Now that you understand how obesity happens, and what you can do to manage it, it’s time to address the medical side of things. In today’s post we will go over all the options medically available to help with weight loss.
Note: If 5% weight loss is not achieved after 12 weeks of a medication at a maximum tolerated dose, an alternative medication should be recommended.
Pharmacotherapy with anti-obesity medications such as glucagon-like peptide-1 receptor agonists, sympathomimetics, and others should be considered for any patient with a BMI of 30 kg per m2 or greater and for any patients who are overweight (i.e., BMI of 27 kg per m2 or greater) with metabolic comorbidities.
Commercially available weight loss medications:
Saxenda (Liraglutide):
Medication class: Glucagon-like peptide- 1 receptor agonist
Expected weight loss: 7% to 8% of total body weight
Contraindications or interactions: personal or family history of medullary thyroid cancer, MEN2, do not use with sulfonylurea medications
Side effects: constipation, abdominal pain, dizziness, fatigue, headache, low blood sugar, nausea, vomiting, increased lipase (a pancreatic enzyme in your body)
Duration of treatment: long-term
Cost: $1,300 monthly (without insurance)
Wegovy (Semaglutide):
Medication class: Glucagon-like peptide- 1 receptor agonist
Expected weight loss: 15% to 16% of total body weight
Contraindications or interactions: personal or family history of medullary thyroid cancer, MEN2, do not use with sulfonylurea medications, lower other diabetes medications
Side effects: constipation, abdominal pain, dizziness, fatigue, headache, low blood sugar, nausea, vomiting, increased lipase (a pancreatic enzyme in your body), acute inflammation of the pancreas, acute inflammation of the gallbladder
Duration of treatment: long-term
Cost: $1,300 monthly (without insurance)
Zepbound (Tirzepatide):
Medication class: Glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist
Expected weight loss: 22%-23% of total body weight
Contraindications or interactions: : personal or family history of medullary thyroid cancer, MEN2, do not use with sulfonylurea medications, lower other diabetes medications
Side effects: Nausea, vomiting, diarrhea, constipation, acid reflux, abdominal pain, gallbladder problems, low blood sugar
Duration of treatment: long-term
Cost: $1000 monthly (without insurance)
Alli or Xenical (Orlistat):
Medication class: lipase inhibitor (blocks digestion of dietary fat)
Expected weight loss: 5% of total body weight
Contraindications or interactions: may decrease absorption of cyclosporine, warfarin, birth control pill, anti-seizure medications, thyroid medication, sluggish gallbladder
Side effects: fecal incontinence, fatty stools, flatulence, risk of severe liver injury, increased risk of gallstones and kidney stones, decreased absorption of fat soluble vitamins (A,D,E,K)
Duration of treatment: long-term
Cost: $280
Contrave (Bupropion/Naltrexone):
Medication class: antidepressant/opioid antagonist
Expected weight loss: 5% to 6% of body weight
Contraindications or interactions: do not use with uncontrolled high blood pressure, seizure disorder, drug or alcohol withdrawal, opioids
Side effects: nausea, constipation, headache, vomiting, dizziness, insomnia, dry mouth, diarrhea
Duration of treatment: long-term
Cost: $200
Phenterimine:
Medication class: stimulant
Expected weight loss: 5% to 12% of total body weight
Contraindications or interactions: avoid use with uncontrolled high blood pressure, seizure, glaucoma, history of heart disease, overactive thyroid
Side effects: headache, high blood pressure, rapid heartbeat, tremor, overstimulation
Duration of treatment: 12 weeks (though can be used longer) in patients with low risk for heart disease
Cost: $10
Qsymia (Phenterimine/Topiramate):
Medication class: stimulant/antiseizure medication
Expected weight loss:
Contraindications or interactions: 10% of total body weight
Side effects: avoid use with alcohol, increased risk of low potassium with diuretic medications
Duration of treatment: long-term
Cost: $170
A moment for the GLP-1 and GIP because they are everywhere:
Mechanism of action:
GLP-1 and GIPs are certainly having a moment in weight management, and the data is promising. However, they are not free of side effects and no medication will be effective without dietary and lifestyle changes.
When using a GLP-1 a GIP or really any weight loss medication you must focus on protein consumption to help maintain muscle mass. As you lose weight you will lose both muscle and fat. As we’ve previously discussed, losing weight will decrease your basal metabolic rate (calories you need to sustain yourself) and may also result in metabolic adaptation. We also discussed that muscle is more metabolically active than fat, meaning that losing muscle would be far more detrimental to your basal metabolic rate than losing fat alone. To help combat or minimize this effect: be sure to engage in weightlifting to help maintain or build muscle and focus on protein consumption to support muscle growth.
According to the AAFP “Data from a study of semaglutide found that participants regained two-thirds of their original weight lost 1 year after discontinuation, whereas another study demonstrated sustained weight loss over 4 years, highlighting the need for long-term management.”
Does this mean that patient’s starting weight loss drugs are going to need them forever?
It depends! Obesity does require long-term management. For many patients this will mean a combination of medication, nutritional and lifestyle changes. For others, perhaps their journey will include the use of weight loss medications at some point, but with a commitment to dietary and lifestyle changes, their own person genetics and the degree to which external factors impact their ability to maintain weight loss (see my previous posts); they may gradually be able to discontinue medications, or as is recommended with all medications, be on the lowest effective dose.
When discussing medical treatment options for obesity, the topic would not be complete without the inclusion of bariatric surgery. I will not go into details in this post, though I will mention that there are 4 main surgical procedures including- laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, and duodenal-ileal bypass with sleeve.
Below is a chart with recommendations for when bariatric surgery should be considered.
“A 2020 meta-analysis found that bariatric surgery was associated with lower all-cause mortality and a decreased risk of developing several common obesity-related conditions. Similarly, in a 5-year follow-up study, bariatric surgery was more effective than medical treatment for resolving hyperglycemia in patients with type 2 diabetes.”1
“Contraindications to bariatric surgery include an increased risk for surgical complications, inflammatory bowel disease, gastric ulcer, gastrointestinal motility disorder, current pregnancy, planned pregnancy in the next 2 years, alcohol or substance use disorder, uncontrolled depression, psychosis, or eating disorder, and being unable to engage with lifestyle changes.”2
Hopefully this has provided some clarity around medical weight loss options.
Sincerely,
Corsano MD- your friendly neighborhood PCP
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