New Guidelines Issued on Treating Obesity with Medicine

Published in February 2015 Issue             

The Endocrine Society has issued a new clinical practice guideline on the use of drugs in managing obesity and promoting weight loss. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline, was published online in January and will be in the February 2015 print edition of the Journal of Clinical Endocrinology and Metabolism (JCEM), a publication of the Endocrine Society.

These guidelines, which were supported by The Obesity Society (TOS) and the European Society of Endocrinology, expand on the Guidelines (2013) for Managing Overweight and Obesity in Adults, published last year by the American Heart Association, American College of Cardiology, and TOS.

Donna Ryan, MD

“The pharmacotherapy guideline provides a roadmap for clinicians considering anti-obesity drug treatment for patients not finding success with diet and exercise alone,” said Donna Ryan, MD, member of the development panel and professor emeritus at Louisiana State University's Pennington Biomedical Research Center, speaking for TOS in a press statement. “The new guideline provides doctors with recommended medications and dosage based on obesity-related comorbidities, including type 2 diabetes and cardiovascular disease. Further, it gives specific recommendations for transitioning patients off drugs that cause weight gain, shifting the treatment paradigm from treating weight last, to treating weight first.”

The new guideline comes at a particularly important time for pharmacotherapy and obesity. In the last two years the U.S. Food and Drug Administration (FDA) approved four anti-obesity medications: Belviq, Qsymia, Contrave and Saxenda. The new guideline is the first to mention specific obesity drugs and provide guidance on how to prescribe them.

"Lifestyle changes should always be a central part of any weight loss strategy," said Caroline M. Apovian, MD, of Boston University School of Medicine and Boston Medical Center, and chair of the task force that authored the guideline, in a press statement. "Medications do not work by themselves, but they can help people maintain a healthy diet by reducing the appetite. Adding a medication to a lifestyle modification program is likely to result in greater weight loss."

The new guideline recommends diet, exercise and behavioral modifications be part of all obesity management approaches. Other tools including weight loss medications and bariatric and metabolic surgery can be combined with behavioral changes to reduce food intake and increase physical activity. Patients who have been unable to successfully lose weight and maintain a goal weight may be candidates for prescription medication if they meet the criteria on the drug's label.

Recommendations include:

  • If a patient responds well to a weight loss medication and loses 5 percent or more of their body weight after three months, the medication should be continued. If the medication is ineffective or the patient experiences side effects, the prescription should be stopped and an alternative medication or approach considered.

  • Since some diabetes medications are associated with weight gain, patients with obesity or overweight should be given medications that promote weight loss or have no effect on weight as first- and second-line treatments. Doctors should discuss medications' potential effects on weight with patients.

  • Certain types of medication - angiotensin converting enzyme inhibitors, angiotensin receptor blockers and calcium channel blockers - should be used as a first-line treatment for high blood pressure in people with type 2 diabetes and obesity. These are effective blood pressure treatments that are less likely to contribute to weight gain than the alternative medication, beta-adrenergic blockers.

  • When patients need medications that can have an impact on weight such as antidepressants, antipsychotic drugs and medications for treating epilepsy, they should be fully informed and provided with estimates of each option's anticipated effect on weight. Doctors and patients should engage in a shared-decision making process to evaluate the options.

John Morton, MD

“More clinicians than ever are focused on evidence-based treatments for obesity and determining which treatment works for which patient and when. These guidelines, along with previous ones that include bariatric and metabolic surgery, will help so will better reimbursement and insurance coverage,” said John M. Morton, MD, ASMBS President. “Targeting obesity itself greatly reduces the development and progression of related diseases and complications including hypertension, type 2 diabetes and heart disease. We’ve seen it work in our surgery patients. These new drug therapies can potentially be used in combination with endoscopic and surgical approaches, creating a multi-modality approach like we see in other disease states like cancer and heart disease.”