Guidelines define an adjunctive role for weight loss and other prescription medications in obesity management
Knowledgeable prescribing of weight loss medications, and choosing other necessary prescription medications with favorable weight profiles, can aid in the prevention and management of obesity and can be useful for patients who have been unsuccessful with diet and exercise alone, according to a clinical practice guideline.
Knowledgeable prescribing of weight loss medications, and choosing other necessary prescription medications with favorable weight profiles, can aid in the prevention and management of obesity and can be useful for patients who have been unsuccessful with diet and exercise alone, according to a clinical practice guideline.
The Clinical Guidelines Subcommittee of the Endocrine Society appointed a task force to create clinical practice guidelines for the pharmacological management of obesity. The guideline focused on use of medications as an adjunct to lifestyle change therapy to promote weight loss and maintenance. It also addressed how prescribers can prevent weight gain when prescribing medicines associated with significant weight gain. This guideline was co-sponsored by the European Society of Endocrinology and The Obesity Society, which reviewed and commented on preliminary drafts.
The guideline was published online Jan. 15 by the Journal of Clinical Endocrinology & Metabolism.
Diet, exercise, and behavioral modification should be used to manage patients with a body mass index (BMI) of 25 kg/m2 or more, the guideline stated. Drugs may increase adherence to behavior change. Pharmacotherapy can be considered as an adjunct to behavioral modification to reduce food intake and increase physical activity in patients with a BMI over 30 kg/m2 or over 27 kg/m2 with comorbidity. Bariatric surgery can be considered for patients with a BMI over 40 kg/m2 or over 35 kg/m2 with comorbidity.
Clinicians should assess efficacy and safety of weight loss medications at least monthly for the first 3 months, then at least every 3 months. If the medication results in weight loss of 5% or more at 3 months and is safe, the medication may be continued. If weight loss is less than 5% at 3 months or if there are safety or tolerability issues, medication should be stopped and alternative medications or treatments should be considered, according to the guideline.
In overweight and obese patients with diabetes, clinicians should suggest weight-losing and weight-neutral medications as first- and second-line agents. Clinicians should discuss possible weight effects of glucose-lowering medications with patients. To offset potential weight gain due to insulin, clinicians should consider metformin, pramlintide, or a GLP-1 agonist for obese diabetic patients. Obese diabetic patients with hypertension should receive angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or calcium-channel blockers rather than beta-adrenergic blockers as first-line therapy for hypertension.
For managing weight gain associated with antidepressants, the guideline recommended a shared decision-making process that provides patients with quantitative estimates of the expected weight gain. Weight-neutral antipsychotic alternatives can be used when clinically indicated.
In women with a BMI over 27 kg/m2 with comorbidities or over 30 kg/m2, oral contraceptives are preferable over injectable options. In patients with a chronic inflammatory disease like rheumatoid arthritis, nonsteroidal anti-inflammatory drugs and disease-modifying antirheumatic drugs are preferable over corticosteroids, which commonly cause weight gain.
The guideline advised against off-label prescribing of drugs for weight loss, although such trials can be attempted by clinicians with expertise in weight management.