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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 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 of Diet + Drug: 10-15% weight loss • Surgery: 15-30% weight loss
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 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
Surgery Pharmacotherapy Lifestyle Modification Diet Physical Activity Obesity Treatment Pyramid
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 • FDA approved • Lorcasarin (Belviq) • Phentermine/topiramate ER (Qsymia) • May be approved in near future • Liraglutide • Bupropion/naltrexone
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 (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 N Engl J Med. 2010 Jul 15;363(3):245-56
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 Lancet. 2011 Apr 16;377(9774):1341-52
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.
Lap Band Gastric Bypass Effectiveness High Low Risk
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 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 JAMA. 2012;307(1):56-65
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 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 N Engl J Med 2012;366:1567-76
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