James K. Rone, MD, FACP, FACE

New Guidelines Call for Wider Use of Weight Loss Drugs

May 12, 2013

Tags: Obesity

RECENTLY THE MEDICAL DIRECTOR OF MY CLINIC’S WEIGHT LOSS PROGRAM LEFT AND I TEMPORARILY TOOK OVER THAT ROLE. AFTER RETURNING FROM THE ANNUAL AACE MEETING IN PHOENIX, I OFFERED THE FOLLOWING DISCUSSION TO MY PARTNERS:

As Interim Medical Director of NexSlim at MMC, I wanted to take this opportunity to update you on the just-published AACE (Amer. Assn. of Clinical Endocrinologists) Comprehensive Diabetes Algorithm, which includes sections on prediabetes management, glycemic control in T2DM, and dyslipidemia—each of which begins, no surprise, with lifestyle modification. But, in each case that recommendation expressly includes “medically assisted weight loss.” Further, a separate algorithm for overweight and obesity calls for “medical therapy” if BMI is greater than 27 with cardiometabolic or biomechanical complications of either low, medium, or high severity, if lifestyle modification fails to achieve goals. They specify this medical therapy can include phentermine, orlistat, lorcaserin, or phentermine/topiramate ER—the latter two being Belviq and Qsymia, both approved by the FDA in 2012.

I find these recommendations groundbreaking, and no doubt will be controversial. Use of anorectic drugs has a historically poor reputation, and has been fraught with toxicity issues—in fact, every drug introduced prior to 2012 for long-term use for weight loss has had to be withdrawn from the market for that purpose, starting with thyroid extracts 120 years ago. My own experience with anorectics is admittedly limited, nor have I been impressed with their efficacy to the extent that I have used them. To be sure, there are genuine concerns about a lack of long-term maintenance of any weight loss that is achieved, but lifestyle interventions have the same failing.

All that said, we need to sit up and take notice that a major mainstream medical organization is strongly calling for the use of these drugs as part of a comprehensive, multifaceted effort. This is a recognition, and a call to action, that mainstream clinicians need to be managing overweight/obesity seriously, and specifically, and with every tool in the box, not just with vague advice, if we are to curb the epidemic of obesity and obesity-related diseases.

In light of the new AACE guidelines, I ask you to give consideration to the use of medically supervised weight loss, to include anorectic drugs when appropriate. Perhaps if we all used these drugs more, and smartly, as part of a comprehensive effort, we might see better results from them. Too often patients use them in a vacuum and street-corner weight-loss clinics dispense them that way, such that their failure is inevitable—perhaps we can do better.

Additionally, the prediabetes portion of the AACE algorithm called for metformin or acarbose use in mild prediabetes not resolving with lifestyle change, and consideration of adding pioglitazone and/or a GLP-1 receptor agonist, like exenatide, if needed, in more severe cases (high fasting and post-meal glucoses, for example).

jkr

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