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JOLIN JAMESRENÉ, KWON MINSOO, BROCK ELIZABETH, CHEN JONATHAN, KOKAN AISHA, MURDOCK RYAN, STANFORD FATIMACODY. Policy Interventions to Enhance Medical Care for People With Obesity in the United States-Challenges, Opportunities, and Future Directions. Milbank Q 2024; 102:336-350. [PMID: 38332667 PMCID: PMC11176406 DOI: 10.1111/1468-0009.12693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/08/2023] [Accepted: 01/24/2024] [Indexed: 02/10/2024] Open
Abstract
Policy Points Health policymakers have insufficiently addressed care for people with obesity (body mass index ≥ 30 kg/m2) in the United States. Current federal policies targeting obesity medications reflect this unfortunate reality. We argue for a novel policy framework to increase access to effective obesity therapeutics and care, recognizing that, though prevention is critical, the epidemic proportions of obesity in the United States warrant immediate interventions to augment care. Reducing barriers to and improving the quality of existing anti-obesity medications, intensive behavioral therapy, weight management nutrition and dietary counseling, and bariatric surgery are critical. Moreover, to ensure continuity of care and patient-clinician trust, combating physician and broader weight stigma must represent a central component of any viable obesity care agenda.
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Affiliation(s)
| | | | | | | | - AISHA KOKAN
- Harvard University
- Global Health and Health PolicyHarvard University
| | | | - FATIMA CODY STANFORD
- MGH Weight CenterMassachusetts General HospitalNutrition Obesity Research Center at Harvard, Harvard Medical School
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Gilden AH, Catenacci VA, Taormina JM. Obesity. Ann Intern Med 2024; 177:ITC65-ITC80. [PMID: 38739920 DOI: 10.7326/aitc202405210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Abstract
Obesity is a common condition and a major cause of morbidity and mortality. Fortunately, weight loss treatment can reduce obesity-related complications. This review summarizes the evidence-based strategies physicians can employ to identify, prevent, and treat obesity, including best practices to diagnose and counsel patients, to assess and address the burden of weight-related disease including weight stigma, to address secondary causes of weight gain, and to help patients set individualized and realistic weight loss goals and an effective treatment plan. Effective treatments include lifestyle modification and adjunctive therapies such as antiobesity medications and metabolic and bariatric surgery.
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Affiliation(s)
- Adam H Gilden
- Anschutz Health and Wellness Center, and Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.H.G.); Anschutz Health and Wellness Center, and Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado (V.A.C.); Anschutz Health and Wellness Center, and Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado (J.M.T.)
| | - Victoria A Catenacci
- Anschutz Health and Wellness Center, and Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.H.G.); Anschutz Health and Wellness Center, and Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado (V.A.C.); Anschutz Health and Wellness Center, and Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado (J.M.T.)
| | - John Michael Taormina
- Anschutz Health and Wellness Center, and Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado (A.H.G.); Anschutz Health and Wellness Center, and Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado (V.A.C.); Anschutz Health and Wellness Center, and Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado (J.M.T.)
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Henderson K, Lewis, Sloan CE, Bessesen DH, Arterburn D. Effectiveness and safety of drugs for obesity. BMJ 2024; 384:e072686. [PMID: 38527759 DOI: 10.1136/bmj-2022-072686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Recent publicity around the use of new antiobesity medications (AOMs) has focused the attention of patients and healthcare providers on the role of pharmacotherapy in the treatment of obesity. Newer drug treatments have shown greater efficacy and safety compared with older drug treatments, yet access to these drug treatments is limited by providers' discomfort in prescribing, bias, and stigma around obesity, as well as by the lack of insurance coverage. Now more than ever, healthcare providers must be able to discuss the risks and benefits of the full range of antiobesity medications available to patients, and to incorporate both guideline based advice and emerging real world clinical evidence into daily clinical practice. The tremendous variability in response to antiobesity medications means that clinicians need to use a flexible approach that takes advantage of specific features of the antiobesity medication selected to provide the best option for individual patients. Future research is needed on how best to use available drug treatments in real world practice settings, the potential role of combination therapies, and the cost effectiveness of antiobesity medications. Several new drug treatments are being evaluated in ongoing clinical trials, suggesting that the future for pharmacotherapy of obesity is bright.
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Affiliation(s)
| | - Lewis
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Caroline E Sloan
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Daniel H Bessesen
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
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Bays HE, Hsia DS, Nguyen LT, Peterson CA, Varghese ST. Effects of phentermine / topiramate extended-release, phentermine, and placebo on ambulatory blood pressure monitoring in adults with overweight or obesity: A randomized, multicenter, double-blind study. OBESITY PILLARS (ONLINE) 2024; 9:100099. [PMID: 38304225 PMCID: PMC10831272 DOI: 10.1016/j.obpill.2024.100099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/06/2024] [Accepted: 01/06/2024] [Indexed: 02/03/2024]
Abstract
Background A fixed-dose combination of phentermine and extended-release topiramate (PHEN/TPM - approved for weight management) has demonstrated in-clinic reduction of blood pressure (BP). Ambulatory BP monitoring (ABPM) may be a better predictor of cardiovascular disease risk than in-clinic BP. Methods This randomized, multicenter, double-blind study enrolled 565 adults with overweight/obesity. Inclusion criteria included participants willing to wear ABPM device for 24 h. Exclusion criteria included screening blood pressure >140/90 mmHg and antihypertensive medications not stable for 3 months prior to randomization. Participants received placebo (n = 184), phentermine 30 mg; (n = 191), or PHEN 15 mg/TPM 92 mg; (n = 190). 24-hour ABPM was performed at baseline and at week 8. The primary endpoint was mean 24-h systolic BP (SBP) as measured by ABPM, in the per protocol population. Results Participants were mostly female (73.5 %) and White (81.6 %), with a mean age of 53.4 years; 32.4 % had no hypertension diagnosis or treatment, 62.5 % had hypertension using 0 to 2 antihypertensive medications, and 5.1 % had hypertension using ≥ 3 antihypertensive medications. Baseline mean SBP/diastolic BP (DBP) was 123.9/77.6 mmHg. At week 8, mean SBP change was -0.1 mmHg (placebo), +1.4 mmHg (phentermine 30 mg), and -3.3 mmHg (PHEN/TPM). Between-group difference for PHEN/TPM versus placebo was -3.2 mmHg (95 % CI: -5.48, -0.93 mmHg; p = 0.0059). The between-group difference for PHEN/TPM versus phentermine 30 mg was -4.7 mmHg (95 % CI: -6.96, -2.45 mmHg; p < 0.0001). Common (>2 % in any treatment group) adverse events (i.e., dry mouth, constipation, nausea, dizziness, paresthesia, dysgeusia, headache, COVID-19, urinary tract infection, insomnia, and anxiety) were mostly mild or moderate. Conclusions In this randomized, multicenter, double-blind ABPM study, PHEN/ TPM reduced SBP compared to either placebo or phentermine 30 mg (Funding: Vivus LLC; ClinicalTrials.gov: NCT05215418).
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Affiliation(s)
- Harold E. Bays
- Louisville Metabolic and Atherosclerosis Research Center, University of Louisville School of Medicine, 3288 Illinois Avenue, Louisville, KY, 40213, USA
| | - Daniel S. Hsia
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
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Lewis KH, Gudzune KA, Ard JD. Phentermine in the Modern Era of Obesity Pharmacotherapy: Does It Still Have a Role in Treatment? Curr Obes Rep 2024; 13:132-140. [PMID: 38172485 DOI: 10.1007/s13679-023-00546-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW This review provides an overview of the history, mechanism of action, and expected treatment effects of the anti-obesity medication (AOM), phentermine. It also includes a summary of recent research and practical guidance for prescribing clinicians. RECENT FINDINGS Recent research on phentermine is sparse and consists primarily of observational studies with methodologic limitations. These studies suggest that phentermine use is associated with clinically significant weight loss in adults and that the medication is generally well tolerated. Large-scale observational studies evaluating phentermine's safety have not identified an increased risk of cardiovascular events or elevations in blood pressure. There is no data to support the notion that phentermine is addictive. Although it remains the most commonly prescribed AOM in the USA, phentermine has little rigorous research to support its efficacy and safety in long-term treatment, which creates a dilemma with guideline-recommended chronic use of AOMs. While we await forthcoming conclusive data on this front, clinicians may consider using phentermine long-term in selected patients, if such prescribing is consistent with local regulatory statutes.
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Affiliation(s)
- Kristina H Lewis
- Department of Epidemiology & Prevention, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC, 27101, USA.
| | - Kimberly A Gudzune
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health Policy & Management, Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Jamy D Ard
- Department of Epidemiology & Prevention, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC, 27101, USA
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Coutinho W, Halpern B. Pharmacotherapy for obesity: moving towards efficacy improvement. Diabetol Metab Syndr 2024; 16:6. [PMID: 38172940 PMCID: PMC10763391 DOI: 10.1186/s13098-023-01233-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024] Open
Abstract
Obesity is a chronic, recurring, progressive disease and a major public health problem associated with several other diseases that lead to disability, morbidity, and mortality. The prevalence of obesity has increased at pandemic levels, along with increasing weight-related comorbidities and deaths worldwide. Lifestyle interventions alone provide clinically significant long-term weight loss in only a small proportion of individuals, and bariatric surgery is not suitable or desirable for all patients. Historically, anti-obesity medications achieved a mean efficacy with weight loss between 5 and 10%, which significantly impacted several comorbidities and risk factors, but the average efficacy of these medications remained lower than that expected by both patients and health care professionals and eventually curbed long-term use. Moreover, there is no direct evidence on the impact of anti-obesity medications on cardiovascular outcomes. Semaglutide is a newer anti-obesity medication that changes the overall landscape, as phase 3 studies show a mean weight loss near the 15% threshold and significant proportions of patients with a weight loss of greater than 20%. In this review, we focus on the currently available anti-obesity medications, discuss the results of semaglutide, and present perspectives on the future of obesity treatment after semaglutide.
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Affiliation(s)
- Walmir Coutinho
- State Institute of Diabetes and Endocrinology, Rua Moncorvo Filho, 90, Rio de Janeiro, RJ, 20211-340, Brazil.
