Medicine used in the Treatment of Obesity

1. Medicine used in the Treatment of Obesity Elaine Neil Lead Pharmacist North Aberdeenshire LCHP

2. Medicine At one time 3 medicines licensed • Orlistat Xenical - POM Alli - OTC

3. Orlistat • Promotes loss of weight by preventing the digestion and absorption of fat • Inhibitor of GI lipases acting in stomach and small intestine • Reduces absorption of dietary fat by around 25-30% • The unabsorbed fat is excreted in the stool.

4. ContraindicationsSee BNF/SPC • Hypersensitivity • Chronic malabsorption • Cholestasis • Breast-feeding • Caution in pregnant women • The effect of orlistat in patients with hepatic and/or renal impairment, children and elderly patients has not been studied.

5. Side – effectsSee BNF/SPC • Liquid or oily stools / Oily leakage from rectum • Flatulence and Bloating/ abdominal pain • Faecal urgency • Faecal incontinence • Dyspepsia Menstrual disturbances • Headache Tooth disorder • Anxiety Gingival disorder • Fatigue Influenza • Respiratory infection Urinary tract infection • Hypoglycaemia

6. Drug InteractionsSee BNF/SPC • Ciclosporin Anti-epileptics • Fat soluble vitamins Amiodarone • Levothyroxine • Warfarin – monitor INR • Oral contraceptives – diarrhoea

7. Orlistat - Xenical Dose • 120mg taken with water immediately before, during or up to one hour after main meals. • Max dose 360mg daily. • Doses above 120 mg three times daily have not been shown to provide additional benefit.

8. Orlistat • Take with calorie controlled diet, 30% calories from fat, distributed over 3 main meals. • Omit dose if no main meal taken or no fat content. • Increase in faecal fat 24 to 48 hours after dosing, levels return to pre-treatment levels, within 48 - 72 hours.

9. Eligible Patients • BMI 30kg/m2 or greater • BMI 28kg/m2 or greater with risk factors diabetes coronary heart disease hypertension hypercholestraemia

10. Additional “treatment” Orlistat must be prescribed in conjunction with other measures to support weight loss • Diet modification • Increase in physical activity • Behaviour modification • Appropriate support and encouragement

11. Weight Monitoring • Serious attempts to lose weight before starting • Monitor weight loss during treatment Weight loss – 5% over 3 months (lower in patients with type 2 diabetes)

12. Weight Monitoring • Treatment with orlistat should be discontinued after 12 weeks if patients have not lost at least 5 % of the body weight measured at the start of therapy. • Stop therapy if weight loss inadequate • May get weight gain on stopping Long-term maintenance of weight lossafter a period of obesity is difficult and often unsuccessful, and thus may require sustained support.

13. Outcomes • Pooled data from five 2 year studies with orlistat and a hypocaloric diet showed that 37 % of orlistat patients and 19 % of placebo patients demonstrated a loss of at least 5 % of their baseline body weight after 12 weeks of treatment. • Of these, 49 % of orlistat treated patients and 40 % of placebo treated patients went on to lose 10 % of their baseline body weight at one year. • Overall, after one year of treatment, the percentage of patients taking 120 mg orlistat who lost 10 % or more of their body weight was 20 % compared to 8 % of patients taking placebo. • The mean difference in weight loss with the drug compared to placebo was 3.2 kg.

14. Xenical – prescription (POM) • Xenical 120mg capsules

15. Alli – over the counter (OTC) • Alli 60mg capsules • Maximum 60mg three times daily • Use for 6 months • Discard any capsules stored in the carry case for more than one month.

16. Costs • Orlistat (Xenical) – 120mg x 3 daily 28 days supply £31.63 • Alli 60mg x 3 daily 28 days supply £15- £35 Pharmacy or Internet supply

17. NHS Grampian Spend

18. NHS Grampian Spend 2010/11 • 9126 prescriptions • £338,643

19. NHS Grampian Spend

20. NHS Grampian Spend