Phentermine and topiramate extended-release: a new treatment for obesity and its role in a complications-centric approach to obesity medical management

Strengths and Limitations of BMI in the Diagnosis of Obesity: What is the Path Forward?

PURPOSE OF REVIEW

This review aims to discuss strengths and limitations of body mass index (BMI) in diagnosing obesity, the use of alternative anthropometric measurements, and potential new technology that may change the future of obesity diagnosis and management.

RECENT FINDINGS

The diagnosis of obesity requires the anthropometric assessment of adiposity. In clinical settings, this should include BMI with confirmation that elevated BMI represents excess adiposity and a measure of fat distribution (i.e., waist circumference (WC), waist to height ratio (WHtR), or WC divided by height0.5 (WHR.5R). Digital anthropometry and bioelectric impedance (BIA) can estimate fat distribution and be feasibly employed in the clinic. In addition, the diagnosis should include a clinical component assessing the presence and severity of weight-related complications. As anthropometric measures used in the diagnosis of obesity, BMI is generally sufficient if confirmed to represent excess adiposity, and there are advantages to the use of WHtR over WC to assess fat distribution. BIA and digital anthropometry have the potential to provide accurate measures of fat mass and distribution in clinical settings. There should also be a clinical evaluation for the presence and severity of obesity complications that can be used to stage the disease.

Screening, Diagnosis, and Treatment of Patients with Binge Eating Disorder and Obesity: What the Endocrinologist Needs to Know

Binge eating disorder (BED) is the most common eating disorder categorized in the DSM-V, but it is often not diagnosed in patients with obesity because it can be difficult to detect in these patients who often have altered eating patterns. In this narrative review, we have highlighted the most recent findings in the screening, diagnosis, and treatment of patients with BED and obesity. The results of our search showed that many BED patients are not obese, and most people with obesity do not have binge behavior. In the diagnostic assessment of these patients, it is important to evaluate not only the clinical and nutritional status and the presence of medical comorbidities, but also the psychological signs and symptoms related to psychiatric comorbidities to define the appropriate diagnosis and the consequent level of treatment. Well-tolerated drugs with action on both body weight and binges can be useful as a second-line complement to cognitive behavioral therapy (CBT). Specific guidelines are needed to obtain consensus on appropriate recommendations in patients with obesity and BED approaching bariatric surgery, taking into account not only weight reduction and clinical data, but also eating behaviors. Identification of BED is important for targeting individuals at high risk of obesity, adverse metabolic patterns, and cardiovascular disease. The challenge is to also achieve lasting weight loss in patients with BED and concomitant obesity.

Pharmacokinetic and pharmacodynamic interaction of DWP16001, a sodium-glucose cotransporter-2 inhibitor, with phentermine in healthy subjects

BACKGROUND

DWP16001, a sodium-glucose cotransporter-2 inhibitor, has shown promise for improving blood glucose control and facilitating weight loss. Co-administration with phentermine could enhance these effects. So, we aimed to evaluate the pharmacokinetic (PK) and pharmacodynamic (PD) interactions of DWP16001 and phentermine.

METHODS

We conducted a randomized, open-label, 3-treatment, 6-sequence, 3-period crossover study involving 24 healthy adults. Participants received either DWP16001 (2 mg), phentermine (37.5 mg), or a combination of both once daily for 7 days. Blood samples, urine samples, and body weights were collected to evaluate the PK and PD.

RESULTS

The PK of the combination was found to be similar to that of the monotherapy. The geometric mean ratio (GMR) of Cmax,ss, and AUCtau,ss were 0.98 and 1.00, respectively, for DWP16001, and 1.01 and 0.94, respectively, for phentermine. Co-administration did not significantly affect the 24-hour urinary glucose excretion compared to DWP16001 monotherapy, and the GMR was 0.90. Participants tended to experience greater weight loss in the combination therapy group, and all demonstrated good tolerance.

