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What You Should Know About Weight Loss Drugs

November 28, 2017 No Comments by Scott Isaacs, M.D.

If you have adiposity you are not alone. The disease of obesity affects more than 93 million Americans, and the numbers continue to increase. Plus, a number of other conditions associated with obesity such as type 2 diabetes, high blood pressure, sleep apnea, arthritis, heart, lung and liver disease and more are on the rise. These conditions greatly impact a person’s quality of life and overall health, both physically and mentally.

However, treating obesity can be a challenge. If you are overweight or obese, you probably know how difficult and frustrating weight loss efforts can be.

It is very difficult to achieve long-term weight loss from diet and exercise alone. In fact, most patients who lose weight on a diet gain back most or all the weight within a few years. Even with intensive exercise, long-term weight loss is difficult to maintain. What few understand is that weight regain occurs because of adaptive changes in the hormones that regulate appetite and metabolism. When you lose weight, your hormones change to increase appetite and lower metabolism, driving weight back up. These metabolic changes persist for years.

The hormonal regulation of appetite is very strong. Willpower alone is not sufficient to overcome these biological drives. Thus, medications are increasingly being used because they can help overcome some of the biological changes that drive appetite. And there are more obesity medications available today than ever before.

This can be empowering, but also intimidating and confusing. Therefore, here are important things you need to know about prescription weight-loss medications and their role in helping you succeed in losing weight.

Weight-Loss Medications Require a Healthy Lifestyle

Taking a medication for weight loss means committing yourself to long-term lifestyle changes. Lifestyle modification is the cornerstone of any weight-loss program and includes:

  • A healthy, reduced-calorie meal plan
  • Physical activity
  • Self-monitoring
  • Adequate sleep
  • Stress reduction

For most people, weight loss can be achieved with a 1,200-1,400 calorie-per-day meal plan. You can work with your physician or dietitian for more precise calorie recommendations based on your individual requirements. Studies have shown that the makeup of the diet is less important than sticking to the diet, so it is recommended you follow a common-sense, reduced calorie meal plan that you can stick to for the long term. For example, a strict vegan diet may work for some people, but for others, the rigidity of the diet can cause feelings of deprivation and rebound cravings or even binge eating. Try to have regular meal times and make meals a family affair – socialize, discuss the day’s events, make the shared meal an enjoyable activity for all.

Physical activity is also a critical component of any weight loss program. Without physical activity, you can still lose weight on a low-calorie meal plan, but for every 10 pounds you lose, three will be muscle. However, with regular physical activity, for every 10 pounds you lose, only one is muscle. A minimum of 150 minutes of moderate intensity physical activity is recommended each week. Resistance training with weights or bands may be added in. Start slow and gradually, and increase the duration and the intensity of the activity. Schedule physical activity on your calendar like you would other important tasks. And ask a friend or your spouse to exercise with you.

Examples of moderate intensity physical activity include:

  • Brisk walking
  • Bike riding
  • Swimming
  • Active play with children
  • Housework
  • Yardwork

Self-monitoring with food and exercise logs, regular self-weighing and using tech gadgets such as pedometers and activity monitors can help modify behaviors that contribute to weight loss. Even though weight loss is more complicated than calories in and calories out, these gadgets are useful tools that help you better understand your own body.

Adequate sleep is also crucial to achieve effective weight loss. You should aim for seven to nine hours of restful sleep each night. If you have excessive daytime sleepiness, you should discuss the possibility of having sleep apnea with your physician. Effective sleep apnea diagnosis and treatment aids in weight loss, which then improves sleep apnea symptoms.

Stress reduction is also an important component of any weight loss program, so don’t be afraid to ask for help. Support from friends and family is vital for helping you stay on track. The more support you have the more likely you’ll succeed.

It’s important that you don’t expect to change your behaviors overnight by keeping focused on long-term results, making small but gradual changes to improve your daily routine. It will take time, but as you stick with your lifestyle changes, you will see your weight and health improve. This can be highly motivating to keep the weight loss going.

