Another Important Contributor to Obesity in the United States: Drug-Induced Weight Gain/Weight Loss Hindrance

| March 1, 2017

A Message from Dr. Christopher Still

Christopher Still, DO, FACN, FACP, Co-Clinical Editor, Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity Research Institute, Geisinger Medical Center, Danville, Pennsylvania.


Dear Readers,
We now know that obesity is a complex disease with many identified contributing factors, including genes, energy-balance dysregulation, hormones, and gut microbiota. Obesity also has many less common secondary “causes,” such as hypothyroidism and polycystic ovarian syndrome (PCOS). Another important, and common,  contributor to obesity is seen in prescription drugs that can promote weight gain or hinder weight loss in patients.

In 2015, The Endocrine Society released a clinical practice guideline on the pharmacological management of obesity.[1] This guideline provides specific recommendations for transitioning patients off drugs that cause weight gain. Classes of drugs associated with weight gain include the following: anti-diabetic therapy, steroid hormones, psychotropic agents, antiepileptic drugs, and miscellaneous drugs, such as antihistamines and progestin only contraceptives. This month I’d like to focus on anti-diabetic therapy and psychotropic drugs.

Anti-diabetic medication. Given that type 2 diabetes mellitus (T2DM) is prevalent in individuals with obesity, it is likely that your patients will already be receiving treatment. It’s important for the provider to evaluate their patient’s current medications, especially because he or she might be on something that has been shown to have a negative effect on weight loss.
For instance, sulfonylureas (e.g., glipizide, glyburide, glimepiride), which work by stimulating insulin release from pancreatic β cells, have been associated with weight gain of 4.4 to 8.8 pounds.[2] Meglitinides, another class of oral antidiabetic agents that include repaglinide and nateglinide, have also been associated with weight gain of up to 6.6 pounds in three months.[3]

The Endocrine Society Guidelines recommend that weight-losing and weight-neutral medications be prescribed as first- and second-line agents in the management of a patient with T2DM with overweight or obesity. The following drugs, which the guidelines suggest adding to a T2DM, have been shown to help mitigate associated weight gain: metformin, pramlintide, the SGLT2 inhibitors and GLP-1 agonists.

Psychotropic drugs. While many psychotropic drugs are effective in patients in whom they are indicated, some have been shown to product weight gain. When conducting a medication evaluation, providers should be on the lookout for the following: amitriptyline, mirtazapine, olanzapine, quetiapine, risperidone, and paroxetine. The Endocrine Society Guidelines recommend using weight-neutral antipsychotic alternatives when clinically indicated, rather than those that cause weight gain. Alternative antipsychotropic drugs found to be either weight neutral or associated with weight loss include bupropion and fluoxetine.[4]

While patients and providers must always discuss the risk/benefit equation of being on a medication, evidence-based guidelines may help in offering a solution that allows patients to receive treatment without untoward side effects on weight. A shared-decision making process in which the patient and physician weigh the risks/benefits will ensure an informed decision about drug choice.

Awareness of the obesity epidemic is increasing among the healthcare community as a whole but I believe there is still a gap in education about these known contributors to obesity, particularly drug-induced weight gain. Education and awareness go a long way. In my practice, we have a handout for patients to share with their primary care and other physicians outlining which drugs have been associated with weight gain or weight loss hindrance. I also believe in fostering good communication with the patient’s other physicians because getting everyone on the same page can only improve care.

Sincerely,

Christopher Still, DO, FACN, FACP

References
1.    Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(2):342–362.
2.    Ness-Abramof RApovian CM. Drug-induced weight gain. Drugs Today (Barc). 2005;41(8):547–555.
3.    Black C, Donnelly P, McIntyre L, Royle P, Shepherd JJ, Thomas S. Meglitinide analogues for type 2 diabetes mellitus. Cochrane Database of Systematic Reviews. 2007, Issue 2. Art. No.: CD004654.
4.    Domecq JP, et al. Clinical review: Drugs commonly associated with weight change: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100(2):363–370.

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