Choosing the Right Weight Loss Medication for Your Patient Requires Careful Consideration

| December 1, 2015

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. Dr. Still is also a board member of the Obesity Action Coalition, Tampa, Florida.


Dear Readers,
Welcome to the December issue of Bariatric Times. It is hard to believe that I have served as Clinical Co-Editor for Bariatric Times for almost a whole year. I have thoroughly enjoyed communicating with you via the monthly editorial message and am looking forward to welcoming a wonderful new year. Bariatric Times has some exciting plans for 2016.

I’m pleased to announce that, starting in January 2016, Tracy Martinez, RN, BSN, CBN, Program Director, Wittgrove Bariatric Center, La Jolla, California, will serve as Integrated Health Section Editor. Tracy is not only a colleague, but also a dear friend of mine. I know she will do great in this role, engaging our IH professionals who remain a crucial element to the multidisciplinary care team. Welcome aboard, Tracy!

This month, I would like to discuss a topic I brought up in a previous editorial: matching a patient with the right weight loss medication given his or her risk, medical history, and preferences.
Currently, there are five FDA-approved pharmacotherapy options for the treatment of obesity:
•    phentermine (and other noradrenergic agents)
•    orlistat (Xenical, Genentech USA, Inc., South San Francisco, California, and Alli, GlaxoSmithKline, Research Triangle Park, North Carolina)
•    phentermine/topiramate extended release (Qsymia, Vivus, Inc., Mountain View, California)
•    lorcaserin (Belviq, Arena Pharmaceuticals GmbH, Zofingen, Switzerland)
•    bupropion sustained release/naltrexone sustained release (Contrave, Takeda Pharmaceuticals America, Inc., Deerfield, Illinois)
•    liraglutide [rDNA origin] injection (Saxenda, Novo Nordisk, Plainsboro, New Jersey)

Expected weight loss for all of these available medications is between 5 and 10 percent.[1] Although it is obviously a main priority, weight loss isn’t the only factor in choosing medication. The provider should also carefully consider three important areas: drug factors, patient factors, and physician factors.

Drug Factors. Drug factors include thorough consideration of a drug’s contraindications or cautions, potential additional health benefits (dual benefit) to the patient, and data in studied patient populations. For instance, phentermine is contraindicated for patients with uncontrolled hypertension[2,3] and naltrexone SR/bupropion SR should be avoided in a patient with a seizure disorder.[4] Lorcaserin should be used with caution in patients who are already taking selective serotonin re-uptake inhibitors (SSRIs) because lorcaserin is serotonergic agonist that can affect the same pathways as SSRIs.[5]

If a patient presents with a history of smoking, I might consider naltrexone SR/bupropion SR because it may help the patient not only lose weight, but also quit smoking even though it is not explicitly approved for smoking cessation. For a patient with type 2 diabetes mellitus, I might consider lorcaserin or liraglutide [rDNA origin] injection as they have been shown to help lower hemoglobin A1c (HA1c).[6,7] Phentermine/ topiramate ER would be at the top of the list when treating a patient with obesity who also suffers from migraines.

Patient factors. Patient factors include patient preferences. For instance, one patient might be comfortable with an injectable medication while another may prefer to take a pill. It’s important to have a thorough conversation and listen to what patients want. Do they feel confident that they will remember to take a pill twice a day? Do any of the options have potential adverse events that he or she should avoid due to medical history or prior experience with similar treatments? Lastly, consider which medication is the best option given the patient’s insurance coverage. Some companies offer providers samples and coupons, so do the research and utilize available resources.

Physician factors. Physician factors include provider knowledge and comfort, which tie into the drug factors. Providers should be knowledgeable of ALL available treatment options for obesity, including pharmacotherapy. Education leads to a better understanding of the medications and thus, a higher comfort level in prescribing the right medication.

Obesity is a complex disease and just like with surgery, diet, and exercise, pharmacotherapy is not “one size fits all.” Different patients respond to different medications, so if one option doesn’t work well, providers should consider others.

Treatment of obesity with pharmacotherapy as an adjunct to lifestyle modification is a valuable option for obesity treatment. I believe that the recipe for success with pharmacotherapy is the same as with diet, lifestyle modification, and weight loss surgery: do your best to match the patient with the right treatment modality and then help to manage his or her expectations.

May you all have a blessed and safe holiday!

Cheers!
Christopher Still, DO, FACN, FACP

References
1.    Powell AG, Apovian CM, Aronne LJ. New drug targets for the treatment of obesity. Clin Pharmacol Ther. 2011;90(1):40–51.
2.    Phentermine [package insert]. Cranford, New Jersey: Alpex Pharma SA: 2011.
3.    Munro JF, MacCuish AC, Wilson EM, Duncan LJ. Comparison of continuous and intermittent anorectic therapy in obesity. BMJ. 1968;1:352–354.
4.    Contrave (naltrexone HCL and bupropion HCL) extended-release tablets [package insert]. Deerfield, Illinois and La Jolla, California: Takeda/Orexigen; 2014.
5.    Gustafson A, King C, Rey JA. A selective serotonin 5-HT2C agonist in the treatment of obesity. P T. 2013;38(9):525–534.
6.    Smith SR, Weissman NJ, Anderson CM, et al. Multicenter, placebo-controlled trial of lorcaserin for weight management.N Engl J Med. 2010;363:245–256.
7.    Pi-Sunyer X, Astrup A, Fujioka K, et al. A randomized, controlled trial of 3.0 mg of liraglutide in weight management. N Engl J Med. 2015;373:11–22.

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