The Lowdown on Medication-Assisted Weight Loss

Medications for weight loss can be considered when lifestyle modification does not produce acceptable weight loss or medical complications are not adequately controlled. Antiobesity medications (AOMs) are indicated for patients with obesity defined as a body mass index (BMI) above 30 kg/m2 or overweight with a BMI above 27 kg/m2 with at least one complication of excess weight such as diabetes, high blood pressure or abnormal blood lipids.

Before you decide on any weight-loss medication, it is important to work with your healthcare team to decide which option is best for you. Prescription weight-loss medications work by helping you eat fewer calories. These medications work on the appetite and reward centers of the brain to reduce hunger and cravings and to increase the feeling of fullness as you eat.

Currently, there are eight medications approved by the Food and Drug Administration (FDA) for weight loss. They are:

  • Phentermine (Adipex-P®, Suprenza®)*
  • Phendimetrazine (Bontril®)*
  • Benzphetamine (Regimex®, Didrex®)*
  • Orlistat (Xenical®, alli®)†
  • Phentermine and Topiramate ER (Qsymia®)†
  • Lorcaserin HCL (BELVIQ®)†
  • Naltrexone HCl and Bupropion HCl (CONTRAVE®)†
  • Liraglutide injection (Saxenda®)†

*Approved for short-term use
†Approved for long-term (chronic) use

Although everyone hopes for a magic weight-loss pill, medications only work when combined with a reducedcalorie meal plan and increased physical activity. These medications are not a substitute to lifestyle modification, but rather a tool to enhance these measures. Taking a medication without lifestyle changes does not result in successful weight loss. It should also be noted that none of the AOMs should be taken while pregnant.

Weight-Loss Medications for Short-Term Use

Approved for short-term use several decades ago, phentermine, phendimetrazine and benzphetamine are weight-loss medications that contain a mild stimulant that is like an amphetamine and work on chemicals in the brain to decrease appetite. These medications can be taken once or several times a day depending on the formulation. Tolerance usually develops after a few months, resulting in an increased appetite and cessation of weight loss. Thus, it is prudent to have a plan for ongoing weight loss or weight maintenance, such as changing to an AOM approved for chronic use, as regaining weight is typical once these medications are discontinued.

These older AOMs are typically used for 12 weeks, although some patients may experience increased weight loss by prolonging the treatment by taking the medication every other day for 24 weeks. Side effects of these AOMs can include an increase in blood pressure and heart rate as well as insomnia, dry mouth, anxiety and agitation. These medications cannot be used if you have certain heart conditions, uncontrolled high blood pressure, a history of stroke, glaucoma (increased eye pressure), or an overactive thyroid. Consequently, you must be monitored closely by a healthcare professional who has experience prescribing these medications.

Medications for Long-Term Use

Since obesity is a chronic disease, the up-to-date approach to AOMs is to treat them like any other medication used to treat a chronic disease. This means that AOMs are intended for long-term chronic use.

The newer anti-obesity medications result in an average weight loss of 5 to 15 percent from the patient’s starting body weight over 6 to 12 months, with weight maintenance if the medication is continued. If the AOM is discontinued, patients tend to gain back the weight that was lost while taking the medication.

Weight loss should be assessed after taking the full dose of an AOM for 12 weeks. It is recommended that the medication be discontinued if at least a 5 percent weight loss has not been achieved at this point, as additional meaningful weight loss is unlikely. An alternative AOM can be substituted, as a person’s response to one AOM may not predict the response to another due to different mechanisms of action. Due to lack of data, combining AOMs is not recommended, with some exceptions discussed below. If a 5 percent weight loss has been achieved and there are no unacceptable adverse reactions, then the same AOM should be continued long-term.

Orlistat (Xenical®, alli®)

Xenical® and the lower potency over-the-counter version alli® contain the medication orlistat. This medication comes as a capsule that is taken before each meal and works by blocking the absorption of about one-third of fat in the meal. This fat gets passed out of the digestive tract in the stool. Orlistat is the only AOM that does not work by decreasing appetite. Side effects of orlistat include oily diarrhea, fecal leakage, cramps and gas discharge that can be avoided by consuming a high-fiber diet that contains less than 30 percent fat. People who take orlistat should take a daily multivitamin as there is potential for a deficiency of some fat-soluble vitamins.