- Department of Medicine, Pontifical Catholic University of Rio de Janeiro, Rua Marquês de São Vicente, 225, Gávea, Rio de Janeiro, RJ, 22541-041, Brazil.
| | - Bruno Halpern
- Department of Endocrinology, Obesity Unit, Hospital das Clínicas Faculdade de Medicina da Universidade de São Paulo. Av. Dr. Enéas de Carvalho Aguiar, 255, 7Th Floor, Room 7037, São Paulo, SP, 05403-000, Brazil
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Hurtado MD, Tama E, D'Andre S, Shufelt CL. The relation between excess adiposity and breast cancer in women: Clinical implications and management. Crit Rev Oncol Hematol 2024; 193:104213. [PMID: 38008197 PMCID: PMC10843740 DOI: 10.1016/j.critrevonc.2023.104213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/16/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND Breast cancer (BC) is the most common cancer in women. While the combination of improved screening, earlier detection, and advances in therapeutics has resulted in lower BC mortality, BC survivors are now increasingly dying of cardiovascular disease. Cardiovascular disease in the leading cause of non-cancer related mortality among BC survivors. This situation underscores the critical need to research the role of modifiable cardiometabolic risk factors, such as excess adiposity, that will affect BC remission, long-term survivorship, and overall health and quality of life. PURPOSE First, this review summarizes the evidence on the connection between adipose tissue and BC. Then we review the data on weight trends after BC diagnosis with a focus on the effect of weight gain on BC recurrence and BC- and non-BC-related death. Finally, we provide a guide for weight management in BC survivors, considering the available data on the effect of weight loss interventions on BC.
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Affiliation(s)
- Maria D Hurtado
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Jacksonville, FL, USA; Precision Medicine for Obesity Program, Mayo Clinic, Rochester, MN, USA.
| | - Elif Tama
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Jacksonville, FL, USA; Precision Medicine for Obesity Program, Mayo Clinic, Rochester, MN, USA
| | - Stacey D'Andre
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Chrisandra L Shufelt
- Center for Women's Health, Division of General Internal Medicine, Jacksonville, FL, USA
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Houssarini JA, Franklin J, Markovic T, Hocking SL. Duration of therapy of cost-subsidised phentermine and topiramate in patients with obesity: A retrospective medical records audit of an Australian single site. Obes Res Clin Pract 2024; 18:73-75. [PMID: 38365507 DOI: 10.1016/j.orcp.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 01/19/2024] [Accepted: 01/26/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Jared A Houssarini
- Royal Prince Alfred Hospital, Sydney, Australia; Central Clinical School, University of Sydney, Sydney, Australia
| | - Janet Franklin
- Royal Prince Alfred Hospital, Sydney, Australia; Central Clinical School, University of Sydney, Sydney, Australia
| | - Tania Markovic
- Royal Prince Alfred Hospital, Sydney, Australia; Central Clinical School, University of Sydney, Sydney, Australia; Boden Initiative, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Samantha L Hocking
- Royal Prince Alfred Hospital, Sydney, Australia; Central Clinical School, University of Sydney, Sydney, Australia; Boden Initiative, Charles Perkins Centre, University of Sydney, Sydney, Australia.
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Purnell JQ, Camacho SA. A New Epoch in Treating Diseases of the Heart. J Clin Lipidol 2024; 18:e5-e9. [PMID: 38514214 DOI: 10.1016/j.jacl.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Affiliation(s)
- Jonathan Q Purnell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon.
| | - Samuel A Camacho
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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Shridharani SM, Kohan J. The Emerging Role of Injectable Weight Loss Medications in Plastic Surgery: A Systematic Review. Aesthet Surg J 2023; 44:68-79. [PMID: 37493261 DOI: 10.1093/asj/sjad240] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/15/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023] Open
Abstract
Obesity is a multifactorial disease that represents a substantial global health concern. As of 2016, the World Health Organization (WHO) estimated that over 650 million adults were obese, and more than 1.9 billion were overweight. Surgical interventions or lifestyle changes are typically suggested to patients who experience comorbidities as a result of their weight; however, more recently, antidiabetic medications have been proposed, specifically sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RAs). This is the first systematic review to evaluate the safety, efficacy, and future role of SGLT-2 inhibitors and GLP-1RAs for weight loss in the world of aesthetic plastic surgery. Sixteen randomized controlled trials were identified that met the eligibility criteria for this systematic review and comprised data from 10,492 patients. All studies reported a decline in body weight following treatment with SGLT-2 inhibitors or GLP-1RAs, ranging from 1.5 to 5 kg. Although adverse events were reported in a large proportion of patients, primarily gastrointestinal manifestations, the literature reports that these were mild to moderate in severity and tended to subside following treatment adjustment. Future research is warranted to determine the ideal SGLT-2 inhibitor or GLP-1RA for weight loss management, and additional randomized controlled trials (RCTs) are needed to determine the efficacy and tolerability of potential combination therapies with SGLT-2 inhibitors and GLP-1RAs. LEVEL OF EVIDENCE: 3
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Ali Ibrahim AI, Mendoza B, Stanford FC, Malhotra S. Real-World Experience of the Efficacy and Safety of Phentermine Use in Adolescents: A Case Series. Child Obes 2023; 19:535-540. [PMID: 36576420 DOI: 10.1089/chi.2022.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Pharmacotherapy has emerged as a practical option for weight management in pediatrics. This study aims to assess the effectiveness and safety of phentermine use in pediatric patients with obesity. Methods: We performed a retrospective single-center analysis of patients younger than or equal to 18 years of age, over 10 years, who underwent phentermine treatment and recommended lifestyle changes. We evaluated efficacy by the change in the percent of the 95th percentile for BMI (%BMIp95). We deemed a 5% decrease in %BMIp95 as a favorable outcome. Results: We identified 30 pediatric patients who were treated with phentermine. The cohort was primarily female, 63% white, with a mean (standard deviation) baseline age of 15.63 (1.97) years. The average duration of treatment was 10 months, with a period ranging from 2 weeks to 2 years. The average %BMIp95 at the start of treatment was 137%, and that at the time of analysis was 122%, with a mean reduction of 15%. Five patients, 17%, experienced side effects that resolved after dose reduction or discontinuing phentermine. Conclusions: Phentermine monotherapy is an effective and safe means for weight loss in pediatric patients when combined with lifestyle interventions. Twenty-one of 30 (70%) patients achieved at least a 5% decrease in %BMIp95 within a mean duration of treatment of 10 months. We noted no severe adverse events.
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Affiliation(s)
- Awab I Ali Ibrahim
- Pediatric Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Fatima Cody Stanford
- Pediatric Endocrinology, MGH Weight Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Nutrition Obesity Research Center at Harvard, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sonali Malhotra
- Pediatric Endocrinology, MGH Weight Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Rhythm Pharmaceuticals, Boston, MA, USA
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Schmitz SH, Aronne LJ. The Effective Use of Anti-obesity Medications. Gastroenterol Clin North Am 2023; 52:661-680. [PMID: 37919019 DOI: 10.1016/j.gtc.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Obesity is a heterogeneous disease and there is wide patient-to-patient variability in response to all anti-obesity treatments including lifestyle modifications, anti-obesity medications (AOMs), devices, and bariatric surgery. To effectively treat obesity, practitioners must be knowledgeable about all of these treatment modalities including on-label and off-label AOMs. Care should be individualized to the patient taking into consideration their unique challenges with weight loss, their goals, the presence of comorbidities, medication contraindications, and drug-drug interactions. There is currently no way to know which AOM will be most effective for a patient without trial and error; therefore, prescribe AOMs in sequence and consider combination therapy for optimal results. This article reviews the efficacy, safety, prescribing information, and other considerations for all of the currently available AOMs.
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Affiliation(s)
- Sarah H Schmitz
- Division of Endocrinology, Diabetes & Metabolism, New York-Presbyterian Hospital/ Weill Cornell Medical College, Comprehensive Weight Control Center, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
| | - Louis J Aronne
- Division of Endocrinology, Diabetes & Metabolism, New York-Presbyterian Hospital/ Weill Cornell Medical College, Comprehensive Weight Control Center, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
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Clayton TL. Obesity and hypertension: Obesity medicine association (OMA) clinical practice statement (CPS) 2023. OBESITY PILLARS (ONLINE) 2023; 8:100083. [PMID: 38125655 PMCID: PMC10728712 DOI: 10.1016/j.obpill.2023.100083] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/06/2023] [Indexed: 12/23/2023]
Abstract
Background This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides an overview of the mechanisms and treatment of obesity and hypertension. Methods The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership. Results Mechanisms contributing to obesity-related hypertension include unhealthful nutrition, physical inactivity, insulin resistance, increased sympathetic nervous system activity, renal dysfunction, vascular dysfunction, heart dysfunction, increased pancreatic insulin secretion, sleep apnea, and psychosocial stress. Adiposopathic factors that may contribute to hypertension include increased release of free fatty acids, increased leptin, decreased adiponectin, increased renin-angiotensin-aldosterone system activation, increased 11 beta-hydroxysteroid dehydrogenase type 1, reduced nitric oxide activity, and increased inflammation. Conclusions Increase in body fat is the most common cause of hypertension. Among patients with obesity and hypertension, weight reduction via healthful nutrition, physical activity, behavior modification, bariatric surgery, and anti-obesity medications mostly decrease blood pressure, with the greatest degree of weight reduction generally correlated with the greatest degree of blood pressure reduction.
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Affiliation(s)
- Tiffany Lowe Clayton
- Diplomate of American Board of Obesity Medicine, WakeMed Bariatric Surgery and Medical Weight Loss USA
- Campbell University School of Osteopathic Medicine, Buies Creek, NC 27546, Levine Hall Room 170 USA
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Hritani R, Al Rifai M, Mehta A, German C. Obesity management for cardiovascular disease prevention. OBESITY PILLARS (ONLINE) 2023; 7:100069. [PMID: 37990683 PMCID: PMC10662048 DOI: 10.1016/j.obpill.2023.100069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/29/2023] [Accepted: 04/29/2023] [Indexed: 11/23/2023]
Abstract
Background Obesity is a complex disease that leads to higher morbidity and mortality and its rate in the United States is rapidly rising. Targeting obesity management is one of the cornerstones of preventive medicine. Early intervention can significantly reduce the risk of developing cardiovascular disease. While it is well known that lifestyle interventions such as healthful nutrition and routine physical activity are the first and most important step in management, some do not achieve the desired results and require further therapies. Methods A literature review was conducted, that included clinical documents, public scientific citations and peer review articles to evaluate anti-obesity medications, endoscopic procedures and bariatric surgeries in the management of obesity. We also included effects of these interventions on weight loss, cardiovascular disease risk reduction and side effects. Results This clinical review summarizes recent evidence for the different approaches in obesity management including medications, common endoscopic procedures and bariatric surgeries. For more detailed review on the different management options discussed, we recommend reviewing Obesity Medicine Association Clinical Practice Statement [1]. Conclusion Management of obesity reduces cardiovascular risk, improves metabolic parameters and other important health outcomes. Different management approaches are available, hence, a high level of awareness of the growing epidemic of obesity is needed to ensure timely referrals to obesity medicine specialists.
