Beyond dieting new weight loss medications treatments on the horizon
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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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Beyond Dieting: New Weight Loss Medications & Treatments on the Horizon

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Beyond dieting new weight loss medications treatments on the horizon

Beyond Dieting: New Weight Loss Medications & Treatments on the Horizon

Daniel Bessesen, MD


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.


Beyond dieting new weight loss medications treatments on the horizon

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


Beyond dieting new weight loss medications treatments on the horizon

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


Stampede trial benefits of surgery for type 2 diabetes

Stampede Trial: Benefits of Surgery for Type 2 Diabetes

N Engl J Med 2012;366:1567-76


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


Thank you

Thank you


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