic EQUIP24 15/92 mg/d 10.9a Paresthesias, Younger Patients with topiramate ER agonist/ 56 weeks a dizziness, patients uncontrolled (Qsymia)23 neurostabilizer 3.75/23 mg/d 5.1 dysgeusia, who need hypertension, Placebo 1.6 insomnia, assistance active or unstable Schedule IV 3.75/23–15/92 constipation, with appetite coronary disease, controlled mg/d a dry mouth suppression hyperthyroidism, CONQUER25 15/92 mg/d 9.8 substance glaucoma, anxiety, Capsule 56 weeks 7.5/46 mg/d 7.8a insomnia, or patients who are Placebo 1.2 generally sensitive to stimulants; patients SEQUEL26 15/92 mg/d 10.5a with a history of drug abuse or recent 108 weeks (52- a week extension 7.5/46 mg/d 9.3 MAOI use; patients with a history of of CONQUER Placebo 1.8 (Weeks nephrolithiasis; trial) 0–108) patients who are pregnant gain but also promote weight loss and, thus, als, poor insurance coverage for new agents, improve blood pressure, cholesterol, glucose, and low reimbursement for office visits to ad- and insulin.40 dress weight.41 Despite the growing obesity epidemic In addition, the number of obesity medi- and the availability of several additional cine specialists, while increasing, is still not medications for chronic weight manage- sufficient. Therefore, it is imperative for ment, use of antiobesity pharmacotherapy other health care professionals—including has been limited. Barriers to use include in- ObGyns—to be aware of the treatment op- adequate training of health care profession- tions available to patients who are overweight 42 OBG Management | August 2018 | Vol. 30 No. 8 mdedge.com/obgmanagement TABLE Antiobesity medications: What to expect and who makes a good candidate9,14–39 (continued) Mechanism, Most dosage, and common available Trial and Weight adverse Good Medication formulations duration Trial arms loss (%) effects candidates Poor candidates Lorcaserin Serotonin BLOOM28 10 mg twice 5.8a Headache, Patients who Patients on other (Belviq, Belviq 52 weeks per day dizziness, report serotonin modulating 5-HT2C XR)27 fatigue, inadequate medications; patients receptor Placebo 2.2 nausea, dry meal satiety with known cardiac Schedule IV agonist BLOSSOM29 10 mg twice 5.8a mouth, valvular disease; controlled 10 mg twice 52 weeks per day constipation patients who are substance pregnant per day or a 4.7 20 mg/d ER 10 mg/d 2.8 Tablet Placebo BLOOM- 10 mg twice 4.5a DM30 per day 52 weeks a 10 mg/d 5.0 Placebo 1.5 Naltrexone Opioid COR-I32 16/180 mg 6.1a Nausea, Patients who Patients with SR/bupropion receptor 56 weeks twice per day vomiting, describe uncontrolled SR antagonist/ constipation, cravings for hypertension, 5.0a (Contrave)31 dopamine and 8/180 mg headache, food and/ uncontrolled pain, norepinephrine twice per day dizziness, or addictive recent MAOI use, reuptake Placebo 1.3 insomnia, dry behaviors history of seizures, inhibitor mouth related to food; or any condition that 33 a COR-II 16/180 mg 6.4 patients who predisposes to seizure 8/90 mg/d– 56 weeks twice per day are trying to quit such as anorexia/ 16/180 mg Placebo 1.2 smoking, reduce bulimia nervosa, twice per day alcohol intake, abrupt discontinuation COR- 16/180 mg 9.3a Tablet and/or have of alcohol, BMOD34 twice per day concomitant benzodiazepines, 56 weeks Placebo 5.1 depression barbiturates, or antiepileptic drugs; a COR- 16/180 mg 5.0 patients who are DIABETES35 twice per day pregnant 56 weeks Placebo 1.8 Liraglutide GLP-1 receptor SCALE 3 mg/d 8.0a Nausea, Patients Patients with an 3 mg agonist Obesity and vomiting, who report aversion to needles, Placebo 2.6 (Saxenda)36 Prediabetes37 diarrhea, inadequate meal history of pancreatitis, 0.6–3 mg/d 56 weeks constipation, satiety, personal or family dyspepsia, and/or have history of medullary Prefilled SCALE 3 mg/d 6a abdominal type 2 diabetes, thyroid carcinoma, pen for 38 Diabetes a subcutaneous 1.8 mg/d 4.7 pain prediabetes, or multiple endocrine 56 weeks injection or impaired neoplasia syndrome Placebo 2 glucose type 2; patients who SCALE 3 mg/d 6.2a tolerance; are pregnant Maintenance39 patients Placebo 0.2 56 weeks (after requiring use initial ≥5% of concomitant psychiatric weight loss medications with LCD) Abbreviations: ER, extended release; GI, gastrointestinal; GLP-1, glucagon-like peptide-1; LCD, low-calorie diet; MAOI, monoamine oxidase inhibitor; XR, extended release. aP<.001 vs placebo. CONTINUED ON PAGE 44 mdedge.com/obgmanagement Vol. 30 No. 8 | August 2018 | OBG Management 43 Obesity: When to consider medication CONTINUED FROM PAGE 43 be problematic for the patient? • Can this medication improve other symp- toms or conditions the patient has? In addition, see “Before prescribing anti- obesity medication . .” on page 45. Phentermine/topiramate ER Phentermine/topiramate ER is a good first choice for this young patient with class I (BMI 30–34.9 kg/m2) obesity and migraines, as she can likely tolerate a stimulant and her migraines might improve with topiramate. Before starting the medication, ask about insomnia and nephrolithiasis in addition to anxiety and other contraindications (ie, glau- coma, hyperthyroidism, recent monoamine oxidase inhibitor use, or a known hypersen- sitivity or idiosyncrasy to sympathomimetic amines).23 The most common adverse events reported in phase III trials were dry mouth, paresthesia, and constipation.24–26 or obese and to be adept at using them.
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