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Affiliation(s)
- Rama Hritani
- Division of Cardiology, Department of Internal Medicine, Medical College of Georgia/Augusta University, Augusta, GA, United States
| | - Mahmoud Al Rifai
- Division of Cardiology, Department of Internal Medicine, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, United States
| | - Anurag Mehta
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University/VCU Health Pauley Heart Center, Richmond, VA, United States
| | - Charles German
- Division of Cardiology, Department of Internal Medicine, University of Chicago, Chicago, IL, United States
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Kim A, Nguyen J, Babaei M, Kim A, Geller DH, Vidmar AP. A Narrative Review: Phentermine and Topiramate for the Treatment of Pediatric Obesity. Adolesc Health Med Ther 2023; 14:125-140. [PMID: 37641650 PMCID: PMC10460571 DOI: 10.2147/ahmt.s383454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023] Open
Abstract
The prevalence of pediatric obesity has increased exponentially over the past four decades. The American Academy of Pediatrics recently released updated clinical practice guidelines highlighting the importance of identifying pediatric obesity as a chronic disease. The guidelines support consideration of concurrent treatment with intensive lifestyle interventions, obesity pharmacotherapy, and bariatric surgery. The dramatic rise in pediatric obesity has spurred interest in utilizing obesity pharmacotherapy to support sustained weight reduction in pediatric cohorts, in the hopes of preventing the emergence of later-appearing, significant co-morbidities. Despite the enormous demand, the obstacles posed by performance of needed clinical trials in the pediatric population markedly limits available pharmacotherapy for the treatment of obesity in pediatrics. Currently, there are five medications approved by the Food and Drug Administration for use in youth with obesity. In 2022, the phentermine/topiramate (PHEN/TPM), once-daily, controlled-release, combination product received FDA approval, for the indication of chronic weight management, in youth with obesity, ages 12 years and older. The objectives of this narrative review are to: (1) Review the mechanism of action of phentermine and topiramate, (2) Summarize the safety and efficacy data of topiramate and phentermine use as both monotherapies and in combination, and (3) Discuss clinical practice guidelines and clinical implications, for the use of these agents in youths with obesity.
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Affiliation(s)
- Anthony Kim
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jennifer Nguyen
- Children’s Hospital Los Angeles and Keck School of Medicine of University of Southern California, Department of Pediatrics, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, USA
| | - Mahsa Babaei
- Children’s Hospital Los Angeles and Keck School of Medicine of University of Southern California, Department of Pediatrics, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, USA
| | - Ahlee Kim
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Children’s Hospital Los Angeles and Keck School of Medicine of University of Southern California, Department of Pediatrics, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, USA
| | - David H Geller
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Children’s Hospital Los Angeles and Keck School of Medicine of University of Southern California, Department of Pediatrics, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, USA
| | - Alaina P Vidmar
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Children’s Hospital Los Angeles and Keck School of Medicine of University of Southern California, Department of Pediatrics, Center for Endocrinology, Diabetes and Metabolism, Los Angeles, CA, USA
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16
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Fourie A, Julyan M, Mostert L, Du Plessis JM. Potential drug-drug interactions with phentermine among long-term phentermine consumers: A retrospective analysis. S Afr Med J 2023; 113:63-68. [PMID: 37882119 DOI: 10.7196/samj.2023.v113i8.428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Phentermine is an internationally recognised amphetamine derivative with significant appetite-suppressing properties. The drug is indicated for the short-term management of obesity, as the long-term (LT) use of phentermine may potentially be associated with severe cardiovascular side-effects, abuse and dependence. The LT use hereinafter describes periods exceeding 12 consecutive weeks. This use may also be associated with potential drug-drug interactions (PDDIs), which may result in adverse drug reactions (ADRs). The literature reports that phentermine is often prescribed LT and for several other off-label indications, increasing the risk for individuals to experience adverse drug events (ADEs) and drug-drug interactions (DDIs). There are, to our knowledge, no South African (SA) studies investigating the prevalence of co-prescribing LT phentermine with drugs that may potentially cause DDIs. OBJECTIVE To determine the prevalence of mild, moderate and severe DDIs with phentermine use when the duration of therapy in private healthcare exceeded 12 consecutive weeks. METHODS A cross-sectional drug utilisation review (DUR) was done by using data obtained from a SA pharmacy benefit management (PBM) company's database. Retrospective data of medicine claims for phentermine, from 1 January 2015 to 31 December 2019, were extracted for analysis. The number of days phentermine was supplied was used to identify the study population, in other words, those patients who received the drug LT. A drug interaction checker (Drugs.com) was used to identify potential mild, moderate and severe DDIs when using phentermine and co-prescribed drugs concurrently. RESULTS A total of 889 patients received phentermine LT. The top 20 drugs identified as being frequently co-prescribed in this study population demonstrated no mild PDDI, 15 (75%) moderate PDDIs and 5 (25%) severe PDDIs. The most common co-prescribed drug in the moderate group was dextromethorphan (n=282, 31.72%) and the least co-prescribed was formoterol (n=52, 5.85%). Among the drug group 'severe PDDIs', tramadol (n=416, 46.79%) was most frequently prescribed, whereas phenylpropanolamine (n=69, 7.76%) was the least prescribed to patients in this group. CONCLUSION There are patients who receive LT phentermine therapy despite the potential severe consequences that may result. These patients may receive concomitant therapy with phentermine and other pharmaceutical constituents, which may potentially cause DDIs, more specifically, moderate and severe DDIs. As such, these patients are not only confronted with the consequences of DDIs but are also at risk to experience ADRs as the residual effect of PDDIs.
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Affiliation(s)
- A Fourie
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University, Potchefstroom, South Africa.
| | - M Julyan
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University, Potchefstroom, South Africa.
| | - L Mostert
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University, Potchefstroom, South Africa.
| | - J M Du Plessis
- Medicine Usage in South Africa (MUSA), Faculty of Health Sciences, North-West University, Potchefstroom, South Africa.
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17
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Jayaprakash MS, Beavers DP, Miller GD, McNatt S, Fernandez A, Edwards-Hampton SA, Ard JD. Impact on Cardiovascular Health of Using Phentermine/Topiramate in Combination With Laparoscopic Sleeve Gastrectomy in Super Obesity. J Surg Res 2023; 286:41-48. [PMID: 36753948 DOI: 10.1016/j.jss.2022.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 12/06/2022] [Accepted: 12/24/2022] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Management of patients with BMI≥50 kg/m2 is challenging. In previous work, pre and postoperative pharmacotherapy with phentermine/topiramate plus laparoscopic sleeve gastrectomy (PT + SG) promoted greater weight loss than sleeve gastrectomy (SG) alone at 24 mo postoperatively. This current secondary analysis studied the impact of PT + SG on blood pressure (BP), heart rate, and antihypertensive usage. METHODS Patients with BMI≥50 kg/m2 planning to have SG (n = 13) were recruited from 2014 to 2016, at an academic medical center in Winston-Salem, North Carolina, for this open-label trial. Participants took phentermine/topiramate (PT; 7.5/46-15/92 mg/d) for ≥3 mo preoperatively and 24 mo postoperatively. The control group (n = 40) underwent SG during the same time frame. We used mixed models for BP and heart rate to compare PT + SG versus SG alone over time, adjusted for age, sex, and initial BP. RESULTS By 24 mo postoperatively the model adjusted changes in systolic blood pressure/diastolic blood pressure (SBP/DBP) (mm Hg) were -24.44 (-34.46,-14.43)/-28.60 (-40.74,-16.46) in the PT + SG group versus -11.81 (-17.58,-6.05)/-13.89 (-21.32,-6.46) in the control group (SBP P = 0.02; DBP P = 0.03). At baseline 8 (61.5%) participants in the PT + SG arm and 22 (55.0%) in the control group used antihypertensives. Excluding patients lost to follow-up (n = 3), by 24 mo postoperatively, none of the PT + SG participants were on antihypertensives compared to 14 (41.2%) in the control group (P = 0.01). CONCLUSIONS Patients with BMI≥50 kg/m2 treated with PT + SG had greater improvement in BP with no use of antihypertensive medication at 24 mo postoperatively versus SG alone, where 41% continued medication use. Larger trials are required to evaluate this.
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Affiliation(s)
| | - Daniel P Beavers
- Department of Statistical Sciences, Wake Forest University, Winston Salem, North Carolina
| | - Gary D Miller
- Department of Health and Exercise Science, Wake Forest University, Winston Salem, North Carolina
| | - Stephen McNatt
- Department of General Surgery, Atrium Health Wake Forest Baptist, Weight Management Center, Winston Salem, North Carolina
| | - Adolfo Fernandez
- Department of General Surgery, Atrium Health Wake Forest Baptist, Weight Management Center, Winston Salem, North Carolina
| | - Shenelle A Edwards-Hampton
- Department of General Surgery, Atrium Health Wake Forest Baptist, Weight Management Center, Winston Salem, North Carolina.
| | - Jamy D Ard
- Department of General Surgery, Atrium Health Wake Forest Baptist, Weight Management Center, Winston Salem, North Carolina; Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
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18
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Abstract
The rising prevalence of obesity in Singapore is a harbinger for a corresponding increase in obesity-related complications such as type 2 diabetes mellitus (T2DM) and coronary heart disease. Obesity is a complex disease driven by multiple factors, and hence, treatment cannot follow a 'one-size-fits-all' approach. Lifestyle modifications involving dietary interventions, physical activity and behavioural changes remain the cornerstone of obesity management. However, similar to other chronic diseases such as T2DM and hypertension, lifestyle modifications are often insufficient on their own, hence the importance of other treatment modalities including pharmacotherapy, endoscopic bariatric therapy and metabolic-bariatric surgery. Weight loss medications currently approved in Singapore include phentermine, orlistat, liraglutide and naltrexone-bupropion. In recent years, endoscopic bariatric therapies have evolved as an effective, minimally invasive and durable therapeutic option for obesity. Metabolic-bariatric surgery remains the most effective and durable treatment for patients with severe obesity, with an average weight loss of 25%-30% after one year.
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Affiliation(s)
- Phong Ching Lee
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Chin Hong Lim
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore
| | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
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19
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Enright C, Thomas E, Saxon DR. An Updated Approach to Antiobesity Pharmacotherapy: Moving Beyond the 5% Weight Loss Goal. J Endocr Soc 2023; 7:bvac195. [PMID: 36686585 PMCID: PMC9847544 DOI: 10.1210/jendso/bvac195] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Indexed: 01/11/2023] Open
Abstract
Despite professional society guidelines recommending that obesity be treated as a chronic disease by emphasizing the use of lifestyle modification in conjunction with pharmacotherapy, antiobesity medications are uncommonly prescribed in most clinical practices. The recent Food and Drug Administration approval of semaglutide 2.4 mg weekly to treat obesity-as well as other forthcoming advancements in diabetes and antiobesity medications-highlights the potential of pharmacotherapy to significantly augment weight loss efforts. In this Expert Endocrine Consult, we review the evolving role of antiobesity pharmacotherapy in clinical practice and suggest a framework for the use of these medications.
