Lifestyle management is not enough to treat some patients.
Specialists indicate that it is important to convey to the patient that excessive body weight is considered a medical condition that requires supportive care. Photo: Shutterstock.
According to Dr. Robert F. Kushner, obesity is now considered a disease of energy dysregulation in which altered biological signals and the environment contribute to weight gain and accumulation of excess body fat.
As with diabetes, a variety of approaches need to be used to help patients better manage their obesity. Counseling about choosing a healthy, calorie-controlled diet, becoming more physically active, and using behavior change strategies are essential steps for patients seeking treatment for obesity.
However, the management of Lifestyle it is often not enough for many of the patients, who continue to struggle with their weight and have co-existing medical problems. It is no longer acceptable to simply tell them to “just try harder” when more effective complementary treatments are available. Therefore, it should be considered whether the patient is a candidate to prescribe a drug approved by the US Food and Drug Administration (FDA) for chronic weight control.
How do the medicines against obesity?
Currently, there are five FDA-approved medications for long-term use: orlistat (Xenical), phentermine/topiramate (Qsymia), naltrexone-bupropion (Contrave), liraglutide (Saxenda), and semaglutide (Wegovy), and one is approved for short-term use (phentermine). All of these drugs, except orlistat, alter a patient’s perception of appetite by modifying biological signaling in the brain.
Although individual responses vary, patients may feel less hungry, feel fuller after a meal and happier between meals, and have fewer cravings and fewer thoughts about food. By controlling the appetite, the patient can adhere to a low-calorie diet more consistently. For this reason, patients who take medication lose 5% to 12% more weight than those who only follow a lifestyle plan.
Who are candidates for anti-obesity drugs?
Anti-obesity drugs are approved for patients with a body mass index = 30 or a body mass index = 27 with a comorbidity. Additional considerations include patients who are actively involved in self-care, attentive to their diet but struggling to make dietary changes, unable to lose or maintain lower body weight, and who want to improve their health.
Which medication to choose depends on existing comorbidities, side effects, patient preference, insurance coverage, and cost.
Concomitant treatment of comorbidities is also an important factor. For example, a patient with diabetes would benefit from the use of a glucagon-like peptide-1 (GLP-1 RA) receptor agonist, such as liraglutide or semaglutide, because they are incretin hormone agents used to treat diabetes. Similarly, a patient with a history of migraines may benefit from phentermine and topiramate because topiramate is also approved for migraine prophylaxis.
Each drug has its own unique titration schedule, so clinicians should be familiar with the dosing instructions. Regardless of the drug selected, the patient should be informed that the treatment is intended for long-term use, because discontinuation will result in a resurgence of increased appetite and weight regain.
For some patients, there is a stigma around taking weight loss medication, a concern that they are perceived as unable or too weak to control their weight on their own. This stems from the mistaken belief that obesity is entirely due to overeating and lack of physical activity. Lack of body weight control is a sign of laziness, lack of personal responsibility and gluttony. So it follows that taking a drug is the “easy way out.”
It is important to convey to the patient that excess body weight is considered a medical condition that requires supportive care, such as lifestyle counseling, referral to a registered dietitian or health psychologist, prescription of medication, or consideration of bariatric surgery. Anti-obesity drugs help the patient control appetite and make adherence to the diet more successful.
What medicines exist?
Semaglutide, a second-generation GLP-1 RA, was approved for chronic weight management in 2021 after publication of the STEP randomized controlled trials. In STEP 1, the average weight loss at 68 weeks was 15% vs. 2.4% with placebo. Semaglutide was also found to be 2.5 times more effective than the first-generation drug liraglutide.
The mean body weight reduction with tirzepatide, a new dual GLP-1 and GIP RA, reached 21% after 72 weeks at the 15 mg dose. Additional combined agents and mono-, dual-, and tri-agonists containing these are currently under investigation. hormones.
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