By Megan Brooks
(Reuters Health) - Anti-obesity medications and surgery can be helpful adjuncts to lifestyle change for obese patients who have failed to lose weight with diet and exercise alone, obesity experts say in a new guideline.
The guideline notes that many medications used for comorbid conditions such as diabetes, depression, and other chronic diseases have weight effect and advises clinicians to choose those with favorable weight profiles to help manage obesity, when possible.
"The take-home message is treat obesity first, then treat comorbidities," Dr. Caroline Apovian, of the Nutrition and Weight Management Center at Boston Medical Center in Massachusetts, and chair of the guideline task force, told Reuters Health by email.
Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline is endorsed by the Obesity Society (TOS) and the American Society for Metabolic and Bariatric Surgery.
The guideline was published online January 15 and will appear in the February 2015 print issue of the Journal of Clinical Endocrinology and Metabolism.
Why now? Dr. Apovian said we are at a "tipping point" with increased recognition that "obesity is a chronic disease that needs to be treated."
Obesity is now recognized as a disease by the American Medical Association (AMA), the Centers for Medicare & Medicaid Service (CMS) now covers visits for obesity management for a primary care physician, and the obesity medicine certification program is up and running, "and certifying over 200 MDs per year," she noted.
In addition, the U.S. Food and Drug Administration (FDA) has approved four new anti-obesity drugs in the past two years that can be used in combination with diet and exercise to help people who are obese lose weight. They are bupropion/naltrexone (Contrave), liraglutide (Saxenda), phentermine/topiramate (Qsymia), and lorcaserin (Belviq).
Therefore, "we need guidelines for doctors for use of the medications and for how to treat obesity," Dr. Apovian said.
The guideline says diet, exercise, and behavior change should be part of all obesity management approaches.
As adjunctive therapy when needed, the guideline endorses FDA-approved weight-loss drugs for people with a body mass index (BMI) of 30 kg/m2 or higher or BMI of least 27 kg/m2 with one or more comorbid conditions. The guideline recommends bariatric surgery at a BMI over 40 kg/m2 or at least 35 kg/m2 with comorbidity.
If a patient responds well to a weight-loss drug and loses at least 5% of their body weight after three months, the medication should be continued, the guideline says. If the medication is not effective or the patient has side effects, the medication should be stopped and an alternative medication or approach considered.
The guideline also encourages "knowledgeable" prescribing of medications for comorbid conditions in obese patients.
Since some diabetes medications are associated with weight gain, people 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, the guideline advises. Doctors should discuss medications' potential effects on weight with patients.
It recommends that angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers be used as a first-line treatment for hypertension in obese people with type 2 diabetes, as they are less likely to contribute to weight gain than beta-adrenergic blockers, the guideline notes.
Antidepressants, antipsychotic drugs, and medications for treating epilepsy can have an impact on weight, and patients should be fully informed and provided with estimates of each option's anticipated effect on weight, the guideline says. It encourages doctors and patients to engage in a shared decision-making process to evaluate the options.
In patients with uncontrolled hypertension or a history of heart disease, the medications phentermine and diethylpropion should not be used, the guideline says.
The guideline advises against the off-label use of medications approved for other diseases for the sole purpose of producing weight loss, with one caveat. "A trial of such therapy can be attempted in the context of research and by healthcare providers with expertise in weight management dealing with a well-informed patient."
Currently in the U.S., an estimated 34% of adults are overweight, 35% are obese, and roughly 6% are extremely obese. "Weight loss is a pathway to health improvement for patients with obesity-associated risk factors and comorbidities," the guideline writers note.
The authors report no disclosures.
J Clin Endocrinol Metab 2015.