Deciding on a Weight Loss Medication

The disease of obesity affects more than ninety-three million Americans, and the numbers continue to increase. At Atlanta Endocrine Associates, Dr. Scott Isaacs offers accurate diagnosis and state-of-the-art weight management. To learn more, contact the office in Atlanta, Georgia.

Many diseases are associated with obesity such as type 2 diabetes, high blood pressure, sleep apnea, arthritis, heart, lung, and liver disease and more. These conditions impact a person’s quality of life and overall health. Treating obesity can be a challenge. If you have obesity, you know how difficult and frustrating this can be. Today, there are more obesity treatment options than ever before. This can be empowering but also intimidating and confusing. It is exceedingly difficult to achieve long term weight loss from diet and exercise alone. In fact, most patients who lose weight on a diet gain back most or all the weight within a few years. Even with intensive exercise, long term weight loss is difficult to maintain. Weight regain occurs because of adaptive changes in hormones that regulate appetite and metabolism. When you lose weight, your hormones change to increase appetite and lower metabolism driving weight back up. These metabolic changes persist for years. The hormonal regulation of appetite is extraordinarily strong. In fact, will-power alone is not sufficient to overcome these biological drives. Therefore, medications are increasingly being used because they can help overcome some of the biological changes that drive appetite.

Weight Loss Medications Require a Healthy Lifestyle Taking a medication for weight loss means committing yourself to long-term lifestyle changes. Lifestyle modification is the cornerstone of any weight loss program and includes:

1. A healthy reduced calorie meal plan
2. Physical activity
3. Self-monitoring
4. Adequate sleep
5. Stress reduction

For most people weight loss can be achieved with a 1200-1400 calorie meal plan. Work with your physician or dietitian for more precise calorie recommendations based on your individual requirements. Studies have shown that the makeup of the diet is less important than adherence to a diet so it is recommended to follow a common-sense reduced-calorie meal plan that you can stick to for the long term. For example, a strict vegan diet may work for some people but for others, the rigidity of the diet can cause feelings of deprivation and rebound cravings or even binge eating. It is better to have a moderate low calorie meal plan that is easier to maintain long term. Try to have regular mealtimes and make meals a family affair.

Physical activity is a critical component of any weight loss program. Without physical activity, you can still lose weight on a low-calorie meal plan, but for every ten pounds you lose, there will be muscle. With regular physical activity, for every ten pounds you lose, only one is muscle. It is recommended to engage in a minimum of 150 minutes of moderate intensity physical activity each week. Resistance training with weights or bands may be added in. Start slow and gradually increase the duration and the intensity of the activity. Schedule physical activity on your calendar like you would other important tasks. Ask a friend or your spouse to exercise with you. Examples of moderate intensity physical activity include Brisk walking, Bike ride, Swimming, Active play with children, Housework, and Yard work.

Self-monitoring with food and exercise logs, regular self-weighing, and tech gadgets such as pedometers and activity monitors can help modify behaviors that contribute to weight loss. Even though weight loss is more complicated than calories in and calories out, these gadgets help you better understand your own body and are a useful tool. For effective weight loss, adequate sleep is critical. You should aim for 7-9 hours of restful sleep each night. If you have excessive daytime sleepiness, you should discuss the possibility of having sleep apnea with your physician. Effective sleep apnea diagnosis and treatment aids in weight loss which then improves sleep apnea symptoms. Stress reduction is a vital component of any weight loss program. Don’t be afraid to ask for help. Support from friends and family is vital for helping you stay on track. The more support you have the more likely your success. Don’t expect to change your behaviors overnight. It is important to keep focused on long-term results, making small but gradual changes to improve your daily routine. It will take time, but as you stick with your lifestyle changes, you will see your weight and health improve. This can be highly motivating to keep weight loss going.

