Background

• Overweight is defined of a BMI: 25-29.9, and obese BMI >= 30 kg/m2; Normal BMI: 18.5- 24.9.
• Overweight puts a person at risk for coronary artery disease, hypertension, stroke, DM.
• Drugs cause weight gain: antipsychotics (risperidone, quetiapine, clozapine/olanzapine), DM drugs (insulin, SU, meglitinides, TZDs), divalproic acid, Li, mirtazepine, steroids.
• Drugs cause weight loss: CNS stimulants (ADHD drugs), DM drugs (GLP agonists/ pramlintide, SGLT inhibitors, metformin,), topiramate.

OTC treatments

• Ephedra alkaloid, bitter orange, caffeine, yerba mate, guarana, green tea.
• Should not be recommended to patient with cardiovascular (CV) risk
• Alli （orlistat OTC, 60mg with each meal: tolerability problems (GI, flatulence), Loss of 5-lbs in 6-mos; take with a healthy meal low in fat in order to reduce GI side effects.

RX treatment

• Only indicated in BMI >= 30, or > 27 with one health complications such as DM, HTN or dyslipidemia. Avoid all weight loss drugs in pregnancy.
• Older CNS stimulants (Phentermine, diethylpropion, sibutramine) are used short term (3-4 weeks) to jump start a diet.
• Newer agents are used for maintenance: Contrave, Belviq, Qsymia, Saxenda, Orlistat. Discontinue if they do not produce >5% weight loss at 12 weeks.
• Bariatric surgery: for BMI >40, or >35 with obesity-related condition.

Long term drugs

• Orlistat (Xenical), bupropion/naltrexone (Contrave), lorcaserin (Belviq), phentermine/topiramate (Qsymia), liraglutide (Saxenda).  
• Orlistat MOA: lipase inhibitor, ↓ absorption of dietary fat by 30%; SE: GI (flatulence, fecal urgency, fatty stool); must be use with a low fat diet, 120mg with each meal containing fat; supplement with fat-soluble vitamins A, D, E, K and beta carotene.
• Naltrexone: reduce food craving, blocks opioid receptors (avoid in patients taking opioids); bupropion: ↓appetite, avoid in uncontrolled HTN, young adults (suicidal risk), seizure disorder (lower SZ threshold), bulimia/anorexia.
• Topiramate: ↑satiety, ↓appetite possibly by ↑GABA ↓glutamate. Qsymia is a REMS drug due to teratogenic risk, must be taper off slowly (topiramate).
• Lorcaserin: 5HT-2 receptor agonist ↑satiety, contraindicated in pregnancy, warnings: serotonin syndrome, priapism, hypoglycemia. A C-IV drug.
• Liraglutide: GLP receptor agonist ↑satiety; a REMS drug (pancreatitis, thyroid carcinoma), warnings: hypoglycemia; primary SE: nausea.

Short term appetite suppressants C-IV

• Drugs: Phentermine (Adipex-P), Diethylpropion, benzphetamine, phendimetrazine
• MOA: sympathomimetic, release of norepinephrine stimulates satiety center which ↓appetite.
• SE: think about CNS stimulant effects (tachycardia, ꝉ BP, weight loss, tremor, agitation, suicidal thoughts), constipation, dry mouth.
• Contraindication: CV diseases (uncontrolled HTN), hyperthyroidism, narrow angle glaucoma, history of drug abuse (C-IV).
• Short term use up to 12 weeks, to jump start a diet.

 

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