Pharmacologic options boost weight loss

Issue: July 2015

Successful obesity treatment starts with behavioral interventions and lifestyle changes. For patients with a BMI greater than 30 kg/m2, or greater than 27 kg/m2 with a weight-related comorbidity, such as diabetes or hypertension, medications can enhance the effects of a healthy diet and increased physical activity, according to Caroline M. Apovian, MD, director of nutrition and weight management at Boston Medical Center and professor of medicine at Boston University School of Medicine.

Six anti-obesity drugs are currently available in the United States. Phentermine, a sympathomimetic drug, has been prescribed since 1959, and the fat-blocker Xenical (orlistat, Hoffmann-La Roche) since 1999. Since 2012, four additional weight-loss agents have joined the market: the 5HT2c serotonin receptor agonist Belviq (lorcaserin, Eisai); Qsymia (combination phentermine plus topiramate extended release, Vivus), which adds the GABA receptor agonist topiramate to phentermine; Contrave (combination bupropion and naltrexone, Takeda), which combines an antidepressant and an anti-addiction agent to synergistically increase satiety; and most recently, the glucagon-like peptide-1 receptor agonist Saxenda (liraglutide 3 mg, Novo Nordisk).

Right drug, right patient

Currently, no clear data indicate which drug will work best for which patient, according to Apovian.

Caroline M. Apovian

“Right now, we feel that there really is going to end up being more than one type of obesity … so that we will eventually be able to predict who is going to do better with which drug. Right now, it’s trial and error,” Apovian told Endocrine Today.

However, less than 5% weight reduction in 12 weeks is a sign that a particular pharmaceutical is unlikely to help, and prescribing information for most of the anti-obesity drugs suggests discontinuing therapy. “That patient is a nonresponder, and you should stop that drug and try another one,” Apovian said.

Right diet

All weight-management drugs are meant to be used as adjuncts to diet and exercise. A well-rounded food plan is essential, but Apovian lets the patient decide on the type of macronutrient content. “If the patient doesn’t like to eat a lot of protein, then it’s probably not going to be a good idea to put them on a high-protein diet,” she said.

The researchers behind the 2013 American Association of Clinical Endocrinologists obesity guidelines found, after reviewing the literature, that no single diet provided a weight-loss advantage over others. People who consume 500 to 1,000 fewer calories a day than they typically do should lose 1 lb to 2 lb per week.

Role for medications

Unfortunately, hormones counteract calorie restriction and make weight loss difficult.

“For example, leptin levels drop as you lose weight, which causes your brain to sense more hunger, and it becomes very difficult to maintain a lower body weight because you’re just going to get more hungry,” Apovian said.

Medications that promote satiety can help counteract the tendency of hormones to maintain a body-weight set-point, making efforts to stick to a diet and exercise program easier, she said. – by Jill Rollet

For more information:

Visit Healio.com/Endocrinology to watch a video of Caroline Apovian, MD, discussing weight-loss drugs.

Disclosures:

Apovian reports financial ties with Amylin, Aspire Bariatrics, GI Dynamics, Johnson and Johnson, Merck, Myos Corporation, Novo Nordisk, Nutrisystem, Orexigen, Sanofi Aventis, Takeda and Zafgen.