Phentermine and Topiramate ER (Qsymia®)

The combination of phentermine and topiramate in an extended release capsule was approved by the FDA in 2012 as the first new AOM in over a decade. Topiramate is a medication that has been approved to treat seizures and migraine headaches. Weight loss is a common side effect of topiramate. Phentermine is an AOM as described above that helps to decrease appetite as well. This is an exception where two medications used in combination at relatively low doses are effective for long-term weight management.

Side effects of phentermine-topiramate ER include a metallic taste in the mouth, dry mouth, a feeling of pins and needles in the What You Should Know About Weight-Loss Drugs (Continued from page 5) EMPOWERYOURHEALTH.ORG 7 extremities, constipation, insomnia, memory loss and fatigue. This medication also has an interesting side effect of making soda taste flat due to the chemical properties of topiramate. Women of childbearing age must use at least one reliable form of contraception and should have a negative pregnancy test before starting the medication and should have monthly negative pregnancy tests while continuing phenterminetopiramate ER, as it is known to cause birth defects.

Lorcaserin HCl (BELVIQ®, BELVIQ XR®)

Lorcaserin is known as a selective 5-HT2C (serotonin) receptor agonist that works on brain chemicals to decrease appetite and help you feel full while eating less. Side effects of lorcaserin include headache, dizziness, fatigue, dry mouth and nausea. Among all the AOMs, lorcaserin has the lowest incidence of side effects and is thought to be the safest for patients with a history of heart disease. Because lorcaserin is a serotonin medication, other serotonin medications such as SSRI antidepressants (fluoxetine, sertraline, citalopram, etc.) and triptan migraine medications should not be combined with lorcaserin, or should be used with very close supervision due to a theoretical risk of a severe side effect known as serotonin syndrome, which occurs when you take medications that cause high levels of the chemical serotonin to accumulate in your body. Symptoms can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever and seizures). Severe serotonin syndrome can be fatal if not treated.

Naltrexone HCl and Bupropion HCl (CONTRAVE®)

CONTRAVE® is also a combination of two medications that have been approved for other uses since the 1980s. Naltrexone is a medication used to treat alcohol and opioid dependency. Bupropion is used as an antidepressant and for helping people to stop smoking. The combination of these two medications work synergistically to reduce appetite and cravings. Side effects include nausea, constipation, headache, dry mouth, vomiting, anxiety and dizziness. There is a potential for elevated blood pressure and heart rate. Those with uncontrolled high blood pressure and a history of a seizure disorder should not take the medication. Because naltrexone blocks the body’s opioid receptor, use of opioid pain medications along with CONTRAVE is inadvisable, as the combination prevents these medications from working properly and may cause withdrawal symptoms.

Liraglutide injection (Saxenda®)

Liraglutide is an injectable medication that is a synthetic version of a hormone that works in the brain to reduce appetite and make you feel full. Liraglutide is also marketed at a lower dose under the name Victoza® for the treatment of type 2 diabetes. Liraglutide increases natural production of insulin and decreases release of the anti-insulin hormone glucagon in response to food intake. The most common side effects are nausea, vomiting, abdominal pain, diarrhea and constipation.

Medication Follow-Up

When on an AOM, frequent visits to your physician (every four weeks) are recommended for the first 12 weeks and every three months thereafter. Frequent visits with a healthcare professional provide better weight-loss results through increased support, accountability and individualized medication management. Since obesity is a chronic, lifelong problem, continued periodic follow-up is advised.

The best weight-loss results are achieved when AOMs are combined with intensive lifestyle modification. The major benefit of weight loss is improvement of diseases caused by obesity such as diabetes, high blood pressure, abnormal blood lipids and heart disease, which can be seen with as little as 5 percent weight loss.

It’s important to keep in mind that AOMs are not a magic bullet, but simply a tool to help you sustain commonsense lifestyle changes. There is no perfect medication for obesity. A medication that may work for a family member or a friend may not be the ideal medication for you. Treating obesity can be complicated, so it is best to work with a knowledgeable healthcare professional who is dedicated to working with you over the long term.

by Scott Isaacs, MD

See the original article here

To learn more about Atlanta Endocrine Associates please visit: www.atlantaendocrine.com

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