74th Scientific Sessions of the American Diabetes Association (ADA):
Pediatric Obesity and Drugs for Chronic Weight Management
Drug Therapies for Pediatric Obesity was part of an important symposium, Obesity in Our Youth, presented during the 74th Scientific Sessions of the American Diabetes Association from June 13-17, 2014 in San Francisco, California. Lorraine Katz, MD spoke on behalf of Robert I. Berkowitz, MD about medication interventions to treat pediatric obesity. Dr. Katz is Associate Professor at the University of Pennsylvania School of Medicine, and an attending physician at the Diabetes Center for Children at The Children’s Hospital of Philadelphia has been involved in numerous studies related to childhood diabetes.
The data Dr. Katz presented is based on adult data because there are so few pharmacotherapeutic options for children. Currently, there are three medications approved for chronic weight management: orlistat, lorcaserin, and a combination drug, phentermine/topiramate. Orlistat is the only drug that is approved for ages 12 and older.
In adults, the criteria are a BMI ≥30 kg/m2 or a BMI of ≥27 kg/m2 with a comorbid condition (eg, type 2 diabetes, hypertension, hyperlipidemia). Selection criteria in adolescents are children who are ≥ to the 95th percentile BMI for age and gender, and free of contraindications for the particular medications.
Dr. Katz emphasized that individuals seen for weight loss therapy should have medical evaluations and monitoring. When medication is recommended, it is as an adjunct to diet and exercise counseling—it is not a substitute. Consider combined treatment, not only for pharmacotherapy, but behavioral therapy and meal replacement. Pharmacotherapy will decrease hunger, preoccupation with food, and nutrient absorption, while it increases satiation.
Orlistat is a peripheral lipase inhibitor available by prescription (Xenical®) or over-the-counter as Alli®. It is approved for long-term use in adults. It blocks the lipases, causes inhibition of lipases and blocks the absorption of dietary fats. Orlistat is given as 120 mg three times per day with meals containing fat as part of a nutritionally balanced, reduced-calorie diet. The diet should contain approximately 30% of calories from fat distributed over three meals per day. A multivitamin is recommended because of potential fat-soluble vitamin loss. In pediatric trials, the results of orlistat are statistically significant.
Lorcaserin (Belviq®) is one newly approved drug. Lorcaserin increases satiety and is given as one fixed-dose 10 mg twice daily. There is no pediatric approval for this drug. The Behavioral Modification and Lorcaserin for Overweight and Obesity Management study (BLOOM Study) showed significant improvements in waist circumference and other parameters.
Phentermine/topiramate extended-release (Qsymia®) is not approved for pediatric use. It has two mechanisms of action.
- Phentermine is sympathomimetic, affects norepinephrine release and blunts appetite.
- Topiramate affects GABA receipt modulation; it’s a carbonic anhydrase inhibitor that causes glutamate antagonism, which prolongs satiety.
Naltrexone sustained-release (SR) and bupropion SR (Contrave®, Orexigen Therapeutics, Inc.) is not yet FDA-approved. “The drug’s preliminary CPD study [Contrave Light Study] appears to be favorable so far,” Dr. Katz stated. Naltrexone is an opium inhibitor, which is commonly used in the treatment of alcoholism. Bupropion increases pro-opiomelanocortin firing, which affects a modest weight loss as a monotherapy.
Dr. Katz also mentioned an interest in liraglutide because of its “satiety-promoting effects.”