FROM THE JOURNAL OF CLINICAL ENDOCRINOLOGY AND METABOLISM
For the first time, a task force of experts has assembled clinical practice guidelines dedicated to the medical treatment of obesity.
The development, spearheaded by the Endocrine Society with support from the Obesity Society and the European Society of Endocrinology, comes after four new anti-obesity drugs hit the market in the past 2 years: lorcaserin (Belviq), phentermine/topiramate (Qsymia), naltrexone/bupropion (Contrave) and liraglutide (Saxenda). The new guidelines expand on guidelines for managing overweight and obesity in adults that were released in 2013 by the Obesity Society, the American Heart Association, and the American College of Cardiology.
“Medications used for the management of conditions other than obesity can contribute to or exacerbate weight gain in susceptible individuals,” the eight-member task force wrote online Jan. 15 in the Journal of Clinical Endocrinology and Metabolism ( doi:10/1210/jc.2014-3415 ).” Many of these conditions are also associated with obesity. Health care providers can help patients prevent or attenuate weight gain by appropriately prescribing medications that would promote weight loss or minimize weight gain when treating these conditions.”
The task force, chaired by Dr. Caroline M. Apovian professor of medicine at Boston University, recommends that diet, exercise, and behavioral modifications be part of all obesity management approaches. “Drugs may amplify adherence to behavior change and may improve physical functioning such that increased physical activity is easier in those who cannot exercise initially,” they wrote. “Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight-loss medications.”
Another recommendation based on high-quality evidence is that if a patient responds well to a weight-loss medication and loses 5% or more of his or her body weight after 3 months, the medication should be continued. If the medication is ineffective or the patient experiences side effects, “we recommend that the medication be discontinued and alternative medications or referral for alternative treatment approaches be considered the prescription should be stopped and an alternative medication or approach considered.”
In a recommendation based on moderate quality evidence, the task force suggests that patients with diabetes who are obese or overweight should be given medications that promote weight loss or have no effect on weight as first-and second-line treatments. “In obese patients with T2DM requiring insulin therapy, we suggest adding at least one of the following: metformin, pramlintide (Symlin), or GLP-1 (glucagonlike peptide-1 receptor) agonists to mitigate associated weight gain due to insulin,” they noted.
Furthermore, the task force advises that ACE inhibitors, angiotensin receptor blockers, and calcium channel blockers should be used as a first-line treatment for high blood pressure in obese people with type 2 diabetes.
The task force also recommends that when patients need medications that can have an impact on weight, such as antidepressants, antipsychotic drugs, and medications for treating epilepsy, they should be fully informed and provided with estimates of each option’s anticipated effect on weight. Clinicians and patients should engage in a shared-decision making process to evaluate the options.
Another recommendation is that phentermine and diethylpropion (Tenuate) should not be used in patients with uncontrolled high blood pressure or a history of heart disease.
“Although there is abundant evidence for the value of shared decision making across several clinical scenarios, specific evidence for obesity management is scant,” the task force members acknowledged. “This highlights a limitation of the existing literature and poses a challenge for implementing a specific strategy for shared decision making in managing obesity.”
The Endocrine Society funded development of the guidelines. Dr. Apovian disclosed that she has a financial and/or leadership position with Zafgen, MYOS Corp., Eisai, Vivus, Orexigen Therapeutics, and Takeda. Other members of the task force disclosed numerous relevant financial conflicts.