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Affiliation(s)
- Connor Enright
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Elizabeth Thomas
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Aurora, CO 80045, USA,Endocrinology Section, Rocky Mountain Veterans Affairs Medical Center, Aurora, CO 80045, USA
| | - David R Saxon
- Correspondence: David Saxon, MD, Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, 12801 East 17th Avenue, Mail Stop: 8106, Aurora, CO 80045, USA.
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20
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Rendell MS. Obesity and diabetes: the final frontier. Expert Rev Endocrinol Metab 2023; 18:81-94. [PMID: 36710450 DOI: 10.1080/17446651.2023.2168643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/11/2023] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Obesity is a key target in the treatment and prevention of diabetes and independently to reduce the burden of cardiovascular disease. We reviewed the options now available and anticipated to deal with obesity. AREAS COVERED We considered the epidemiology, genetics, and causation of obesity and the relationship to diabetes, and the dietary, pharmaceutical, and surgical management of the condition. The literature search covered both popular media via Google Search and the academic literature as indexed on PubMed with search terms including obesity, childhood obesity, adipocytes, insulin resistance, mechanisms of satiety, bariatric surgery, GLP-1 receptor agonists, and SGLT2 inhibitors. EXPERT OPINION Although bariatric surgery has been the primary approach to treating obese individuals, the emergence of agents impacting the brain satiety centers now promises effective, non-invasive treatment of obesity for individuals with and without diabetes. The GLP-1 receptor agonists have assumed the primary role in treating obesity with significant weight loss. Long-term results with semaglutide and tirzepatide are now approaching the success seen with bariatric surgery. Future agents combining the benefits of satiety control and thermogenesis to dissipate caloric excess are under investigation.
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Affiliation(s)
- Marc S Rendell
- The Association of Diabetes Investigators, Newport Coast, CA, USA
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21
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Cuda S, Censani M, Kharofa R, O'Hara V, Conroy R, Williams DR, Paisley J, Browne AF, Karjoo S, Browne NT. Medication-induced weight gain and advanced therapies for the child with overweight and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement 2022. OBESITY PILLARS (ONLINE) 2022; 4:100048. [PMID: 37990664 PMCID: PMC10662101 DOI: 10.1016/j.obpill.2022.100048] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 11/30/2022] [Indexed: 11/23/2023]
Abstract
Background This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details medication-induced weight gain and advanced therapies for the child with overweight or obesity. Methods The scientific information and clinical guidance in this CPS are based on scientific evidence, supported by the medical literature, and derived from the clinical perspectives of the authors. Results This OMA Clinical Practice Statement addresses medication-induced weight gain and advanced therapies for the child with overweight or obesity. Conclusions This OMA Clinical Practice Statement on medication induced-weight gain and advanced therapies for the child with overweight or obesity is an overview of current recommendations. These recommendations provide a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications. This CPS also addresses treatment recommendations. This section is designed to help the provider with clinical decision making.
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Affiliation(s)
- Suzanne Cuda
- Alamo City Healthy Kids and Families, 1919 Oakwell Farms Parkway, Ste 145, San Antonio, TX, 78218, USA
| | - Marisa Censani
- Division of Pediatric Endocrinology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, Box 103, New York, NY, 10021, USA
| | - Roohi Kharofa
- Department of Pediatrics, University of Cincinnati College of Medicine Center for Better Health & Nutrition, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | | | - Rushika Conroy
- Division of Pediatric Endocrinology, Baystate Children's Hospital Subspecialty Center, 50 Wason AvenueSpringfield, MA, 01107, USA
| | - Dominique R Williams
- The Ohio State University College of Medicine Center for Healthy Weight and Nutrition, Nationwide Children's Hospital 700 Children's Drive LA, Suite 5F, Columbus, OH, 43215, USA
| | - Jennifer Paisley
- St Elizabeth Physician's Group Primary Care, 98 Elm Street Lawrenceburg, IN, 47025-2048, USA
| | | | - Sara Karjoo
- Johns Hopkins All Children's Hospital Pediatric Gastroenterology 501 6th Ave S St. Petersburg, FL, 33701, USA
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22
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Damani D, Hassan M, Mahapatra S, Prakash S, Alhariri S, Bies J, Trivedi B, Edwards BP. A Rare Case of Phentermine-Induced Nonischemic Cardiomyopathy. Cureus 2022; 14:e31114. [DOI: 10.7759/cureus.31114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2022] [Indexed: 11/06/2022] Open
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Grunvald E, Shah R, Hernaez R, Chandar AK, Pickett-Blakely O, Teigen LM, Harindhanavudhi T, Sultan S, Singh S, Davitkov P. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology 2022; 163:1198-1225. [PMID: 36273831 DOI: 10.1053/j.gastro.2022.08.045] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND & AIMS Pharmacological management of obesity improves outcomes and decreases the risk of obesity-related complications. This American Gastroenterological Association guideline is intended to support practitioners in decisions about pharmacological interventions for overweight and obesity. METHODS A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, and conduct an evidence synthesis of the following agents: semaglutide 2.4 mg, liraglutide 3.0 mg, phentermine-topiramate extended-release (ER), naltrexone-bupropion ER, orlistat, phentermine, diethylpropion, and Gelesis100 oral superabsorbent hydrogel. The guideline panel used the evidence-to-decision framework to develop recommendations for the pharmacological management of obesity and provided implementation considerations for clinical practice. RESULTS The guideline panel made 9 recommendations. The panel strongly recommended the use of pharmacotherapy in addition to lifestyle intervention in adults with overweight and obesity (body mass index ≥30 kg/m2, or ≥27 kg/m2 with weight-related complications) who have an inadequate response to lifestyle interventions. The panel suggested the use of semaglutide 2.4 mg, liraglutide 3.0 mg, phentermine-topiramate ER, and naltrexone-bupropion ER (based on moderate certainty evidence), and phentermine and diethylpropion (based on low certainty evidence), for long-term management of overweight and obesity. The guideline panel suggested against the use of orlistat. The panel identified the use of Gelesis100 oral superabsorbent hydrogel as a knowledge gap. CONCLUSIONS In adults with overweight and obesity who have an inadequate response to lifestyle interventions alone, long-term pharmacological therapy is recommended, with multiple effective and safe treatment options.
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Affiliation(s)
- Eduardo Grunvald
- Department of Medicine, University of California San Diego, La Jolla, California.
| | - Raj Shah
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruben Hernaez
- Division of Gastroenterology and Hepatology, Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Division of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Octavia Pickett-Blakely
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Levi M Teigen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Tasma Harindhanavudhi
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Perica Davitkov
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Division of Gastroenterology, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
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24
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Bays HE, Lazarus E, Primack C, Fitch A. Obesity pillars roundtable: Phentermine - Past, present, and future. OBESITY PILLARS (ONLINE) 2022; 3:100024. [PMID: 37990729 PMCID: PMC10661986 DOI: 10.1016/j.obpill.2022.100024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2023]
Abstract
Background Phentermine is a sympathomimetic amine, approved for "short-term"treatment of patients with obesity. Among phentermine contraindications include use in patients with cardiovascular disease or patients with uncontrolled hypertension. Methods This roundtable discussion includes perspectives from 3 obesity specialists with experience in the clinical use of phentermine. The questions asked of the panelists were derived from publications regarding phentermine safety and efficacy. Results While the panelists generally agreed upon core principles of phentermine use, each obesity specialist had their own priorities and style regarding the administration of phentermine. Among the variances in perceptions (based upon their individual "real world" clinical experiences) included the degree of efficacy and degree of clinical benefit of phentermine, degree of concern regarding phentermine use in patients with cardiovascular disease risk factors, the advisability of a screening electrocardiogram, and the role of telehealth in prescribing phentermine and monitoring for the efficacy and safety of phentermine. Conclusions Providing universal guidance regarding phentermine treatment for obesity is challenging because of the lack of long-term, prospective, randomized, placebo-controlled, health outcomes data. Such data is unlikely forthcoming any time soon. Also challenging are the substantial variances in governmental restrictions on phentermine use. Therefore, clinicians are left to rely on the best available evidence, their individual practical clinical experience, as well as the collective clinical experiences of others - as reflected by this roundtable.
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Affiliation(s)
- Harold Edward Bays
- Diplomate of American Board of Obesity Medicine, Louisville Metabolic and Atherosclerosis Research Center, University of Louisville Medical School, 3288 Illinois Avenue, Louisville, KY, 40213, USA
| | - Ethan Lazarus
- Diplomate American Board of Obesity Medicine, Obesity Medicine Association Delegate to the American Medical Association, Clinical Nutrition Center, Greenwood Village, Colorado, USA
| | - Craig Primack
- Diplomate American Board of Obesity Medicine, Scottsdale Weight Loss Center, Scottsdale, AZ, 85258, USA
| | - Angela Fitch
- Diplomate American Board of Obesity Medicine, Medicine Harvard Medical School, Massachusetts General Hospital Weight Center, Boston, MA, 02114, USA
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25
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Abstract
During the past decade, several effective antiobesity medications and devices have been developed. In addition, new information regarding the mechanism of action, benefits, and long-term efficacy of bariatric surgery continues to emerge. More than 90% of patients who qualify for therapy for obesity remain untreated. This article aims to provide an overview of the indications and efficacy of currently available medical and surgical therapies for obesity, along with a look toward promising therapies on the horizon.
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Affiliation(s)
- Tirissa J Reid
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA; Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 161 Fort Washington Avenue, Room 512, New York, NY 10032, USA.
| | - Judith Korner
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA; Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 650 West 168th Street, Black Building, Room 20-08, New York, NY 10032, USA
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26
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Cho YJ, Kim KK. Pharmacotherapy in obesity: the current state and the near future. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.8.514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: In Korea, the prevalence of obesity, morbid obesity with serious complications, and childhood obesity are rapidly increasing. To control the obesity pandemic, both prevention and treatment are essential strategic targets. While lifestyle modification is fundamental in obesity treatment, due to the complex appetite-controlling system in the body and the rapidly Westernizing environment, more effective treatment tools are required.Current Concepts: There are 4 types of drugs that have been approved for the treatment of obesity in Korea. They are (1) appetite suppressants for short-term therapy, (2) dietary fat absorption inhibitors, (3) glucagon-like peptide-1 (GLP-1) receptor agonists, and (4) fixed-dose combination drugs for appetite control. However, a large amount of weight reduction cannot be achieved with these drugs. The greatest amount of weight reduction of approximately 11% has been reported for phentermine/topiramate combination treatment. Recently, peptide agents have been under development and 2 of these agents, semaglutide, a second generation GLP-1 receptor agonist, and tirzepatide, a glucose-dependent insulinotropic polypeptide/GLP-1 receptor dual agonist, are expected to be available in the near future.Discussion and Conclusion: Both semaglutide and tirzepatide are more effective than currently available anti-obesity drugs. Semaglutide and tirzepatide reduced the body weight of people with obesity without diabetes by 14.9% and 20.9%, respectively. However, because of the mechanism of GLP-1 receptor agonism, gastrointestinal adverse events, including nausea, diarrhea, vomiting, and abdominal pain, were problematic in many patients, although these adverse events were generally acceptable. Both drugs will be excellent options for obesity treatment in the near future.