CONCLUSIONS

Our findings indicate that there were no significant interactions during co-administration. These results suggest that the combination of DWP16001 and phentermine may be safe and effective for the treatment of obesity and diabetes.

CLINICAL TRIAL REGISTRATION

NCT05321732.

Early intervention and intensive management of patients with diabetes, cardiorenal, and metabolic diseases

Increasing rates of obesity and diabetes have driven corresponding increases in related cardiorenal and metabolic diseases. In many patients, these conditions occur together, further increasing morbidity and mortality risks to the individual. Yet all too often, the risk factors for these disorders are not addressed promptly in clinical practice, leading to irreversible pathologic progression. To address this gap, we convened a Task Force of experts in cardiology, nephrology, endocrinology, and primary care to develop recommendations for early identification and intervention in obesity, diabetes, and other cardiorenal and metabolic diseases. The recommendations include screening and diagnosis, early interventions with lifestyle, and when and how to implement medical therapies. These recommendations are organized into primary and secondary prevention along the continuum from obesity through the metabolic syndrome, prediabetes, diabetes, hypertension, dyslipidemia, nonalcoholic fatty liver disease (NAFLD), atherosclerotic cardiovascular disease (ASCVD) and atrial fibrillation, chronic kidney disease (CKD), and heart failure (HF). The goal of early and intensive intervention is primary prevention of comorbidities or secondary prevention to decrease further worsening of disease and reduce morbidity and mortality. These efforts will reduce clinical inertia and may improve patients' well-being and adherence.

Natural Dietary and Medicinal Plants with Anti-Obesity Therapeutics Activities for Treatment and Prevention of Obesity during Lock Down and in Post-COVID-19 Era

Overweight and obesity have become global epidemics, especially during the lockdown due to the COVID-19 pandemic. The potential of medicinal plants as a better and safe option in treating obesity and overweight has gained attention in recent years. Obesity and overweight has become a major public health concern, and its incidence rising at an alarming rate. Obesity is one of the major types of metabolic syndrome, resulting in various types of problems such as hypertension, diabetes, dyslipidemia, and excess fat accumulation. The current searching was done by the keywords in main indexing systems including Scopus, PubMed/MEDLINE, the search engine of Google Scholar, and Institute for Scientific Web of Science. The keywords were traditional medicine, health benefits, pharmaceutical science, pomegranate, punicalin, punicalagin, and ellagitannins. Google Scholar was searched manually for possible missing manuscripts, and there was no language restriction in the search. This review was carried out to highlight the importance of medicinal plants which are common in traditional medicinal sciences of different countries, especially Asia to prevent and treatment of obesity and overweight during the global pandemic and the post-COVID-19 era.

Case Report: Bilateral Ciliary Body Detachment in a Patient Taking Oral Diet Pills

SIGNIFICANCE

The use of antiobesity drugs is becoming more widespread, and the resulting adverse effects are also increasing. Visual impairments caused by weight-loss pills need a timely and accurate diagnosis and treatment. Prompt diagnosis and treatment can achieve a satisfactory prognosis.

PURPOSE

This report describes a case of a significant decline in bilateral visual acuity caused by taking diet pills and explores the possible pathogenesis.

CASE REPORT

A 32-year-old Chinese woman showed shallow anterior chambers, and intraocular pressure (IOP) was 38 mmHg bilaterally after taking Korean prescription diet pills for 6 days. The best-corrected visual acuity of both eyes was 0.03. The ultrasound biomicroscopy showed complete ciliary body detachment accompanied with angle closure. The central anterior chamber depths were 1.70 mm in the right eye and 1.61 mm in the left eye. The patient was diagnosed with ciliary body detachment with secondary elevated IOP. The patient was treated with pilocarpine, carteolol hydrochloride, brinzolamide, mannitol, and dexamethasone sodium phosphate. The patient had rewarding prognosis after treatment with discontinuation of diet pills, control of IOP, and glucocorticoids.

