Obesity, part 2

By Alan Koenigsberg, M.D.

Last week, I presented a high-level overview of obesity. This week, I read a transcript of a podcast about the medications available for the treatment of obesity, which I’ll summarize here.

There have been medications to treat obesity for decades. Obetrol, a mixture of amphetamine salts used today to treat ADHD, was marketed in the 1950s and 1960s, with mixed results. Most adults found that they noticed reduced appetite and lost five to 10 pounds in the first few weeks, but then the appetite suppressant effect wore off and no more weight was lost. This medicine continued to be prescribed somewhat for decades, but with little benefit.

Today, for treating adults with ADHD, we notice the same situation with Adderall, which has the identical formulation to Obetrol. It is not effective for weight loss in adults. In children, however, we need to be careful because the appetite suppressant effects may last and cause problems with weight loss.

Other medications have come on the scene, including Adipex, Contrave, Qsymia, Orlistat, liraglutide and semaglutide.

Adipex is phentermine, which has a mild direct appetite suppressant effect. Its side effect profile is minimal and most people tolerate the medicine well.

Contrave is relatively new and is a combination medication consisting of naltrexone and bupropion. Naltrexone is often used to treat narcotic addictions and bupropion is used to treat depressive disorders as well as used for smoking cessation. This combination medication has been found to be reasonably effective in appetite suppression.

Qsymia is another combination medication, phentermine and topiramate. In addition to the phentermine described above, it has the added medication topiramate, which is used to treat epilepsy, and has been found to help with appetite suppression in this combination.

Orlistat is marketed under the name Alli and blocks fat absorption in the intestines. It works for weight loss by preventing food from being absorbed. It can cause diarrhea.

The two new kids on the block are liraglutide, marketed as Victoza and Saxenda, as well as semaglutide, which is marketed as Ozempic and Wegovy.

Liraglutide is intended for treating people with diabetes, as is Ozempic, and they are available as subcutaneous, once-weekly injections. For people used to taking pills, this is a major change of paradigm, as they need to learn how to inject the medications into their bellies. It’s not difficult; it’s easy to learn and done just once weekly.

These two newer medications work by several mechanisms and seem to be very effective in losing substantial weight and keeping it off. People may experience nausea and some vomiting, so it is recommended to start at very low doses and increase monthly, under a physician’s supervision.

The medications affect the parts of the brain that let you know you are full, as well as slowing down stomach motility so that you feel full longer. The weight loss is a result of eating less and feeling satisfied. There is new thinking about how these may be legitimate weight loss treatments.

These medications may not have lasting effects if stopped, so they may need to be taken long-term to ensure weight loss maintenance.

Secondly, they are approved for the most part only for diabetes treatment, so while it is legal to prescribe them off-label, most insurance companies will not pay for them if not used to treat diabetes and these medications may cost in the ballpark of $1,000 per month out-of-pocket.

Obesity is being considered a disease process by the medical community now and we use medications to treat high blood pressure, congestive heart failure and many other chronic conditions. Obesity may join that group of conditions that benefit from serious treatment.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas. He can be reached at akoenigsberg@mac.com.

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