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New Guideline Released on Pharmacological Management of Obesity

The Endocrine Society has released a clinical practice guideline on the pharmacological management of obesity that includes recommendations on strategies for prescribing weight loss drugs…

During a recent press conference, Caroline Apovian, MD, of Boston University, the lead author of the new guideline, “This is really the first guideline of its kind. We do have the 2013 obesity management guidelines endorsed by The Obesity Society (TOS), the American Heart Association (AHA) and the American College of Cardiology (ACC), which covered the management of obesity through lifestyle, diet and exercise, and surgery. Although medications for anti-obesity drugs were mentioned, the guidelines did not go into detail. There were very few medications on the market and therefore very few randomized clinical trials with which to make recommendations. The Endocrine Society guideline fills that gap.”

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Further, she explained that the newly released guideline offers a “blueprint” on the medical management of obesity while taking into account the 2013 TOS/AHA/ACC guidelines, noting that the task force stands by national recommendations for management of overweight and obese patients.

Currently, six drugs are approved by the FDA for treatment of obesity. In addition to orlistat and orlistat OTC, four medications have been approved during the last 2 years, including lorcaserin (Belviq, Eisai), phentermine/topiramate (Qsymia, Vivus), naltrexone/bupropion (Contrave, Takeda) and liraglutide (Saxenda, Novo Nordisk).
Despite the addition of these medical therapies to clinicians’ armamentarium, the guideline emphasizes the importance of diet, exercise and behavioral modifications, recommending that all should play a role in approaches to obesity management. By making these lifestyle changes, patients will experience greater weight loss overall and better maintenance of that weight loss.

The current requirements for using FDA-approved weight loss medications include a BMI of at 27 with at least one weight-related comorbidity, such as diabetes or hypertension, or a BMI of 30 or more.

If patients meet these requirements and do opt for a weight management plan that includes anti-obesity medications, clinicians should see them frequently. Face-to-face encounters yield the best results, according to Dr. Apovian, although the addition of Web-based programs can be beneficial for those patients who cannot meet with their physician that often. At present, the Centers for Medicare and Medicaid Services (CMS) covers 15 visits per year.

More highlights from the guideline include the following:

  • Medication should be continued in patients who respond well to the treatment and lose at least 5% of their body weight after 3 months. However, if the drug proves ineffective or the patient experiences significant side effects, the medication should be discontinued and other medications or therapeutic strategies should be pursued.
  • In overweight or obese patients with diabetes, medications that promote weight loss or have no effect on weight should be given as first- and second-line therapies, as some type 2 diabetes medications are associated with weight gain. Metformin is still first-line therapy. If the patient requires the addition of a second medication, clinicians should then consider adding a GLP-1 agonist, such as exenatide or liraglutide or even pramlintide, followed by SGLT-2 inhibitors before sulfonylureas or insulin, as these drugs will promote weight loss in addition to glycemic control, according to the guideline. Recommendations are also made for patients who are already using diabetes medications that promote weight gain.
  • For first-line treatment for hypertension, certain types of medication, including angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and calcium channel blockers, should be used in obese patients with type 2 diabetes because these drugs are less likely to contribute to weight gain.
  • Patients who need medications that may affect weight, such as antidepressants, antipsychotic drugs and medications for epilepsy, should be fully informed and provided with estimates of anticipated effect on weight for each option. Shared decision-making between patient and provider is recommended.
  • Phentermine and diethylpropion should not be used in patients with uncontrolled high blood pressure (BP) or a history of heart disease.

These newer treatment strategies are based on the concept of managing obesity first with lifestyle changes and medications and then managing the remainder of comorbidities that have not been successfully managed with weight loss.

This is the first guideline that specifically names medications, recommended doses and how to use them; addresses patients election criteria that goes beyond BMI; which drugs to suggest; and which drugs to taper off.

In response to a query from Diabetes In Control, Louis J. Aronne, MD, FACP added that: “These comprehensive guidelines dealing with the important topic of medical management of obesity have been endorsed by The Obesity Society (TOS) and the American Society for Metabolic and Bariatric Surgery (ASMBS). They are part of a shift towards managing obesity more aggressively as a disease rather than waiting to treat it’s complications. This approach, which has spawned the newest medical specialty, Obesity Medicine, is gaining increased acceptance.” Dr Arrone is a Sanford I. Weill Professor of Metabolic Research and director of the Comprehensive Weight Control Center at Weill-Cornell Medical College in New York.

Practice Pearls:

  • Medication should be continued in patients who respond well to the treatment and lose at least 5% of their body weight after 3 months.
  • Metformin is still first-line therapy. If the patient requires the addition of a second medication, clinicians should then consider adding a GLP-1 agonist, such as exenatide or liraglutide or even pramlintide, followed by SGLT-2 inhibitors before sulfonylureas or insulin, as these drugs will promote weight loss in addition to glycemic control.
  • Shared decision-making between patient and provider is recommended.

The guideline, titled “Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline,” was co-sponsored by the European Society of Endocrinology and The Obesity Society. It is now available online and will be published in the February 2015 print issue of the Journal of Clinical Endocrinology & Metabolism.
http://dx.doi.org/10.1210/jc.2014-3415