CONCLUSIONS

Extensive publicity and education are needed to ensure that consumers do not abuse diet pills; meanwhile, a timely diagnosis and withdrawal are crucial for a desirable prognosis. Clinicians need to consider the possibility of drug-secondary ocular diseases.

Medications Available for Weight Reduction in Elective Total Joint Arthroplasty

Arthroplasty in patients with elevated body mass index results in increased rates of reoperation, instability, revision, and infection. Preoperative weight loss may reduce the complication rate associated with orthopaedic surgery. In addition to lifestyle modification, anti-obesity medications are available to help patients to reduce their preoperative weight. Currently, there are 6 U.S. Food and Drug Administration (FDA)-approved anti-obesity medications in the United States: phentermine, orlistat, phentermine with topiramate extended release (ER), lorcaserin, sustained release (SR) naltrexone with bupropion, and liraglutide. Anti-obesity medications potentially provide a new way to optimize patients before surgery and to ensure successful recovery postoperatively.

Cooperative role of the glucagon-like peptide-1 receptor and β3-adrenergic-mediated signalling on fat mass reduction through the downregulation of PKA/AKT/AMPK signalling in the adipose tissue and muscle of rats

AIM

To explore the cooperation of GLP-1 receptor and β3-adrenergic receptor (β3-AR)-mediated signalling in the control of fat mass/feeding behaviour by studying the effects of a combined therapy composed of the GLP-1R agonist liraglutide and the β3-AR agonist CL316243.

METHODS

The study included the analysis of key mechanisms regulating lipid/cholesterol metabolism, and thermogenesis in brown (BAT) and epididymal white (eWAT) adipose tissues, abdominal muscle and liver of male rats.

RESULTS

CL316243 (1 mg kg^-1 ) and liraglutide (100 μg kg^-1 ) co-administration over 6 days potentiated an overall negative energy balance (reduction in food intake, body weight gain, fat/non-fat mass ratio, liver fat content, and circulating levels of non-essential fatty acids, triglycerides, very low-density lipoprotein-cholesterol and leptin). These effects were accompanied by increased plasma levels of insulin and IL6. We also observed increased gene expression of uncoupling proteins regulating thermogenesis in BAT/eWAT (Ucp1) and muscle (Ucp2/3). Expression of transcription factor and enzymes involved either in de novo lipogenesis (Chrebp, Acaca, Fasn, Scd1, Insig1, Srebp1) or in fatty acid β-oxidation (Cpt1b) was enhanced in eWAT and/or muscle but decreased in BAT. Pparα and Pparγ, essentials in lipid flux/storage, were decreased in BAT/eWAT but increased in the muscle and liver. Cholesterol synthesis regulators (Insig2, Srebp2, Hmgcr) were particularly over-expressed in muscle. These GLP-1R/β3-AR-induced metabolic effects were associated with the downregulation of cAMP-dependent signalling pathways (PKA/AKT/AMPK).

CONCLUSION

Combined activation of GLP-1 and β3-ARs potentiate changes in peripheral pathways regulating lipid/cholesterol metabolism in a tissue-specific manner that favours a switch in energy availability/expenditure and may be useful for obesity treatment.

Weight maintenance: challenges, tools and strategies for primary care physicians

Obesity is recognized as a chronic disease and one of the major healthcare challenges facing us today. Weight loss can be achieved via lifestyle, pharmacological and surgical interventions, but weight maintenance remains a lifetime challenge for individuals with obesity. Guidelines for the management of obesity have highlighted the role of primary care providers (PCPs). This review examines the long-term outcomes of clinical trials to identify effective weight maintenance strategies that can be utilized by PCPs. Because of the broad nature of the topic, a structured PubMed search was conducted to identify relevant research articles, peer-reviewed reviews, guidelines and articles published by regulatory bodies. Trials have demonstrated the benefit of sustained weight loss in managing obesity and its comorbidities. Maintaining 5-10% weight loss for ≥1 year is known to ameliorate many comorbidities. Weight maintenance with lifestyle modification - although challenging - is possible but requires long-term support to reinforce diet, physical activity and behavioural changes. The addition of pharmacotherapy to lifestyle interventions promotes greater and more sustained weight loss. Clinical evidence and recently approved pharmacotherapy has given PCPs improved strategies to support their patients with maintenance of weight loss. Further studies are needed to assess the translation of these strategies into clinical practice.

