Pharmacotherapy for obesity: What you need to know

Sophie Bersoux; Tina H. Byun; Swarna S. Chaliki; Kenneth G. Poole

doi:10.3949/ccjm.84a.16094

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TABLE 1

Drugs approved by the US Food and Drug Administration for treating obesity^a

Drug	Mechanism of action	Contraindications and warnings	Serious interactions	Adverse reactions	Dosage and monitoring	Cost^b
Phentermine	Suppresses appetite	Contraindications Hyperthyroidism Glaucoma Agitation Pregnancy or breastfeeding (category X) MAO inhibitor within 14 days Use with caution Cardiovascular disease History of drug abuse	Monoamine oxidase (MAO) inhibitors	Nervousness Insomnia Dry mouth	15, 30, or 37.5 mg daily before breakfast or 1–2 hours after Schedule IV	$12
Orlistat	Inhibits fat absorption	Contraindications Pregnancy or breastfeeding (category X)	Cyclosporine Warfarin Other fat-soluble drugs (see text)	Gastrointestinal: abdominal pain, bowel urgency, steatorrhea, fecal incontinence Hepatotoxicity Oxalate nephropathy	60 or 120 mg 3 times a day during or within 1 hour of a fat-containing meal Monitor renal function	$530
Phentermine-topiramate^c	Phentermine: see above Topiramate: unknown	Contraindications Hyperthyroidism Glaucoma Agitation Pregnancy or breastfeeding (category X) MAO inhibitor within 14 Use with caution Cardiovascular disease History of drug abuse Depression	MAO inhibitors Opioid or other central nervous system depressants CYP3A4 and CYP1A2 inducers	Dry mouth Dizziness Constipation Paresthesia Psychiatric and cognitive adverse events Nephrolithiasis Increased heart rate Angle-closure glaucoma Acute myopia	3.75/23 mg daily for 14 days, then 7.5/46 mg daily If < 3% weight loss at 12 weeks, increase to 11.25/69 mg daily for 14 days, followed by 15/92 mg daily thereafter Gradually discontinue if < 5% weight loss at 12 weeks on highest dose Pregnancy test at baseline and monthly for women of childbearing age Schedule IV Adjust for renal impairment	$199
Lorcaserin	Suppresses appetite	Contraindications Creatinine clearance < 30 mL/min Pregnancy (category X) Use with caution Creatinine clearance 30–50 mL/min Severe hepatic impairment	Serotonergic agents	Dry mouth Dizziness Somnolence Headache Gastrointestinal disturbance	10 mg twice a day Discontinue if < 5% weight loss at 12 weeks Monitor blood glucose level closely in patients with diabetes mellitus because of risk of hypoglycemia Schedule IV	$212
Naltrexone bupropion	Suppresses appetite	Contraindications End-stage renal disease Pregnancy or breastfeeding (category X) MAO inhibitor within 14 days Uncontrolled hypertension Seizure disorder Eating disorder	Bupropion Chronic opioid use or acute opiate withdrawa Linezolid CYP2B6 inhibitors	Nausea, vomiting Constipation or diarrhea Headache Dizziness Insomnia Dry mouth	8/90 mg for 7 days; then twice a day for 7 days; then 2 tablets in morning and 1 tablet in the evening for 7 days, followed by 2 tablets twice a day thereafter Discontinue if < 5% weight loss at 12 weeks Adjust for renal and hepatic impairment	$212
Liraglutide	Slows gastric emptying, increases satiety	Contraindications Personal or family history of medullary thyroid cancer (multiple endocrine neoplasia type 2 syndrome) Pregnancy or breastfeeding (category X) Moderate to severe renal impairment Use with caution History of pancreatitis Severe renal insufficiency	Other hypoglycemic agents	Nausea, vomiting Diarrhea, constipation Hypoglycemia Pancreatitis Gallbladder disease Renal impairment Suicidal thoughts	0.6 mg subcutaneously daily, increase by 0.6 mg weekly to a daily target dose of 3 mg Discontinue if < 4% weight loss at 16 weeks	$1,095

↵a In various trials, these drugs led to weight loss of 5.0 to 12.9 kg compared with placebo.
↵b Average wholesale cost for 1 month, per Healthcare Bluebook. https://healthcarebluebook.com/page_ConsumerFront.aspx.
↵c Prescribers must complete Healthcare Provider Training Program and HCP Registration Form before they can prescribe this medication; see www.qsymiarems.com/.

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TABLE 2
Treatments by body mass index and comorbidity
Body mass index (kg/m²) Lifestyle modification Pharmacotherapy Bariatric surgery
25–29.9 X
30–39.0 or
27–34.9 with comorbidities X X
≥ 40 or
≥ 35 with comorbidities X X X