Pharmacological treatment of obesity in clinical practice

Abstract

Anti-obesity medications may be considered in the subjects with BMI ≥30 kg/m2, or with BMI 27-29.9 kg/m2 and weight-related comorbidities, whom weight reduction is not achieved via lifestyle modifications alone. If weight loss is inadequate (<4-5%) after 12 weeks of treatment, the medication should be changed. Orlistat and Liraglutide are available in our country. Orlistat inhibits pancreatic lipase, increases fat excretion, improves hypertension or lipid profile besides weight-reduction. No dosage adjustment is necessary in renal or liver impairment. Orlistat may lead flatus, intestinal cramps, fecal incontinence, oily spotting, and should not be used in malabsorption syndrome, cholestasis, or pregnancy. Liraglutide is a biochemically modified GLP1 which slows gastric emptying and decreases appetite. It is preferred as a first-line agent in most situations. It was shown to decrease major cardiovascular events. Liraglutide is initiated once a day subcutaneously 0.6 mg/day, then dose is increased up to 3mg/ day. Nausea and vomiting are common with liraglutide, renal impairment, gallbladder disease or pancreatitis less common. Liraglutide is contraindicated in pregnancy, lactation, MEN 2 or medullary thyroid cancer. Phentermine/topiramate combination may be considered in subjects without any cardiovascular diseases who do not tolerate liraglutide or orlistat. It is contraindicated in pregnancy due to a risk of orofacial defects, and not recommended in hypertension, coronary heart disease, hyperthyroidism or monoamine oxidase use. Bupropion/Naltrexone combination provides anorexigenic effect by acting on feeding and reward circuitry. It may be preferred if pharmacological therapy both for smoking cessation and weight loss is desired. Vomiting, constipation, dry mouth or suicidal thoughts may be observed, and contraindicated in pregnancy, seizure, uncontrolled hypertension, opioid or monoamine oxidase inhibitor use. Phentermine, diethylpropion, benzphetamine, and phendimetrazine are used for short-term due to risk of abuse, and contraindicated in uncontrolled hypertension, coronary heart disease, or thyrotoxicosis. Safety of dietary supplements used for obesity is limited.