In Part I of Treating Obesity, we talked about obesity being recognized as a chronic disease, the latest scientific research on obesity, and our body’s physiological response to weight gain. In the management and treatment of obesity, there is a four-pronged approach that includes the following: 1. Medications, 2. Nutrition, 3. Activity, and 4. Behavior Therapy. If any of these parts are missing, the plan is more likely to fail. You can’t begin an exercise program to lose weight without changing your diet. If you try new diets only to fail after 2 weeks, you need to look deeper as to why you aren’t successful. In Part II, we will discuss the medications involved in the treatment of obesity.
Do I really need help losing weight? Only 5% of people lose weight and keep it off on their own. Many overweight people have tried 8 to 12 diets by the time they seek help for weight loss. They have lost and regained the same weight over and over. Dieters can lose weight in the short term when trying to achieve a specific goal such as fitting into a dress for a special occasion or losing weight for a vacation, but very few can maintain the weight loss.
Many doctors tell their patients to lose weight when they are diagnosed with high blood pressure or diabetes but never give any specific information on how to do this. Most primary care physicians receive little training in managing or talking to obese patients. Doctors specializing in weight loss can find the best nutrition plans for you, prescribe weight loss medications, guide you through the challenges, and help you through maintenance.
Part of the medical management of obesity is accountability and medications. The doctor will review a patient’s history to see if there are any medications that can cause weight gain. Sometimes these medications can be stopped or changed to a more weight-neutral option. Medications are an important part of a weight loss program and are safe to use under the care of a physician trained in Obesity Medicine. If the medications are working, there is no reason to stop taking them. Remember the hormones leptin and grehlin are working against us. They cause hunger and work against us to get your body back to that set point or highest weight. Weight loss medications help decrease our appetite. If we stop taking them, appetite goes up and so does weight.
Medication Options:
Adipex/Phentermine-the most commonly prescribed weight loss medicine is a mild stimulant. Phentermine reduces the appetite by acting on the hypothalamus in the brain. It also increases metabolism by 5-10%. Phentermine was approved in 1959 for a limited period of 12 weeks because obesity was considered an acute problem like an ear infection or strep throat that could be treated for 5-10 days and was cured. We now know that obesity doesn’t work that way.
In 1990, two medications, phentermine and fenfluramine were combined to make the weight loss drug phen-fen. Fenfluramin stimulates serotonin receptors in the brain, but also stimulates the receptors in the heart valves which created growths on the valves and caused them to leak. The FDA eventually banned Fenfluramine and that caused all weight loss medications to be under scrutiny. Phentermine was deemed safe by the FDA but only for short term use: 12 weeks. Phentermine can be given long term by trained weight loss physicians as an “off-label” use. Phentermine has been used safely since 1959 and probably won’t be studied for long term use due to cost.
Common side effects include dry mouth and insomnia. Increased heart rate, anxiety and increased blood pressure occur less often. Phentermine cannot be used with patients who have coronary artery disease or severe arrhythmias. For this reason, patients need an EKG prior to starting phentermine. Monthly blood pressure and pulse are also monitored.
Qysmia/Phentermine plus Topiramate- Qysmia is a brand name medication that contains phentermine and topiramate, two medicines that have been around a long time. It is available in an extended release formula and has been approved by the FDA for long term use even though phentermine has not. This combination of medications results in greater weight loss than either medication separately. Topiramate reduces hunger through a neurotransmitter pathway, the GABA system. It also has a calming effect and can help with sleep. Topiramate can help people who have gained weight after bariatric surgery.
Side effects related to topiramate can be sedation and less likely, memory change (difficulty in word finding), and depression. Topamax can increase the risk of kidney stones.
Tenuate/Diethylproprion-Tenuate is a milder and shorter-acting stimulant than phentermine. It lowers appetite and raises metabolism. It can be used alone or in combination with phentermine. It can help with evening hunger since it lasts just a few hours. Common side effects are insomnia (less often), anxiety, and increased blood pressure or heart rate. These need to be monitored at least monthly by your weight loss physician. Not for use in people with significant coronary artery disease and chronic heart arrhythmia.
Bontril/Phendimetrazine- works by increasing metabolism and decreasing appetite. It is a stimulant that comes in short and long-acting forms. Avoid in people with heart arrhythmias or heart disease. Side effects are anxiety, insomnia, increased blood pressure, and increased heart rate. The DEA (Drug Enforcement Agency) classified phendimetrazine as a schedule 3 drug which means it has a slightly higher potential for dependency. Patients need to be monitored closely for side effects.
Contrave/Bupropion plus Naltrexone extended release- Contrave is a combination of bupropion and naltrexone. Contrave is non-stimulating and helps with appetite and cravings. Bupropion (Wellbutrin) is used for treating depression. Patients with low energy or mood can see improvement after taking Contrave. Naltrexone enhances the effect of bupropion. This medicine is not recommended for people with severe anxiety and people with seizure disorders. Patients taking opioids for pain relief should not take Contrave as naltrexone blocks the effects of opioids and could cause withdrawal symptoms. The FDA has approved Contrave for long-term use. Contrave is not a stimulant therefore it can be safely used in patients with heart disease. Wellbutrin is prescribed for smoking cessation and naltrexone for alcohol cessation. The combination Contrave helps with food cravings. Common side effects are nausea in one out of every three people. Only three to four percent had to stop taking Contrave during the trials due to nausea.
Belviq/Lorcaserin- Belviq works on the appetite centers of the brain. Its molecule is similar to serotonin. Stimulation of the brain serotonin receptor decreases appetite. Belviq acts on the serotonin receptors. It does not affect metabolism and can be used in patients with heart disease. The studies done on Belviq show half of the patients who take it will show a decreased appetite and weight loss and the other half do not notice any benefit.
Saxenda/Liraglutide-is similar to glucagon-like peptide one (GLP-1) which is produced in our body. GLP-1 decreases appetite and blood sugar. Natural GLP-1 is secreted from the small intestine and travels to the hypothalamus. In its natural state, GLP-1 lasts 60-120 seconds before it is broken down. The body makes more to signal to the brain the feeling of fullness. The synthetic version lasts much longer with a half life of 13 hours. Saxenda is given once a day by injection. Side effects include nausea, diarrhea and occasional headaches. Not for use in patients with thyroid cancer or family history of multiple endocrine neoplasia. Do not use if history of pancreatitis as it has a slight risk of pancreatitis. GLP-1 analogs have a significant role in managing obesity and diabetes. Future versions will be more potent and require less frequent injections. This medication is very expensive and rarely covered by insurance.
Xenical/Orlistat- reduces fat absorption in the intestine. Xenical blocks the gut enzyme lipoprotein lipase needed to break down fat. The body absorbs 30% less of the fat ingested. Increased fat intake leads to increased gas, greasy diarrhea, and bloating. This medication is limited in use due to diarrhea and limited weight loss.
Off-Label Medications- Metformin can increase weight loss by raising the body’s GLP-1, reducing sugar absorption and decreasing the production of sugar by the liver. Topiramate can be used alone in people with anxiety disorder, insomnia, or migraines.
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