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27
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Oo WM, Mobasheri A, Hunter DJ. A narrative review of anti-obesity medications for obese patients with osteoarthritis. Expert Opin Pharmacother 2022; 23:1381-1395. [PMID: 35855642 DOI: 10.1080/14656566.2022.2104636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : The prevalence of both obesity and osteoarthritis (OA) are increasing worldwide (twindemic), and the association between the two chronic diseases is also well-established. AREAS COVERED : In this narrative review, we will briefly describe the double burdens of both diseases, the impact of weight loss or gain on OA incidence and structural progression and discuss the biomechanical and anti-inflammatory mechanisms mediating these effects. FDA-approved anti-obesity drugs are summarized in terms of their clinical efficacy and safety profile, and the completed or ongoing phase 2/3 clinical trials of such drugs in OA patients with obesity are examined. EXPERT OPINION : We will discuss the perspectives related to principles of prescription of anti-obesity drugs, the potential role of phenotype-guided approach, time to drug effects in clinical trials, sustainability of weight loss based on the real-world studies, the importance of concomitant therapies such as dieting and exercises, and the role of weight loss on non-weight bearing OA joints. Although obesity is the major risk factor for OA pathogenesis and progression, and there are a variety of anti-obesity medications on the market, research on the use of these disease-modifying drugs in OA (DMOAD) is still sparse..
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Affiliation(s)
- Win Min Oo
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Physical Medicine and Rehabilitation, Mandalay General Hospital, University of Medicine, Mandalay, Mandalay, Myanmar
| | - Ali Mobasheri
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, Oulu, Finland.,Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania.,Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,World Health Organization Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liege, Belgium
| | - David J Hunter
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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28
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Bays HE, Fitch A, Christensen S, Burridge K, Tondt J. Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022. OBESITY PILLARS (ONLINE) 2022; 2:100018. [PMID: 37990711 PMCID: PMC10662004 DOI: 10.1016/j.obpill.2022.100018] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2023]
Abstract
Background This "Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association Clinical Practice Statement 2022" is intended to provide clinicians an overview of Food and Drug Administration (FDA) approved anti-obesity medications and investigational anti-obesity agents in development. Methods The scientific information for this Clinical Practice Statement (CPS) is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership. Results This CPS describes pharmacokinetic principles applicable to those with obesity, and discusses the efficacy and safety of anti-obesity medications [e.g., phentermine, semaglutide, liraglutide, phentermine/topiramate, naltrexone/bupropion, and orlistat, as well as non-systemic superabsorbent oral hydrogel particles (which is technically classified as a medical device)]. Other medications discussed include setmelanotide, metreleptin, and lisdexamfetamine dimesylate. Data regarding the use of combination anti-obesity pharmacotherapy, as well as use of anti-obesity pharmacotherapy after bariatric surgery are limited; however, published data support such approaches. Finally, this CPS discusses investigational anti-obesity medications, with an emphasis on the mechanisms of action and summary of available clinical trial data regarding tirzepatide. Conclusion This "Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association Clinical Practice Statement 2022" is one of a series of OMA CPSs designed to assist clinicians in the care of patients with pre-obesity/obesity.
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Affiliation(s)
- Harold E. Bays
- Louisville Metabolic and Atherosclerosis Research Center, University of Louisville School of Medicine, 3288 Illinois Avenue, Louisville, KY, 40213, USA
| | - Angela Fitch
- Assistant Professor of Medicine Harvard Medical School, Co-Director Massachusetts General Hospital Weight Center, Boston, MA, USA
| | - Sandra Christensen
- Integrative Medical Weight Management, 2611 NE 125th St, Suite 100B, Seattle, WA, 98125, USA
| | - Karli Burridge
- Enara Health, 16501 106th Court, Orland Park, IL, 60467, USA
- Gaining Health, 528 Pennsylvania Ave #708, Glen Ellyn, IL, 60137, USA
| | - Justin Tondt
- Department of Family and Community Medicine, Eastern Virginia Medical School, P.O. Box 1980, Norfolk, VA, 23501, USA
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Horn DB, Almandoz JP, Look M. What is clinically relevant weight loss for your patients and how can it be achieved? A narrative review. Postgrad Med 2022; 134:359-375. [PMID: 35315311 DOI: 10.1080/00325481.2022.2051366] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Obesity is a chronic disease with increasing prevalence. It affects quality of life and renders those affected at increased risk of mortality. For people living with obesity, weight loss is one of the most important strategies to improve health outcomes and prevent or reverse obesity-related complications. In line with newly released clinical practice guidelines, weight loss targets for people living with obesity should be defined individually based on their clinical profile, and progress measured in the context of improvements in health outcomes, rather than weight loss alone. We outline current treatment options for clinically meaningful weight loss and briefly discuss pharmacological agents and devices under development. Numerous studies have shown that weight loss of ≥5% results in significant improvements in cardiometabolic risk factors associated with obesity; this degree of weight loss is also required for the approval of novel anti-obesity medications by the US Food and Drug Administration. However, some obesity-related comorbidities and complications, such as non-alcoholic steatohepatitis, obstructive sleep apnea, gastroesophageal reflux disease and remission of type 2 diabetes, require a greater magnitude of weight loss to achieve clinically meaningful improvements. In this review, we assessed the available literature describing the effect of categorical weight losses of ≥5%, ≥10%, and ≥15% on obesity-related comorbidities and complications, and challenge the concept of clinically meaningful weight loss to go beyond percentage change in total body weight. We discuss weight-loss interventions including lifestyle interventions and therapeutic options including devices, and pharmacological and surgical approaches as assessed from the available literature.
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Affiliation(s)
- Deborah B Horn
- University of Texas McGovern Medical School, Center for Obesity Medicine and Metabolic Performance, Bellaire, TX, USA
| | - Jaime P Almandoz
- Department of Internal Medicine, Division of Endocrinology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michelle Look
- San Diego Sports Medicine & Family Health Center, San Diego, CA, USA
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Pulipati VP, Pannain S. Pharmacotherapy of obesity in complex diseases. Clin Obes 2022; 12:e12497. [PMID: 34889046 DOI: 10.1111/cob.12497] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/09/2021] [Accepted: 10/26/2021] [Indexed: 12/16/2022]
Abstract
More than 40% of adults in the United States suffer from obesity. Obesity is inextricably linked to many chronic illnesses like type-2 diabetes mellitus, hypertension, hyperlipidemia, heart disease, sleep apnea, stroke, and cancers. When used in combination with lifestyle modifications, pharmacotherapy has a vital role in treating obesity and improves short-term and long-term outcomes. A growing number of physicians are now interested in obesity medicine, and many of them are seeking guidance on how to treat complex patients with co-morbidities. This review provides a practical guide to the use of anti-obesity medications across various obesity-related comorbidities. It provides a general review of the currently approved anti-obesity medications and effective combinations. It discusses the highlights of the major trials and recent studies assessing the benefits of anti-obesity medications in comorbid conditions such as type-2 diabetes mellitus, psychiatric disorders, cardiovascular diseases, hypertension, renal diseases, and liver diseases. This review briefly examines the aspects of recognizing and addressing iatrogenic weight gain; discusses the precautions and prescribing considerations of anti-obesity medications, including side effects and possible dose adjustments in various comorbid conditions; and provides an expert opinion on an individualized choice of the best anti-obesity medication.
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Affiliation(s)
| | - Silvana Pannain
- Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Chicago, Chicago, Illinois, USA
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31
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Lingvay I, Sumithran P, Cohen RV, le Roux CW. Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation. Lancet 2022; 399:394-405. [PMID: 34600604 DOI: 10.1016/s0140-6736(21)01919-x] [Citation(s) in RCA: 198] [Impact Index Per Article: 99.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/05/2021] [Accepted: 08/17/2021] [Indexed: 12/11/2022]
Abstract
Obesity is now recognised as a disease that is associated with serious morbidity and increased mortality. One of its main metabolic complications is type 2 diabetes, as the two conditions share key pathophysiological mechanisms. Weight loss is known to reverse the underlying metabolic abnormalities of type 2 diabetes and, as such, improve glucose control; loss of 15% or more of bodyweight can have a disease-modifying effect in people with type 2 diabetes, an outcome that is not attainable by any other glucose-lowering intervention. Furthermore, weight loss in this population exerts benefits that extend beyond glycaemic control to improve risk factors for cardiometabolic disease and quality of life. We review the evidence supporting the role of weight loss in the management of type 2 diabetes and propose that many patients with type 2 diabetes would benefit from having a primary weight-centric approach to diabetes treatment. We discuss the logistical challenges to implementing a new weight-centric primary treatment goal in people with type 2 diabetes.
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Affiliation(s)
- Ildiko Lingvay
- Division of Endocrinology, Department of Internal Medicine and Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Priya Sumithran
- Department of Medicine (St Vincent's Hospital), University of Melbourne, Melbourne, VIC, Australia; Department of Endocrinology, Austin Health, Melbourne, VIC, Australia
| | - Ricardo V Cohen
- The Center for Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | - Carel W le Roux
- Diabetes Complications Research Centre, Conway Institute, School of Medicine, University College Dublin, Dublin, Ireland; Diabetes Research Centre, Ulster University, Coleraine, UK
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Weight Loss at First Month and Development of Tolerance as Possible Predictors of 30 mg Phentermine Efficacy at 6 Months. J Pers Med 2021; 11:jpm11121354. [PMID: 34945825 PMCID: PMC8707701 DOI: 10.3390/jpm11121354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 12/23/2022] Open
Abstract
The efficacy of anti-obesity drugs usually does not consider the high degree of interindividual variability in responses to the drug which could affect the decision to withdraw the drug early due to ineffectiveness or to continue therapy according to specific expectations of success. The aim of this study was to analyze body weight loss in kilograms during the first month (1 mo-BWLkg) of treatment with 30 mg phentermine and development of tolerance to phentermine, on its 6-month efficacy. One hundred sixty-six subjects with obesity were individually or jointly analyzed in the study. Subjects with 1 mo-BWLkg of <1 kg, 1–3 kg, 3–5 kg, and ≥5 kg reached 6-month mean percentage body weight reductions (BWR%) of approximately 3%, 5%, 10%, and 15%, respectively. Development of late tolerance (4–6 months) to phentermine had a lower impact than early tolerance (2–3 months). Subjects with 1 mo-BWLkg < 3 kg who developed early tolerance did not achieve relevant BWR% (≥5%) at month 6, while the rest of the subgroups achieved increasing and progressive BWR%, according to their 1 mo-BWLkg range and time of onset of tolerance. The 1 mo-BWLkg and development of tolerance to phentermine could be useful to predict the expected 6-month efficacy trends in obese patients treated with 30 mg phentermine.