Amphetamine-Like Analogues in Diabetes: Speeding towards Ketogenesis

Obesity is common in patients with type 1 and type 2 diabetes. Amphetamine-like analogues comprise the most popular class of weight loss medications. We present a case of a 34-year-old African American female with a history of type 1 diabetes, dyslipidemia, and obesity who developed diabetic ketoacidosis (DKA) after starting Diethylpropion for the purpose of weight loss. Shortly after starting Diethylpropion, she developed nausea, vomiting, and periumbilical pain. Blood work revealed glucose of 718 mg/dL, pH 7.32 (7.35–7.45), bicarbonate 16 mmol/L (22–29 mmol/L), and anion gap 19 mmol/L (8–16 mmol/L). Urine analysis demonstrated large amount of ketones. She was hospitalized and successfully treated for DKA. Diethylpropion was discontinued. Amphetamine-like analogues administration leads to norepinephrine release from the lateral hypothalamus which results in the appetite suppression. Peripheral norepinephrine concentration rises as well. Norepinephrine stimulates adipocyte lipolysis and thereby increases nonesterified fatty acids (NEFA) availability. It promotes β-oxidation of NEFA to ketone bodies while decreasing metabolic clearance rate of ketones. In the setting of acute insulin deficiency these effects are augmented. Females are more sensitive to norepinephrine effects compared to males. In conclusion, amphetamine-like analogues lead to a release of norepinephrine which can result in a clinically significant ketosis, especially in the setting of insulin deficiency.

Tolerability and safety of the new anti-obesity medications

Worldwide obesity prevalence has nearly doubled since 1980. Due to numerous co-morbidities, obesity represents a serious health and socioeconomic problem worldwide. Pharmacotherapy should be an integral part of comprehensive obesity management. Drug therapy can assist in weight loss and its maintenance in those individuals who do not achieve appropriate weight loss through lifestyle interventions alone. After the withdrawal of sibutramine from the market in 2010, orlistat, a lipase inhibitor, was the only remaining prescription drug approved for the long-term treatment of obesity. In 2012, phentermine/topiramate extended-release (PHEN/TPM ER) combination and lorcaserin were approved by the US FDA as novel medications for long-term weight management. Three major phase III trials conducted with each drug confirmed their efficacy in terms of weight loss/maintenance and improvement of cardiometabolic risks. No head-to-head studies between the two new anti-obesity drugs have been carried out. However, in the existing studies PHEN/TPM ER had a superior weight loss profile to lorcaserin but the incidence of adverse effects was lower with lorcaserin. Both drugs were well-tolerated, and adverse events were modest in intensity, dose dependent, rather rare, and tended to decrease with the duration of treatment. Major safety concerns regarding PHEN/TPM ER include elevations in resting pulse rate, teratogenicity, mild metabolic acidosis, and psychiatric and cognitive adverse events. Valvulopathy, cognitive impairment, psychiatric disorders, and hypoglycemia represent major safety concerns for lorcaserin. Although existing trials have not demonstrated any significant issues with PHEN/TPM ER-induced heart rate elevation and lorcaserin-induced valvulopathy, all safety concerns should be seriously taken into account in patients treated with either of these novel anti-obesity medications.

