The new guidelines signal a shift toward aggressive treatment for obesity as a primary disease and following with treatment for comorbidites that do not respond to weight loss.
Guidelines recently published by The Endocrine Society stress the importance of aggressive management of obesity before tackling the host of comorbidities commonly associated with the disease including diabetes, hypertension, and dyslipidemia. The guidelines were published online in the Journal of Clinical Endocrinology and Metabolism in mid-January
The first guideline of its kind, the collected recommendations focus on the appropriate and most effective use of the numerous medications now available to treat overweight and obesity. Lead guideline author Caroline Apovian, MD, of Boston University, notes that existing guidelines from The Obesity Society (TOS), the American Heart Association (AHA), and the American College of Cardiology (ACC) cover management of obesity through lifestyle, diet and exercise, and surgery. Anti-obesity drugs are mentioned but little guidance is provided. At the time each of these guidelines was published ,there were very few agents available and so a dearth of randomized clinical trials on which to base recommendations.
Describing the new guideline as a "blueprint" on the medical management of obesity, Apovian explains it also takes into account the 2013 TOS/AHA/ACC guidelines and that the task force she heads stands by national recommendations for management of overweight and obese patients.
There are 6 FDA-approved drugs for the treatment of obesity, 4 of them approved during the past 2 years: lorcaserin (Belviq, Eisai), phentermine/topiramate (Qsymia, Vivus), naltrexone/bupropion (Contrave, Takeda), and liraglutide (Saxenda, Novo Nordisk). Orlistat 160 mg (Xenical, Glaxo Smith Kline) and orlistat OTC (alli, Glaxo Smith Kline) have been available since 2007.
The guideline stresses that use of pharmacologic therapy in no way lessens the role of the essential components of obesity management-diet, exercise, and behavioral modifications. Maintenance of weight loss over time depends on incorporating durable lifestyle changes in these domains.
The current requirements for using FDA-approved weight loss medications include a BMI of 27 with at least one weight-related comorbidity (eg, diabetes, hypertension) or a BMI of 30 or more.
The guideline’s recommended treatment strategies are based on a shift toward managing obesity more aggressively as a primary disease rather than “waiting” until complications ensue and then tackling much larger and multifactorial metabolic dysfunction.
For eligible patients who elect to include anti-obesity medications in a weight-loss program, Dr Apovian emphasizes the importance of regular, face-to-face visits. The Centers for Medicare and Medicaid Services (CMS) covers 15 visits per year as of this writing.
Highlights from the guideline include:
o Continue medication in patients who respond well and lose at least 5% of their body weight after 3 months. Poor efficacy or significant adverse effects should trigger a switch to other medications and/or therapeutic strategies.
o For overweight or obese patients with diabetes, prescribe medications that promote weight loss or are weight-neutral; metformin remains first-line. Consider adding a GLP-1 agonist, then SGLT2 inhibitor before sulfonylureas or insulin.
o Limit potential for weight gain in obese patients with hypertension and diabetes by using ACE inhibitors, ARBs, and CCBs for first-line treatment
o For patients who need medications associated with weight gain (eg, antidepressants, antipsychotics, antiepileptic drugs) provide full disclosure and estimates of anticipated effect on weight for each option; decision making should be shared by patient and provider.
o Phentermine and diethylpropion should not be used in patients with uncontrolled hypertension or history of heart disease.
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Apovian CM, Aronne JL, Bessesen JH, et al. Pharmacological management of obesity: an endocrine society clinical practice guidline. J Clin Endocrinol Metab. 2015; doi:10.1210/jc.2014-3415.
Jensen MD, Ryan DH, Donato KA, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Obesity. 2013. Published online before print November 12, 2013. http://dx.doi.org/10.1002/oby.20660.