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Calderon G, Gonzalez-Izundegui D, Shan KL, Garcia-Valencia OA, Cifuentes L, Campos A, Collazo-Clavell ML, Shah M, Hurley DL, Abu Lebdeh HS, Sharma M, Schmitz K, Clark MM, Grothe K, Mundi MS, Camilleri M, Abu Dayyeh BK, Hurtado Andrade MD, Mokadem MA, Acosta A. Effectiveness of anti-obesity medications approved for long-term use in a multidisciplinary weight management program: a multi-center clinical experience. Int J Obes (Lond) 2021; 46:555-563. [PMID: 34811486 DOI: 10.1038/s41366-021-01019-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/30/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Randomized clinical trials have proven the efficacy and safety of Food and Drug Administration (FDA) approved anti-obesity medications (AOMs) for long-term use. It is unclear whether these outcomes can be replicated in real-world clinical practice where clinical complexities arise. The aim of this study was to evaluate the effectiveness and side effects of these medications in real-world multidisciplinary clinical practice settings. METHODS We reviewed the electronic medical records (EMR) of patients with obesity who were prescribed an FDA-approved AOM for long-term use in academic and community multidisciplinary weight loss programs between January 2016 and January 2020. INTERVENTION We assessed percentage total body weight loss (%TBWL), metabolic outcomes, and side effect profile up to 24 months after AOM initiation. RESULTS The full cohort consisted of 304 patients (76% women, 95.2% White, median age of 50 years old [IQR, 39-58]). The median follow-up time was 9.1 months [IQR, 4.2-14.1] with a median number of 3 visits [IQR, 2-4]. The most prescribed medication was phentermine/topiramate extended-release (ER) (51%), followed by liraglutide (26.3%), bupropion/naltrexone sustained-release (SR) (16.5%), and lorcaserin (6.2%). %TBWL was 5.0%, 6.8%, 9.3%, 10.3%, and 10.5% at 3, 6, 12, 18, and 24 months. 60.2% of the entire cohort achieved at least 5% TBWL. Overall, phentermine/topiramate-ER had the most robust weight loss response during follow-up, with the highest %TBWL at 12 months of 12.0%. Adverse events were reported in 22.4% of patients. Only 9% of patients discontinued the medication due to side effects. CONCLUSIONS AOMs resulted in significant long-term weight loss, that was comparable to outcomes previously reported in clinical trials.
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Affiliation(s)
- Gerardo Calderon
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel Gonzalez-Izundegui
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kuangda L Shan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, and Fraternal Order of Eagles Diabetes Research Center, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Oscar A Garcia-Valencia
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lizeth Cifuentes
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alejandro Campos
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Maria L Collazo-Clavell
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Meera Shah
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Haitham S Abu Lebdeh
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Mayank Sharma
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristine Schmitz
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Matthew M Clark
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Karen Grothe
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Michael Camilleri
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Barham K Abu Dayyeh
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Maria D Hurtado Andrade
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA. .,Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic Health System, La Crosse, WI, USA.
| | - Mohamad A Mokadem
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, and Fraternal Order of Eagles Diabetes Research Center, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Andres Acosta
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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Ahmad NN, Robinson S, Kennedy-Martin T, Poon JL, Kan H. Clinical outcomes associated with anti-obesity medications in real-world practice: A systematic literature review. Obes Rev 2021; 22:e13326. [PMID: 34423889 PMCID: PMC9285776 DOI: 10.1111/obr.13326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/26/2022]
Abstract
Anti-obesity medications (AOMs) are efficacious and well tolerated in randomized controlled trials, but findings may not be generalizable to routine clinical practice. This systematic literature review aimed to identify real-world (RW) evidence for AOMs to treat adults ( ≥ 18 years) with obesity or overweight (BMI ≥ 27 kg/m2 ). Searches conducted in MEDLINE, Embase, Health Technology Assessment (HTA) Database, National Health Service (NHS) Economic Evaluation Database, and Cochrane Central Register of Controlled Trials for studies of relevant FDA-approved AOMs yielded 41 publications. Weight loss (WL) was consistently observed, with 14% to 58.6% of patients achieving ≥ 5% WL on orlistat, phentermine/topiramate, naltrexone/bupropion, phentermine, or liraglutide in studies of 3-6 months' duration where this was measured. When cardiometabolic risk factors were assessed, AOMs reduced or had no impact on blood pressure, lipids, or glycemia. RW data on the impact of AOMs on existing obesity-related comorbidities and mortality were generally lacking. AOMs were associated with various adverse events, but these were of mild to moderate severity and no unexpected safety signals were reported. A pattern of poor adherence and persistence with AOMs was observed across studies. Overall, the review confirmed the effectiveness of AOMs in RW settings but demonstrated large gaps in the evidence base.
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Affiliation(s)
- Nadia N Ahmad
- Research and Development - Obesity, Lilly Diabetes, Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | - Jiat Ling Poon
- Global Patient Outcomes and Real World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
| | - Hong Kan
- Global Patient Outcomes and Real World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
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Abstract
Obesity is a treatable chronic disease. Primary care providers play an essential role in diagnosis, treatment, and comprehensive care of patients with obesity. In recent years, treatment approaches have rapidly evolved, increasing effective and safe therapies. In this review, we provide practical information on the care of patients with obesity with a focus on antiobesity pharmacotherapy within the context of currently available therapeutic modalities such as intensive lifestyle interventions and bariatric surgery.
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Affiliation(s)
- Mona Gossmann
- Department of Internal Medicine (Endocrinology & Metabolism), Yale University School of Medicine, New Haven, CT, USA
| | - W Scott Butsch
- Department of Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Internal Medicine and Geriatrics, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ania M Jastreboff
- Department of Internal Medicine (Endocrinology & Metabolism), Yale University School of Medicine, New Haven, CT, USA; Department of Pediatrics (Pediatric Endocrinology), Yale University School of Medicine, New Haven, CT, USA.
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Iwamoto SJ, Abushamat LA, Zaman A, Millard AJ, Cornier MA. Obesity Management in Cardiometabolic Disease: State of the Art. Curr Atheroscler Rep 2021; 23:59. [PMID: 34345933 PMCID: PMC8358925 DOI: 10.1007/s11883-021-00953-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To summarize research from the last 5 years on the effects of weight loss treatments, including lifestyle changes, anti-obesity medications, and bariatric procedures on cardiovascular disease (CVD) risk factors and CVD outcomes in adults. RECENT FINDINGS This narrative review includes and summarizes the contemporary evidence of the effects of these different weight loss approaches individually. A literature search was performed using the key words obesity, weight loss, CVD, cardiometabolic, and risk factors and included key clinical trials from the past 5 years. Obesity management through weight loss is associated with improvements in CVD risk factors, such as improved blood pressure, lipid profiles, and glycemic control, with greater weight loss leading to greater improvements in CVD risk factors. Bariatric surgery is associated with greater weight loss than the other procedures and treatments for obesity, and for this, and possibly for other reasons, it is associated with greater reductions in CVD outcomes and mortality. Obesity is an independent risk factor and modulator of other CVD risk factors, and thus, treatment of obesity should be an integral part of management strategies to reduce CVD risk. Future trials and real-world studies of longer duration are needed to inform providers and patients on how to individualize the approach to modifying risks of cardiometabolic disorders through obesity management.
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Affiliation(s)
- Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
- Center for Women's Health Research, Department of Medicine, Anschutz Medical Campus, University of Colorado, 12348 E Montview Blvd, C263, Aurora, CO, USA
- Anschutz Health and Wellness Center, University of Colorado School of Medicine, Anschutz Medical Campus, 12348 E Montview Blvd, C263, Aurora, CO, 80045, USA
- Rocky Mountain Regional Veterans Administration, Aurora, CO, USA
| | - Layla A Abushamat
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Adnin Zaman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
- Anschutz Health and Wellness Center, University of Colorado School of Medicine, Anschutz Medical Campus, 12348 E Montview Blvd, C263, Aurora, CO, 80045, USA
| | - Anthony J Millard
- Anschutz Health and Wellness Center, University of Colorado School of Medicine, Anschutz Medical Campus, 12348 E Montview Blvd, C263, Aurora, CO, 80045, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Marc-Andre Cornier
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
- Anschutz Health and Wellness Center, University of Colorado School of Medicine, Anschutz Medical Campus, 12348 E Montview Blvd, C263, Aurora, CO, 80045, USA.
- Rocky Mountain Regional Veterans Administration, Aurora, CO, USA.
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Abstract
CONTEXT Obesity is a chronic disease that is difficult to manage without holistic therapy. The therapeutic armamentarium for obesity primarily consists of 4 forms of therapy: lifestyle modification (ie, diet and exercise), cognitive behavioral therapy, pharmacotherapy, and bariatric surgery. EVIDENCE ACQUISITION Evidence was consolidated from randomized controlled trials, observational studies, and meta-analyses. EVIDENCE SYNTHESIS After 2 years, lifestyle interventions can facilitate weight loss that equates to ~5%. Even though lifestyle interventions are plagued by weight regain, they can have substantial effects on type 2 diabetes and cardiovascular disease risk. Although 10-year percentage excess weight loss can surpass 50% after bariatric surgery, weight regain is likely. To mitigate weight regain, instituting a multifactorial maintenance program is imperative. Such a program can integrate diet, exercise, and pharmacotherapy. Moreover, behavioral therapy can complement a maintenance program well. CONCLUSIONS Obesity is best managed by a multidisciplinary clinical team that integrates diet, exercise, and pharmacotherapy. Bariatric surgery is needed to manage type 2 diabetes and obesity in select patients.
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Affiliation(s)
- Karim Kheniser
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - David R Saxon
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine and Rocky Mountain VA Medical Center, Anschutz Medical Campus, Aurora, CO, USA
| | - Sangeeta R Kashyap
- Department of Endocrinology and Metabolism, Cleveland Clinic, Cleveland, OHUSA
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San Giovanni CB, Sweeney B, Skelton JA, Kelsey MM, Kelly AS. Aversion to Off-label Prescribing in Clinical Pediatric Weight Management: The Quintessential Double Standard. J Clin Endocrinol Metab 2021; 106:2103-2113. [PMID: 33901290 PMCID: PMC8600003 DOI: 10.1210/clinem/dgab276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Pediatric obesity is now recognized as a chronic disease; yet few treatment options exist besides lifestyle modification therapy and bariatric surgery. We describe the limited availability of United States Food and Drug Administration (FDA)-approved antiobesity medications for adolescents and compare this to what is available for adults. We offer a rationale for off-label prescribing to assist with lifestyle modification therapy. We also highlight the need for more pharmacotherapy options and additional research into novel treatments for pediatric obesity. CASE DESCRIPTION We describe a patient who is struggling with managing her weight and starting to develop complications of obesity. We offer a framework in which off-label prescribing may be beneficial to patients who have been engaging in lifestyle modification therapy yet fail to see improvement. CONCLUSION Lifestyle modification therapy is necessary but often insufficient in stimulating clinically meaningful weight loss when used alone in children and adolescents who struggle with weight management. Until more FDA-approved antiobesity medications are available, pediatricians may be able to help more patients achieve weight reduction goals by familiarizing themselves with the responsible use of off-label medications and implementing these tools to improve clinical outcomes. There is a critical need for more pharmacotherapy options to help pediatric patients in managing their weight and preventing or improving the insidious complications resulting from untreated obesity.