Pharmacokinetic interactions between topiramate and diltiazem, hydrochlorothiazide, or propranolol

Drug-drug interactions between topiramate and diltiazem, hydrochlorothiazide, or propranolol were evaluated along with safety/tolerability in three open-label studies. Healthy participants (aged 18-45 years) received topiramate 75 mg every 12 hours (q12h) and diltiazem 240 mg/day (study 1); topiramate 96 mg q12h and hydrochlorothiazide 25 mg/day (study 2); topiramate 100 mg q12h and propranolol 40-80 mg q12h (study 3). The pharmacokinetic parameters for topiramate, diltiazem (and active metabolites, desacetyldiltiazem [DEA], N-demethyl diltiazem [DEM]), hydrochlorothiazide, and propranolol (and its active metabolite) were assessed at steady state. Results showed no effect of diltiazem on topiramate pharmacokinetics. However, a modest reduction in systemic exposures of diltiazem and DEA (10-27%) occurred during coadministration with topiramate. Systemic exposure of DEM was unaffected. Furthermore, oral and renal clearance of topiramate decreased (22-30%) significantly (P < 0.05) during coadministration with hydrochlorothiazide, while systemic exposure increased by 27-29%. Topiramate had no effect on hydrochlorothiazide pharmacokinetics. The results demonstrated lack of pharmacokinetic interaction between topiramate and propranolol. Overall, no new safety concerns emerged when topiramate was coadministered with diltiazem, hydrochlorothiazide, or propranolol.

The progression of cardiometabolic disease: validation of a new cardiometabolic disease staging system applicable to obesity

OBJECTIVE

To validate a Cardiometabolic Disease Staging (CMDS) system for assigning risk level for diabetes, and all-cause and cardiovascular disease (CVD) mortality.

DESIGN AND METHODS

Two large national cohorts, CARDIA and NHANES III, were used to validate CMDS. CMDS: Stage 0: metabolically healthy; Stage 1: one or two metabolic syndrome risk factors [other than impaired fasting glucose (IFG)]; Stage 2: IFG or impaired glucose tolerance (IGT) or metabolic syndrome (without IFG); Stage 3: two of three (IFG, IGT, and/or metabolic syndrome); and Stage 4: type 2 diabetes mellitus/CVD.

RESULTS

In the CARDIA study, compared with Stage 0 metabolically healthy subjects, adjusted risk for diabetes exponentially increased from Stage 1 [hazard ratio (HR) 2.83, 95% confidence interval (CI): 1.76-4.55], to Stage 2 (HR 8.06, 95% CI 4.91-13.2), to Stage 3 (HR 23.5, 95% CI 13.7-40.1) (P for trend <0.001). In NHANES III, both cumulative incidence and multivariable adjusted HRs markedly increased for both all-cause and CVD mortality with advancement of the risk stage from Stages 0 to 4. Adjustment for body mass index (BMI) minimally affected the risks for diabetes and all-cause/CVD mortality using CMDS.

CONCLUSION

CMDS can discriminate a wide range of risk for diabetes, CVD mortality, and all-cause mortality independent of BMI, and should be studied as a risk assessment tool to guide interventions that prevent and treat cardiometabolic disease.

New tools for weight-loss therapy enable a more robust medical model for obesity treatment: rationale for a complications-centric approach

OBJECTIVE

Recent advances in lifestyle intervention programs, pharmacotherapy, and bariatric surgery have enabled the development of medical models for the treatment of obesity. Regarding pharmacotherapy, in 2012 the U.S. Food and Drug Administration approved two new effective and safe weight-loss medications, phentermine/topiramate extended release and lorcaserin, which has greatly augmented options for medically assisted weight loss.

METHODS

The rationale for advantages of a complications-centric medical model over current body mass index (BMI)-centric indications for therapy is examined.

RESULTS

Currently, the baseline BMI level is the principle determinant of indications for obesity treatment using medication and surgery. However, the BMI-centric approach fails to target therapy to those obese patients who will benefit most from weight loss. In contrast, a complications-centric medical model is proposed that will earmark the modality and intensity of the therapeutic intervention based on the presence and severity of complications that can be ameliorated by weight loss.

CONCLUSION

The complications-centric approach to "medicalizing" obesity care employs weight loss primarily as a tool to treat obesity-related complications and promotes the optimization of health outcomes, the benefit/risk ratio, and the cost-effectiveness of therapy.