Medication-Assisted Weight Loss

Before you decide on any weight-loss medication, it is important to work with your health care provider to decide which option is best for you. Prescription weight loss medications, also known as anti-obesity medications or AOMs work by helping you consume fewer calories. These medications work in appetite and reward centers of the brain to reduce hunger and cravings and to increase the feeling of fullness as you eat. Medications for weight loss can be considered when lifestyle modification does not produce acceptable weight loss or medical complications are not adequately controlled. AOMs are indicated for patients with obesity defined as a body mass index (BMI) above 30 kg/m2 or overweight with a BMI above 27 kg/m2 with at least one complication of excess weight such as diabetes, high blood pressure or abnormal blood lipids.

Anti-Obesity Medications (AOMs) Currently, these are the medications approved by the Food and Drug Administration (FDA) for weight loss. phentermine (Adipex-P®, Lomaira®)* phendimetrazine (Bontril®)* benzphetamine (Regimex®, Didrex®)* orlistat (Xenical®, alli®)† phentermine and topiramate ER (Qsymia®)† Plenity® naltrexone HCl and bupropion HCl (CONTRAVE®)† liraglutide injection (Saxenda®)† semaglutide injection (wegovy®)† *Approved for short term use †Approved for long term (chronic) use

Tirzepatide (Mounjaro) is a new injection medication that works on two receptors for hunger hormones GIP and GLP-1. Tirzepatide is known as a twincreatin because of this double effect. The average weight loss is an astonishing 22.5%, which is more than any other medication for weight loss, approaching weight loss results of bariatric surgery.

Although everyone is hopeful for a magic pill, medications only work when combined with a reduced calorie meal plan and increased physical activity. These medications are not a substitute to lifestyle modification but rather a tool to enhance these measures. Taking a medication without these changes does not result in successful weight loss. It should also be noted that none of the AOMs should be taken while pregnant.

Medications for Short Term Use: (Phentermine, Phendimetrazine and Benzphetamine).

Phentermine, phendimetrazine and benzphetamine are weight loss medications that have been approved for short term use for several decades. These medications work on chemicals in the brain to decrease appetite and contain a mild stimulant that is like an amphetamine. These medications can be taken once or several times a day depending on the formulation. Tolerance usually develops after a few months where increased appetite returns and weight loss stops. These older AOMs are typically used for 12 weeks, although some patients may have increased weight loss with the same total amount of medication by prolonging the treatment duration by taking it every other day for 24 weeks. It is prudent to have a plan for ongoing weight loss or weight maintenance such as changing to an AOM approved for chronic use as weight regain is typical once these medications are discontinued. Due to the stimulant effects, these medications can cause an increase in blood pressure and heart rate as well as insomnia, dry mouth, anxiety and agitation. These medications cannot be used if you have certain heart conditions, uncontrolled high blood pressure, a history of having a stroke, glaucoma (increased eye pressure), stroke or an overactive thyroid. Therefore, you must be monitored closely by a health care professional who has experience prescribing these medications.

Medications for Long-Term Use:

Since obesity is a chronic disease, the up-to-date approach to AOMs is to treat them like any other medication used to treat a chronic disease. This means that AOMs are intended for long-term chronic use. The newer anti-obesity medications have published long-term (one year or longer) studies with on-going studies for longer periods of time. Most medication studies show an average weight loss of 5-15% from starting body weight over 6-12 months with weight maintenance if the medication is continued. If the AOM is discontinued, patients tend to gain back the weight that was lost while taking the medication. Weight loss should be assessed after taking the medication at the full dose of an AOM for 12 weeks. It is recommended to discontinue the medication if at least 5% weight loss has not been achieved at this point as additional meaningful weight loss is unlikely. An alternative AOM can be substituted as response to one AOM may not predict the response to another due to different mechanisms of action. Due to lack of data, combining AOMs is not recommended. If 5% weight loss has been achieved and there are no unacceptable adverse reactions, then the same AOM should be continued long-term.

Semaglutide (wegovy®) and Liraglutide (Saxenda®).

