Obesity and Chronic Weight Management Medications
Comments by Caroline Apovian, MD, FACP, FACN
Only 2% of the millions of Americans who are eligible for chronic weight management medications are prescribed these agents and only 1% of the millions of Americans who are eligible for bariatric surgery receive this intervention, explained Caroline Apovian, MD, FACP, FACN, during a presentation at the American Association of Clinical Endocrinologists (AACE) 24th Annual Scientific & Clinical Congress in Nashville, TN in May 2015.
“Now if I told you that was true for heart disease, you would tell me that we have got a serious issue—that there’s malpractice and negligence. And this is true, I believe, for obesity,” said Dr. Apovian, who is Professor of Medicine and Pediatrics at Boston University School of Medicine, Director of the Nutrition and Weight Management Center and Director of the Nutrition Support Service both at the Boston Medical Center.
In January 2015, the Endocrine Society released a guideline on the pharmacologic management of obesity, on which Dr. Apovian was lead author.1 The guideline offers recommendations on use of weight loss medications and addressed medications that can cause weight gain, with recommendations on transitioning patients onto medications that promote weight neutrality or weight loss.
Importantly, the guideline stresses that chronic weight loss medications should be used as adjuncts, but “not a substitute for lifestyle modifications," Dr. Apovian said. “These medications can help patients lose approximately 5% to 10% of their initial body weight and the more intensive the lifestyle program, the more weight loss the patient will achieve,” Dr. Apovian said. Similarly, lifestyle changes are a central part of treatment for patients who undergo bariatric surgery.
Frequent Follow-up is Essential To Care
“Frequent patient follow-up is very important specifically for obesity management,” Dr. Apovian said. “We suggest that patients are seen at least monthly for the first 3 months, and then at least every 3 months during the first year,” she said. Thereafter, patients should be seen once or twice a year to make sure that the patient is maintaining the weight loss. This follow-up is supported by the Centers for Medicare and Medicaid Services (CMS) (Table 1).
Initial Weight Loss Predicts Permanent Success
Both medication trials and studies of behavioral modification suggest that initial weight loss predicts permanent success. For example, among patients who were given an intensive lifestyle intervention in the Look AHEAD (Action for Health in Diabetes) study:3
- 70% of those who lose ≥10% of initial body weight at 1 year maintained ≥5% loss at 4 years
- 40% of those who lost ≥5% to <10% of initial body weight at 1 year maintained ≥5% loss at 4 years
- 22% of those who lost <5% of initial body weight at 1 year had ≥5% loss at 4 years
“In the studies that have looked at chronic use of weight loss medications, if patients don’t lose weight at 12 weeks on the medication, they are not going to lose weight even if you increase the dose,” Dr. Apovian said. “So the caveat is: treat patients at the recommended dose, see them at 12 weeks at least, and if they haven’t lost 5%, stop the drug and try something else,” she noted.
Pharmacotherapies, Devices, and Bariatric Surgeries
Currently available pharmacotherapies for chronic weight loss are shown in Table 2. “In the future, these pharmacotherapies are probably going to be used in combination with devices and bariatric surgery just like we use combination treatment for other diseases,” Dr. Apovian said.
In terms of devices, options include laparoscopic adjustable gastric banding, which produces approximately 20% of total body weight loss but its use in the United States is waning because of high reoperation rate and lack of maintenance weight loss, Dr. Apovian noted. Another device, called the vBloc® (EnteroMedics Inc., St. Paul, MN), was recently approved and is a vagal nerve blocker that results in an average weight loss of approximately 9% of total body weight, Dr. Apovian noted. The device’s electrodes wrap around the vagus nerve and are connected to a pacemaker that is placed under the skin.
“Gastric bypass, sleeve gastrectomy surgeries, and biliopancreatic diversion with duodenal switch work on restricting the stomach and bypassing portions of the small intestines,” Dr. Apovian said. These surgeries allow for satiety hormones to be secreted earlier so patients feel full with less food intake, she explained.
October 28, 2015