American College of Physicians: Internal Medicine — Doctors for Adults ®

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Weight loss drugs: Give your patients facts, not lectures

Addressing the pros and cons of medications may be the best way to get patients on track for lifestyle changes

From the June ACP Observer, copyright 2005 by the American College of Physicians.

By Janet Colwell

SAN FRANCISCO—One-half of the standing-room only crowd of physicians attending an Annual Session program on obesity management raised their hands when asked if they'd recently prescribed a weight loss drug. But when the facilitator asked if their patients had been requesting such drugs, nearly everyone's hand shot up.

Despite tough problems with managing obesity, many physicians still avoid pharmaceutical options, said session co-leader Daniel H. Bessesen, MD, associate professor of medicine at Denver's University of Colorado Health Sciences Center and chief of endocrinology at the Denver Health Medical Center. Common reasons, he said, include cost, potential side effects and physicians' ingrained skepticism about the drugs' effectiveness. Some physicians simply tell patients there's no "magic pill" to substitute for diet and exercise.

But advocating lifestyle changes—when the patient has already tried and failed that course many times—may be unproductive, said Dr. Bessesen.

Most obese patients, he said, have already tried so many commercial weight loss programs and meal replacements that they've given up hope on dieting and want to try a medication. Regardless of how you feel about weight loss drugs, "Do you spend the remaining few minutes of the visit talking about diet or drugs?"

Drugs are "what the patient wants to know about," Dr. Bessesen said. "If you don't discuss these medications honestly, chances are they will continue to hope that a pill is the key to weight loss."

Addressing the benefits and drawbacks of medications, he said, "may be the fastest way to get them back on track and start thinking about diet and exercise again."

Drug options

The drugs most commonly prescribed—the newer orlistat and sibutramine, and the older, cheaper phentermine—have been shown to result in a modest weight loss of between 5% and 8%, he said. However, patients typically regain that weight once they stop taking a drug, causing a dilemma for physicians worried about the lack of long-term safety data.

According to the ACP guideline issued earlier this year on the pharmacologic and surgical management of obesity, current data support the use of medications for three months. One study showed that orlistat proved effective and safe after four years, but there are no long-term data on side effects or on whether the drugs reduce morbidity or mortality from obesity-related conditions. (Also see "A guide to selecting treatment.")

Knowing this, is it unethical for a physician to recommend long-term use?

You need to make that decision on a case-by-case basis, Dr. Bessesen said, taking into account a patients' tolerance of side effects and whether the medication has helped them. Clinical studies have shown that sibutramine can raise blood pressure to an excessive degree in less than 1% of patients, and can also cause dry mouth, constipation, insomnia and dizziness. People using orlistat, added Dr. Bessesen, should take a daily multivitamin to prevent nutritional deficiencies.

Clinicians need to realize that other medications can negate the drugs' effects and even promote weight gain. Those include anti-diabetic medications such as insulin; mood stabilizers and antipsychotics; birth control pills, especially medroxyprogesterone acetate (Depo Provera); and glucocorticoids, especially prednisone.

The cost factor

Weight loss drugs can cost between $40 and $120 a month, and often aren't covered by insurance. That makes cost a legitimate concern—and that's why physicians prescribe phentermine, the cheapest approved drug, about twice as often as other medications.

If you prescribe phentermine, make sure you address the lack of data on its long-term safety and efficacy, noted Dr. Bessesen. While it is FDA-approved for only three months, many physicians prescribe phentermine for longer periods, he said, after discussing the ethical issues of an "off label" approach.

Another option is intermittent use, he said. Patients can take breaks from a medication, then resume therapy if their weight drifts up or when they expect to have trouble sticking to a diet and exercise regimen, such as during vacations or important social events.

While the list of medications for obesity is short, physicians will likely have more options in the near future, he added. For example, rimonabant—another drug that, like sibutramine, controls appetite—is in clinical trials and may be approved within the next year. In early trials, 62% of participants taking the drug maintained a 5% weight loss after two years, compared with 33% of those on placebo.

When considering whether to prescribe, remember that how you present the pros and cons can influence patients.

"Just present the facts," advised Dr. Bessesen. "The issue of whether a side effect offsets the benefit of a medication is something the patient should decide."

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