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Affiliation(s)
- Christine B San Giovanni
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA
- Correspondence: Christine B San Giovanni, Department of Pediatrics, 135 Rutledge Avenue, Charleston, SC 29425, USA.
| | - Brooke Sweeney
- Department of Pediatrics, University of Missouri, Kansas City, MO 65211, USA
| | - Joseph A Skelton
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Megan M Kelsey
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Aaron S Kelly
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota Medical School, Minneapolis, MN 55812, USA
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Odi R, Invernizzi RW, Gallily T, Bialer M, Perucca E. Fenfluramine repurposing from weight loss to epilepsy: What we do and do not know. Pharmacol Ther 2021; 226:107866. [PMID: 33895186 DOI: 10.1016/j.pharmthera.2021.107866] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 12/21/2022]
Abstract
In 2020, racemic-fenfluramine was approved in the U.S. and Europe for the treatment of seizures associated with Dravet syndrome, through a restricted/controlled access program aimed at minimizing safety risks. Fenfluramine had been used extensively in the past as an appetite suppressant, but it was withdrawn from the market in 1997 when it was found to cause cardiac valvulopathy. Available evidence indicates that appetite suppression and cardiac valvulopathy are mediated by different serotonergic mechanisms. In particular, appetite suppression can be ascribed mainly to the enantiomers d-fenfluramine and d-norfenfluramine, the primary metabolite of d-fenfluramine, whereas cardiac valvulopathy can be ascribed mainly to d-norfenfluramine. Because of early observations of markedly improved seizure control in some forms of epilepsy, fenfluramine remained available in Belgium through a Royal Decree after 1997 for use in a clinical trial in patients with Dravet syndrome at average dosages lower than those generally prescribed for appetite suppression. More recently, double-blind placebo-controlled trials established its efficacy in the treatment of convulsive seizures associated with Dravet syndrome and of drop seizures associated with Lennox-Gastaut syndrome, at doses up to 0.7 mg/kg/day (maximum 26 mg/day). Although no cardiovascular toxicity has been associated with the use of fenfluramine in epilepsy, the number of patients exposed to date has been limited and only few patients had duration of exposure longer than 3 years. This article analyzes available evidence on the mechanisms involved in fenfluramine-induced appetite suppression, antiseizure effects and cardiovascular toxicity. Despite evidence that stimulation of 5-HT2B receptors (the main mechanism leading to cardiac valvulopathy) is not required for antiseizure activity, there are many critical gaps in understanding fenfluramine's properties which are relevant to its use in epilepsy. Particular emphasis is placed on the remarkable lack of publicly accessible information about the comparative activity of the individual enantiomers of fenfluramine and norfenfluramine in experimental models of seizures and epilepsy, and on receptors systems considered to be involved in antiseizure effects. Preliminary data suggest that l-fenfluramine retains prominent antiseizure effects in a genetic zebrafish model of Dravet syndrome. If these findings are confirmed and extended to other seizure/epilepsy models, there would be an incentive for a chiral switch from racemic-fenfluramine to l-fenfluramine, which could minimize the risk of cardiovascular toxicity and reduce the incidence of adverse effects such as loss of appetite and weight loss.
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Affiliation(s)
- Reem Odi
- Institute of Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Tamar Gallily
- Yissum Technology Transfer Company of the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Meir Bialer
- Institute of Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel; David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Emilio Perucca
- Division of Clinical and Experimental Pharmacology, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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Ard JD, Lewis KH, Cohen SS, Rothberg AE, Coburn SL, Loper J, Matarese L, Pories WJ, Periman S. Differences in treatment response to a total diet replacement intervention versus a food-based intervention: A secondary analysis of the OPTIWIN trial. Obes Sci Pract 2020; 6:605-614. [PMID: 33354339 PMCID: PMC7746973 DOI: 10.1002/osp4.444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/30/2020] [Accepted: 07/25/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE For every weight loss treatment, there are usually groups of people who lose less than expected. This study sought to determine if response rates to a total diet replacement (TDR) differed from those of a calorie-restricted, food-based (FB) diet. METHODS Data from OPTIWIN, a 12-month multicenter trial in adults with a BMI of 30-55 kg/m2, with 26-week weight-loss and weight-maintenance phases, were utilized. Participants (n = 330) were randomized to the OPTIFAST programme (OP) or to a reduced-energy FB diet. Treatment non-responders were defined as those who lost <3% of initial weight at months 6 or 12. RESULTS There were 103 (76%) responders in the OP compared with 78 (57%) in the FB group at 12 months. The odds of treatment response at 12 months among participants who were non-responders at 3 months was not significantly different between the OP and FB groups (p = 0.64). Race, type 2 diabetes status and previous weight loss attempts were significantly associated with responder status. OP responders had higher meal plan adherence and non-caloric fluid intake compared with FB responders. CONCLUSION Early treatment response is more likely and better sustained with TDR compared with an FB diet. Individual and treatment level factors appear to influence early treatment response to behavioural interventions for weight reduction.
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Affiliation(s)
- Jamy D. Ard
- Department of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Kristina H. Lewis
- Department of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | | | - Amy E. Rothberg
- Department of Internal MedicineMichigan MedicineAnn ArborMichiganUSA
| | | | - Judy Loper
- The Central Ohio Nutrition Center, Inc.GahannaOhioUSA
| | - Laura Matarese
- Department of SurgeryEast Carolina University Brody School of MedicineGreenvilleNorth CarolinaUSA
| | - Walter J. Pories
- Department of SurgeryEast Carolina University Brody School of MedicineGreenvilleNorth CarolinaUSA
| | - Seletha Periman
- Nestlé Health Science, Global Research & DevelopmentBridgewaterNew JerseyUSA
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Neurochemical regulators of food behavior for pharmacological treatment of obesity: current status and future prospects. Future Med Chem 2020; 12:1865-1884. [PMID: 33040605 DOI: 10.4155/fmc-2019-0361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In recent decades, obesity has become a pandemic disease and appears to be an ultimate medical and social problem. Existing antiobesity drugs show low efficiency and a wide variety of side effects. In this review, we discuss possible mechanisms underlying brain-gut-adipose tissue axis, as well as molecular biochemical characteristics of various neurochemical regulators of body weight and appetite. Multiple brain regions are responsible for eating behavior, hedonic eating and food addiction. The existing pharmacological targets for treatment of obesity were reviewed as well.
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Gadde KM, Atkins KD. The limits and challenges of antiobesity pharmacotherapy. Expert Opin Pharmacother 2020; 21:1319-1328. [PMID: 32292094 PMCID: PMC7523877 DOI: 10.1080/14656566.2020.1748599] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/25/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Pharmacotherapy is a useful adjunct when patients with obesity are unable to achieve adequate benefit from lifestyle interventions. AREAS COVERED This review covers the history of antiobesity drugs, efficacy, and risks of currently approved drugs, limits of their usefulness in clinical practice, gaps in knowledge, methodological limitations of clinical trials, and reasons for underutilization. EXPERT OPINION In randomized controlled trials, currently approved antiobesity drugs have yielded an average weight loss ranging from approximately 3% to 9% relative to placebo at 1 year. Inadequate inclusion of racial and ethnic minorities and men, and high dropout rates in clinical trials limit generalizability of these findings to clinical practice. Weight loss achieved with antiobesity drugs is generally associated with lowered glycemia, but improvements in blood pressure and lipid measures tend to be marginal. There is limited evidence for sustained weight loss beyond 1 year and for safety and efficacy of antiobesity drugs in children and adolescents, and in post-bariatric surgery patients. None have demonstrated reduction in major adverse cardiovascular events or other significant disease outcomes. Limited health insurance coverage and negative perceptions of physicians have hindered the utilization of antiobesity drugs.
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Affiliation(s)
- Kishore M Gadde
- Pennington Biomedical Research Center , Baton Rouge, LA, USA
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Lee M, Lauren BN, Zhan T, Choi J, Klebanoff M, Abu Dayyeh B, Taveras EM, Corey K, Kaplan L, Hur C. The cost-effectiveness of pharmacotherapy and lifestyle intervention in the treatment of obesity. Obes Sci Pract 2020; 6:162-170. [PMID: 32313674 PMCID: PMC7156872 DOI: 10.1002/osp4.390] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/29/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Food and Drug Administration has approved several pharmacotherapies for the treatment of obesity. This study assesses the cost-effectiveness of six pharmacotherapies and lifestyle intervention for people with mild obesity (body mass indices [BMIs] 30 to 35). METHODS A microsimulation model was constructed to compare seven weight loss strategies plus no treatment: intensive lifestyle intervention, orlistat, phentermine, phentermine/topiramate, lorcaserin, liraglutide, and semaglutide. Weight loss, quality-of-life scores, and costs were estimated using clinical trials and other published literature. Endpoints included costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) with a willingness-to-pay (WTP) threshold of $100 000/QALY. Results were analysed at 1-, 3-, and 5-year time horizons. RESULTS At each of the three follow-up periods, phentermine was the cost-effective strategy, with ICERs of $46 258/QALY, $20 157/QALY, and $17 880/QALY after 1, 3, and 5 years, respectively. Semaglutide was the most effective strategy in the 3- and 5-year time horizons, with total QALYs of 2.224 and 3.711, respectively. However, the ICERs were prohibitively high at $1 437 340/QALY after 3 years and $576 931/QALY after 5 years. Deterministic and probabilistic sensitivity analyses indicated these results were robust. CONCLUSIONS Phentermine is the cost-effective pharmacologic weight-loss strategy. Although semaglutide is the most effective, it is not cost-effective because of its high price.
