Full Guideline: Pharmacological Management of Obesity
JCEM | February 2016
Caroline M. Apovian (Chair), Louis J. Aronne, Daniel H. Bessesen, Marie E. McDonnell, M. Hassan Murad, Uberto Pagotto, Donna H. Ryan, and Christopher D. Still
The 2016 guideline on the pharmacological management of obesity addresses:
- Management of chronic obesity, including managing comorbid conditions
- Monitoring progress of weight loss using medication
- Choosing alternative medications that are weight-losing or weight-neutral in the management of other medical conditions such as T2D, depression and other mental health conditions, chronic inflammatory diseases and arthritis, and epilepsy
Essential Points
The Endocrine Society recommends that diet, exercise and behavioral modifications be part of all obesity management approaches. Other tools such as weight loss medications and bariatric 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.
Other 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, people with diabetes who are obese or overweight should be given medications that promote weight loss or have no effect on weight as first- and second-line treatments. 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 obese people with Type 2 diabetes. 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.
- In patients with uncontrolled high blood pressure or a history of heart disease, the medications phentermine and diethylpropion should not be used.
Summary of Recommendations
+ 1.0 Care of the patient who is overweight or obese
- 1.1 We recommend that diet, exercise, and behavioral modification be included in all obesity management approaches for body mass index (BMI) ≥ 25 kg/m2 and that other tools such as pharmacotherapy (BMI ≥ 27 kg/m2 with comorbidity or BMI over 30 kg/m2) and bariatric surgery (BMI ≥ 35 kg/m2 with comorbidity or BMI over 40 kg/m2) be used as adjuncts to behavioral modification to reduce food intake and increase physical activity when this is possible. Drugs may amplify adherence to behavior change and may improve physical functioning such that increased physical activity is easier in those who cannot exercise initially. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications. (1|⊕⊕⊕⊕)
- 1.2 In order to promote long-term weight maintenance, we suggest the use of approved 1 weight loss medication (over no pharmacological therapy) to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI ≥ 30 kg/m2 or in individuals with a BMI of ≥ 27 kg/m2 and at least one associated comorbid medical condition such as hypertension, dyslipidemia, type 2 diabetes (T2DM), and obstructive sleep apnea. (2|⊕⊕⚪⚪)
- 1.3 In patients with uncontrolled hypertension or a history of heart disease, we recommend against using the sympathomimetic agents phentermine and diethylpropion. (1|⊕⊕⊕⚪)
- 1.4 We suggest assessment of efficacy and safety at least monthly for the first 3 months, then at least every 3 months in all patients prescribed weight loss medications. (2|⊕⊕⚪⚪)
- 1.5 If a patient's response to a weight loss medication is deemed effective (weight loss ≥ 5% of body weight at 3 mo) and safe, we recommend that the medication be continued. If deemed ineffective (weight loss < 5% at 3 mo) or if there are safety or tolerability issues at any time, we recommend that the medication be discontinued and alternative medications or referral for alternative treatment approaches be considered. (1|⊕⊕⊕⊕)
- 1.6 If medication for chronic obesity management is prescribed as adjunctive therapy to comprehensive lifestyle intervention, we suggest initiating therapy with dose escalation based on efficacy and tolerability to the recommended dose and not exceeding the upper approved dose boundaries. (2|⊕⊕⚪⚪)
- 1.7 In patients with T2DM who are overweight or obese, we suggest the use of antidiabetic medications that have additional actions to promote weight loss (such as glucagon-like peptide-1 [GLP-1] analogs or sodium-glucose-linked transporter-2 [SGLT-2] inhibitors), in addition to the first-line agent for T2DM and obesity, metformin. (2|⊕⊕⊕⚪)
- 1.8 In patients with cardiovascular disease who seek pharmacological treatment for weight loss, we suggest using medications that are not sympathomimetics such as lorcaserin and/or orlistat. (2|⊕⚪⚪⚪)
+ 2.0 Drugs that cause weight gain and some alternatives
- 2.1 We recommend weight-losing and weight-neutral medications as first- and second-line agents in the management of a patient with T2DM who is overweight or obese. Clinicians should discuss possible weight effects of glucose-lowering medications with patients and consider the use of antihyperglycemic medications that are weight neutral or promote weight loss. (1|⊕⊕⊕⚪)
- 2.2 In obese patients with T2DM requiring insulin therapy, we suggest adding at least one of the following: metformin, pramlintide, or GLP-1 agonists to mitigate associated weight gain due to insulin. The first-line insulin for this type of patient should be basal insulin. This is preferable to using either insulin alone or insulin with sulfonylurea. We also suggest that the insulin therapy strategy be considered a preferential trial of basal insulin prior to premixed insulins or combination insulin therapy. (2|⊕⊕⊕⚪)
- 2.3 We recommend angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers rather than β-adrenergic blockers as first-line therapy for hypertension in patients with T2DM who are obese. (1|⊕⊕⊕⊕)
- 2.4 When antidepressant therapy is indicated, we recommend a shared decision-making process that provides patients with quantitative estimates of the expected weight effect of the antidepressant to make an informed decision about drug choice. Other factors that need to be taken into consideration include the expected length of treatment. (1|⊕⊕⊕⚪)
- 2.5 We recommend using weight-neutral antipsychotic alternatives when clinically indicated, rather than those that cause weight gain, and the use of a shared decision-making process that provides patients with quantitative estimates of the expected weight effect of the alternative treatments to make an informed decision about drug choice. (1|⊕⊕⊕⚪)
- 2.6 We recommend considering weight gain potential in choosing an antiepileptic drug (AED) for any given patient, and the use of a shared decision-making process that provides patients with quantitative estimates of the expected weight effect of the drugs to make an informed decision about drug choice. (1|⊕⊕⊕⚪)
- 2.7 In women with a BMI > 27 kg/m2 with comorbidities or BMI > 30 kg/m2seeking contraception, we suggest oral contraceptives over injectable medications due to weight gain with injectables, provided that women are well-informed about the risks and benefits (ie, oral contraceptives are not contraindicated). (2|⊕⚪⚪⚪)
- 2.8 We suggest monitoring the weight and waist circumference of patients on antiretroviral therapy due to unavoidable weight gain, weight redistribution, and associated cardiovascular risk. (2|⊕⊕⊕⚪)
- 2.9 We suggest the use of nonsteroidal anti-inflammatory drugs and disease-modifying antirheumatic drugs when possible in patients with chronic inflammatory disease like rheumatoid arthritis because corticosteroids commonly produce weight gain. (2|⊕⊕⊕⚪)
- 2.10 We suggest the use of antihistamines with less central nervous system activity (less sedation) to limit weight gain. (2|⊕⊕⚪⚪)
+ 3.0 Off label use of drugs approved of other indications for chronic obesity management
- 3.1 We suggest against the off-label use of medications approved for other disease states for the sole purpose of producing weight loss. A trial of such therapy can be attempted in the context of research and by healthcare providers with expertise in weight management dealing with a well-informed patient. (Ungraded Best Practice Recommendation)
