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Beyond Dieting: New Weight Loss Medications & Treatments on the Horizon. Daniel Bessesen , MD. Low. High. Currently Available Options. Effectiveness. Accept weight where it is Diet/Exercise: 3-10% weight loss Drugs: 5-12% weight loss Medically Supervised/Combination

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currently available options

Low

High

Currently Available Options

Effectiveness

  • Accept weight where it is
  • Diet/Exercise: 3-10% weight loss
  • Drugs: 5-12% weight loss
  • Medically Supervised/Combination

of Diet + Drug: 10-15% weight loss

  • Surgery: 15-30% weight loss
currently available options1

Low

High

Currently Available Options

Risks/Time/Money

  • Accept weight where it is
  • Diet/Exercise: 3-10% weight loss
  • Drugs: 5-12% weight loss
  • Medically Supervised/Combination

of Diet + Drug: 10-15% weight loss

  • Surgery: 15-30% weight loss
a guide to selecting treatment
A Guide to Selecting Treatment

Body Mass Index category

Treatment

25-26.9

27-29.9

30-34.9

35-39.9

40

Diet, physical activity,

and behavior therapy

With

co-morbidity

+

+

+

+

With

co-morbidity

+

+

+

Pharmacotherapy

With

co-morbidity

+

Surgery

NIH The Practical Guide. 2000 http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity

in Adults: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.citation

obesity treatment pyramid

Surgery

Pharmacotherapy

Lifestyle Modification

Diet

Physical Activity

Obesity Treatment Pyramid
pharmacologicaltreatment of obesity
PharmacologicalTreatment of Obesity
  • Current medications 5-12% wt loss
  • Benefits only last as long as patient takes the medication. Chronic treatment likely needed.
  • Drugs probably not paid for by insurance so cost is a big issue for patients.
  • Issues of FDA approval, long term safety, and efficacy.
  • Are medications an appropriate treatment modality for obesity?
new and emerging medications
New and Emerging Medications
  • FDA approved
    • Lorcasarin (Belviq)
    • Phentermine/topiramate ER (Qsymia)
  • May be approved in near future
    • Liraglutide
    • Bupropion/naltrexone
lorcasarin belviq
Lorcasarin (Belviq)
  • Serotonin 2C receptor agonist
  • Previous serotonin agonists fenfluramine and dexfenfluramine caused cardiac valve disease, removed from market
  • 2C receptor only in the brain not in heart
  • Studies in 1-2,000 people for up to 2 years do not show evidence if valvulopathy with lorcasarin.
lorcasarin belviq1
Lorcasarin (Belviq)
  • Weight loss: 3-5% no better than phentermine or orlistat
  • Side effects: headache, dizziness and nausea
  • Cost: $220/month
  • Unclear if physicians will prescribe off label with phentermine (no data on safety or efficacy)
lorcasarin weight effects
Lorcasarin: Weight Effects

N Engl J Med. 2010 Jul 15;363(3):245-56

phentermine topiramate
Phentermine/Topiramate
  • Combination gives greater effectiveness with fewer side effects
  • Cost: $150.00/month
  • Side effects: dry mouth, numbness, tingling, insomnia, dizziness, anxiety, irritability and disturbance in attention
topiramate phentermine qsymia effects on weight
Topiramate/Phentermine (Qsymia) Effects on Weight

Lancet. 2011 Apr 16;377(9774):1341-52

phentermine topiramate1
Phentermine/Topiramate
  • Risk of birth defects: women need – pregnancy test on starting and monthly while using.
  • Reduces blood pressure, glucose, insulin, triglycerides and raises HDL
  • Unclear if physicians will prescribe off label using generic phentermine and topiramate.
  • Most effective medication available 10-12% weight loss.
slide14

Lap Band

Gastric Bypass

Effectiveness

High

Low

Risk

comparison of operations
Comparison of Operations
  • Lap band: 20% weight loss, very low mortality, 1% serious or 2.4% any complication
  • Sleeve gastrectomy: 25% weight loss, 0.1% mortality, 2.4% serious or 6.3% any complication
  • Gastric bypass: 30% weight loss, 0.2% mortality, 2.5% serious or 10% any complication

Ann Surg 2013;257: 791–797; Flum DR, N Engl J Med.

2009 Jul 30;361(5):445-54

benefits of weight loss surgery the swedish obese subjects trial bariatric surgery vs usual care
Benefits of Weight Loss Surgery the Swedish Obese Subjects TrialBariatric Surgery vs. Usual Care
  • Nonrandomized prospective controlled study
  • 2010 pts. had surgery compared to 2037 contemporaneously matched controls
  • Began 1987
  • Median follow up 14.7 years
weight loss in the sos
Weight loss in the SOS

JAMA. 2012;307(1):56-65

slide18

Bariatric Surgery is Associated with a

Reduced Mortality: the SOS Study

30% lower risk

Of dying

MI: 25 in control

Group 13 in the

Surgery group

Cancer: 47 in

The control group

29 in the surgery

group

Sjostrom L NEJM 2007: 357-741-752

benefits of bariatric surgery for t2dm n engl j med 2012 366 1567 76
Benefits of Bariatric Surgery for T2DMN Engl J Med 2012;366:1567-76
  • 150 patients randomized to intensive medical therapy, gastric bypass or sleeve gastrectomy for management of type 2 diabetes
  • Average baseline A1C was 9.2% (diabetes >6.5, goal <7%)
  • Followed for 12 months
who is a good candidate
Who is a Good Candidate?
  • BMI>35 with co-morbidities or >40 without
  • Age 20-60
  • Co-morbidities: Diabetes, sleep apnea, reflux > Hypertension, DJD
  • Failed other forms of therapy
  • No serious, active cardiac, pulmonary, or psychiatric disease
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