These are injectable medications known as glucagon-like peptide- 1 (GLP-1) agonists. The medications are a synthetic version of a satiety hormone that makes you feel full. Studies have shown that liraglutide 3 mg produces 9% weight loss, about 17-18 pounds on average after 1 year of treatment, compared with a loss of 4.5 pounds in the placebo-treated group and 8.5 pounds in a orlistat-treated comparator group. Semaglutide is a once weekly injection with an average weight loss of 15% or about 34 pounds. All GLP-1 medications are contraindicated in people with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2. These medications should not be used if you have a history of pancreatitis or gastroparesis. If there is not at least 4% weight loss by 16 weeks on the full dose, the medication is ineffective, and it should be discontinued. A cardiovascular outcome in patients with type 2 diabetes showed that liraglutide lowered the rate of the first occurrence of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke.

Plenity®

Plenity is an FDA cleared supplement for weight management made from naturally derived cellulose and citric acid. Three capsules are taken twice a day, 20 minutes before lunch and dinner with 16 ounces of water. The capsules swell up to fill your stomach to make you feel full. The ingredients are not absorbed systemically and are eliminated from the body in the same manner as food. The average weight loss with Plenity is about 10% (about 22 pounds).

Orlistat (Xenical®, alli®)

Xenical® and the lower potency over-the-counter version alli® contain the medication orlistat. This medication comes as a capsule that is taken before each meal and works by blocking the absorption of about one-third of fat in the meal. This fat gets passed out of the digestive tract in the stool. Orlistat is the only AOM that does not work by decreasing appetite. Side effects of orlistat include oily diarrhea, fecal leakage, cramps and gas discharge that can be avoided by consuming a high-fiber diet that contains less than 30% fat. People who take orlistat should take a daily multivitamin as there is a potential for a deficiency of some fat-soluble vitamins.

Phentermine and Topiramate ER (Qsymia®)

The combination of phentermine and topiramate in an extended-release capsule was approved by the FDA in 2012 as the first new AOM in over a decade. Topiramate is a medication that has been approved to treat seizures and migraine headaches. Weight loss is a common side effect of topiramate. Phentermine is an AOM as described above that helps to decrease appetite as well. The two medications used in combination at low doses are effective for long term weight management. Side effects of phentermine-topiramate ER include a metallic taste in the mouth, dry mouth, a feeling of pins and needles in the extremities, constipation, insomnia, memory loss and fatigue. This medication also has an interesting side effect of making soda taste flat due to chemical properties of topiramate. Women of childbearing age must use at least one reliable form of contraception and should have a negative pregnancy test before starting and monthly negative pregnancy tests while continuing phentermine-topiramate ER as it is known to cause birth defects.

Naltrexone HCl and Bupropion HCl (CONTRAVE®)

CONTRAVE® is a combination of two medications that have been approved for other uses since the 1980s. Naltrexone is a medication used to treat alcohol and opioid dependency. Bupropion is used as an antidepressant and for helping people stop smoking. The combination of these two medications work synergistically to reduce appetite and cravings. Side effects include nausea, constipation, headache, dry mouth, vomiting, anxiety, and dizziness. There is a potential for elevating blood pressure and heart rate. Uncontrolled high blood pressure and a history of a seizure disorder are contraindications. Because naltrexone blocks the opioid receptor, use of opioid pain medications is a contraindication as it does not allow these medications to work properly and may precipitate withdrawal symptoms.

Medication Follow Up

Frequent visits (every 4 weeks) are recommended for the first 12 weeks to an AOM and every three months thereafter. Frequent visits with a health care provider give better weight loss results through increased support, accountability, and individualized medication management. Since obesity is a chronic life-long problem, periodic continued follow up is advised. The best weight loss results are achieved when AOMs are combined with intensive lifestyle modification. The major benefit of weight loss is improvement of diseases caused by obesity such as diabetes, high blood pressure, abnormal blood lipids and heart disease which can be seen with as little as 5% weight loss. Remember, AOMs are not a magic bullet but simply a tool to help you sustain common sense lifestyle changes. There is no perfect medication for obesity. A medication that may work for a family member or a friend may not be the ideal medication for you. Treating obesity can be complicated so it is best to work with a knowledgeable health care professional who is dedicated to working with you over the long term. If you’d like to learn more about permanent weight loss, please feel free to call us or schedule an appointment with Dr. Isaacs.