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Affiliation(s)
- Minyi Lee
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Brianna N. Lauren
- Department of General MedicineColumbia University Irving Medical CenterNew YorkNew York
- Healthcare Innovation Research and EvaluationColumbia University Irving Medical CenterNew YorkNew York
| | - Tiannan Zhan
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
| | - Jin Choi
- Department of General MedicineColumbia University Irving Medical CenterNew YorkNew York
- Healthcare Innovation Research and EvaluationColumbia University Irving Medical CenterNew YorkNew York
| | - Matthew Klebanoff
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Institute for Technology AssessmentMassachusetts General HospitalBostonMassachusetts
- Yale School of MedicineNew HavenConnecticut
| | - Barham Abu Dayyeh
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesota
| | - Elsie M. Taveras
- Department of PediatricsMassachusetts General HospitalBostonMassachusetts
| | - Kathleen Corey
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Harvard Medical SchoolBostonMassachusetts
| | - Lee Kaplan
- Gastroenterology DivisionMassachusetts General HospitalBostonMassachusetts
- Harvard Medical SchoolBostonMassachusetts
| | - Chin Hur
- Department of General MedicineColumbia University Irving Medical CenterNew YorkNew York
- Healthcare Innovation Research and EvaluationColumbia University Irving Medical CenterNew YorkNew York
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Chen KY, Brychta RJ, Abdul Sater Z, Cassimatis TM, Cero C, Fletcher LA, Israni NS, Johnson JW, Lea HJ, Linderman JD, O'Mara AE, Zhu KY, Cypess AM. Opportunities and challenges in the therapeutic activation of human energy expenditure and thermogenesis to manage obesity. J Biol Chem 2019; 295:1926-1942. [PMID: 31914415 DOI: 10.1074/jbc.rev119.007363] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The current obesity pandemic results from a physiological imbalance in which energy intake chronically exceeds energy expenditure (EE), and prevention and treatment strategies remain generally ineffective. Approaches designed to increase EE have been informed by decades of experiments in rodent models designed to stimulate adaptive thermogenesis, a long-term increase in metabolism, primarily induced by chronic cold exposure. At the cellular level, thermogenesis is achieved through increased rates of futile cycling, which are observed in several systems, most notably the regulated uncoupling of oxidative phosphorylation from ATP generation by uncoupling protein 1, a tissue-specific protein present in mitochondria of brown adipose tissue (BAT). Physiological activation of BAT and other organ thermogenesis occurs through β-adrenergic receptors (AR), and considerable effort over the past 5 decades has been directed toward developing AR agonists capable of safely achieving a net negative energy balance while avoiding unwanted cardiovascular side effects. Recent discoveries of other BAT futile cycles based on creatine and succinate have provided additional targets. Complicating the current and developing pharmacological-, cold-, and exercise-based methods to increase EE is the emerging evidence for strong physiological drives toward restoring lost weight over the long term. Future studies will need to address technical challenges such as how to accurately measure individual tissue thermogenesis in humans; how to safely activate BAT and other organ thermogenesis; and how to sustain a negative energy balance over many years of treatment.
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Affiliation(s)
- Kong Y Chen
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892.
| | - Robert J Brychta
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Zahraa Abdul Sater
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Thomas M Cassimatis
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Cheryl Cero
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Laura A Fletcher
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Nikita S Israni
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - James W Johnson
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Hannah J Lea
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Joyce D Linderman
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Alana E O'Mara
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Kenneth Y Zhu
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892
| | - Aaron M Cypess
- Diabetes, Endocrinology, and Obesity Branch, Intramural Research Program, NIDDK, National Institutes of Health, Bethesda, Maryland 20892.
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Saxon DR, Iwamoto SJ, Mettenbrink CJ, McCormick E, Arterburn D, Daley MF, Oshiro CE, Koebnick C, Horberg M, Young DR, Bessesen DH. Antiobesity Medication Use in 2.2 Million Adults Across Eight Large Health Care Organizations: 2009-2015. Obesity (Silver Spring) 2019; 27:1975-1981. [PMID: 31603630 PMCID: PMC6868321 DOI: 10.1002/oby.22581] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to examine the prescribing patterns and use of antiobesity medications in a large cohort of patients using data from electronic health records. METHODS Pharmacy- and patient-level electronic health record data were obtained on 2,248,407 adults eligible for weight-loss medications from eight geographically dispersed health care organizations. RESULTS A total of 29,964 patients (1.3% of total cohort) filled at least one weight-loss medication prescription. This cohort was 82.3% female, with median age 44.9 years and median BMI 37.2 kg/m2 . Phentermine accounted for 76.6% of all prescriptions, with 51.7% of prescriptions being filled for ≥ 120 days and 33.8% filled for ≥ 360 days. There was an increase of 32.9% in medication days for all medications in 2015 compared with 2009. Higher prescription rates were observed in women, black patients, and patients in higher BMI classes. Of 3,919 providers who wrote at least one filled prescription, 23.8% (n = 863) were "frequent prescribers" who wrote 89.6% of all filled prescriptions. CONCLUSIONS Weight-loss medications are rarely prescribed to eligible patients. Phentermine accounted for > 75% of all medication days, with a majority of patients filling it for more than 4 months. Less than one-quarter of prescribing providers accounted for approximately 90% of all prescriptions.
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Affiliation(s)
- David R Saxon
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | | | | | - David Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Matthew F Daley
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado, USA
| | - Caryn E Oshiro
- Kaiser Permanente Center for Health Research Hawaii, Honolulu, Hawaii, USA
| | - Corinna Koebnick
- Department of Research and Evaluation, Kaiser Permanente, Pasadena, California, USA
| | - Michael Horberg
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | - Deborah R Young
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | - Daniel H Bessesen
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Denver Health Medical Center, Denver, Colorado, USA
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Safavi R, Lih A, Kirkpatrick S, Haller S, Bailony MR. Impact of anti-obesity medication initiation and duration on weight loss in a comprehensive weight loss programme. Obes Sci Pract 2019; 5:468-478. [PMID: 31687171 PMCID: PMC6819971 DOI: 10.1002/osp4.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This retrospective study aimed to evaluate the impact of anti-obesity medication (AOM) initiation, usage and duration on weight loss in a 72-week precision obesity programme. The type of AOM, diet and exercise plan was chosen based upon an individual's biological and psychosocial needs. The 72-week study duration allowed for a fair investigation of the downstream impact of delayed versus early AOM initiation. METHODS Participants, aged ≥18 years with body mass index ≥30 kg m-2, enrolled from 1 March 2015 to 1 April 2017, were included. Subgroups were assigned by AOM usage (users versus non-users, early [before 8 weeks] versus delayed [after 8 weeks] AOM initiation and short [<6 months] versus long [≥6 months] AOM duration). Primary endpoints included change in baseline weight at 72 weeks and proportions achieving ≥5%, ≥10% and ≥15% weight loss. Outcomes were compared between subgroups. RESULTS Mean age and body mass index (N = 129) were 45.0 ± 14.0 years and 37.0 ± 6.0 kg m-2, respectively; 67% were female. At week 72, AOM users (N = 71) achieved significantly greater mean percentage reduction in baseline weight than non-users (N = 58). On average, baseline weight decreased by 14.04 ± 6.2% in users versus 10.9 ± 6.8% in non-users (P = 0.008); 84% and 94% of non-user and AOM users lost >5% weight loss (P = 0.006). A higher proportion of users lost ≥15% of weight (45.1% vs. 19.0%; P < 0.001). Mean percentage reduction in weight was greater for early versus delayed starters (-17.60 ± 5.3% vs. -13.95 ± 5.5%; P = 0.024), and longer AOM usage trended towards increased weight loss. CONCLUSION Early initiation of AOM may enhance weight loss.
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Affiliation(s)
- R. Safavi
- University of CaliforniaSanta CruzCaliforniaUSA
| | - A. Lih
- Research DepartmentEnara Health Inc.San MateoCaliforniaUSA
| | - S. Kirkpatrick
- Research DepartmentEnara Health Inc.San MateoCaliforniaUSA
| | - S. Haller
- Research DepartmentEnara Health Inc.San MateoCaliforniaUSA
| | - M. R. Bailony
- Research DepartmentEnara Health Inc.San MateoCaliforniaUSA
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Marra S, Arnaldi D, Nobili L. The pharmacotherapeutic management of obstructive sleep apnea. Expert Opin Pharmacother 2019; 20:1981-1991. [DOI: 10.1080/14656566.2019.1652271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Stefano Marra
- Department of Neuroscience, IRCCS, G. Gaslini Institute, Genoa, Italy
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Dario Arnaldi
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
- Neurology Unit, IRCCS San Martino Hospital, Genoa, Italy
| | - Lino Nobili
- Department of Neuroscience, IRCCS, G. Gaslini Institute, Genoa, Italy
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
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Lewis KH, Fischer H, Ard J, Bessesen D, Daley M, Desai J, Fitzpatrick S, Horberg M, Koebnick C, Oshiro C, Young DR, Arterburn DE. Response to "Knowledge Gaps in Long-Term Phentermine Use". Obesity (Silver Spring) 2019; 27:1220. [PMID: 31264802 DOI: 10.1002/oby.22517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kristina H Lewis
- Department of Epidemiology and Prevention and Department of Implementation Science, Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA
| | - Heidi Fischer
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jamy Ard
- Department of Epidemiology and Prevention and Department of Implementation Science, Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA
| | | | - Matt Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Jay Desai
- HealthPartners Institute, Bloomington, Minnesota, USA
| | | | - Michael Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
| | - Corinna Koebnick
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Caryn Oshiro
- Center for Health Research, Kaiser Permanente Hawaii, Honolulu, Hawaii, USA
| | - Deborah R Young
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
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50
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Bramante CT, Raatz S, Bomberg EM, Oberle MM, Ryder JR. Cardiovascular Risks and Benefits of Medications Used for Weight Loss. Front Endocrinol (Lausanne) 2019. [PMID: 32010059 DOI: 10.3389/fendo.2019.00883/bibtex] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Abstract
Obesity is a complex disease influenced by many neurohormonal pathways which regulate body weight toward homeostasis. Presently, the disease of obesity effects over a billion individuals worldwide with scalable treatment options in dire need. Pharmacologic interventions for obesity have been developed to help promote weight loss in individuals with obesity. This area is rapidly developing and will only exponentially increase to serve the demand for persons with obesity seeking biologically orientated solutions to treat their disease. Therefore, understanding the cardiovascular risks and benefits of these weight loss medications is of particularly importance due to obesities strong association with cardiovascular (CV) disease risk. Moreover, past experiences with pharmacotherapy agents with weight loss properties have demonstrated an association with adverse CV outcomes, leading to market removal, in most cases and concerns over using similar medications. To better understand the CV risks and benefits pharmacotherapy agents used for weight loss, this review will discuss medications which are FDA-approved for weight loss, as well as medications commonly used off-label for this indication. The goal is to provide an overview of the risks and benefits many of these medications can offer to help guide clinical decision making and patient education.
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Affiliation(s)
- Carolyn T Bramante
- Center for Pediatric Obesity Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Sarah Raatz
- Center for Pediatric Obesity Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Eric M Bomberg
- Center for Pediatric Obesity Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
- Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Megan M Oberle
- Center for Pediatric Obesity Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
- Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Justin R Ryder
- Center for Pediatric Obesity Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
- Division of Pediatric Epidemiology and Clinical Research, University of Minnesota Medical School, Minneapolis, MN, United States
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