Diagnosing, staging and treatment of obesity has dramatically changed for endocrinologists in the past couple of years, and even greater changes are on the horizon.
New obesity medications are being combined in novel ways, and obesity is now being managed as a chronic disease. The old way of thinking that obesity results from lifestyle choices has been replaced with new obesity management treatment models.
“It used to be that you would just try to kick-start diets with the pills that were approved for 30 days or 90 days,” said Michael Bush, MD, who specializes in endocrinology, diabetes and metabolism in Beverly Hills, California. “We have better tools in the toolbox now. We are doing about twice as well with the newer medicines.”
The growing numbers of approved medications for obesity work in a variety of ways, including blocking the absorption of fat. Some agents make patients feel less hungry or feel full more quickly.
On Sept. 10, 2014, the U.S. Food and Drug Administration (FDA) approved naltrexone hydrochloride and bupropion hydrochloride extended-release tablets (Contrave) as a treatment option for chronic weight management. The drug was approved for use in adults with a BMI of 30 or greater or in adults with a BMI of 27 or greater who have at least one weight-related condition, such as hypertension, type 2 diabetes or dyslipidemia.
Naltrexone previously was approved for treating alcohol and opioid dependence and bupropion previously was approved for treating depression, seasonal affective disorder (SAD) and to help with smoking cessation.
This new treatment is added to a list that includes orlistat (Xenical and Alli), lorcaserin (Belviq), phentermine-topiramate (Qsymia), phentermine, benzphetamine, diethylpropion and phendimetrazine.
On Sept. 12, 2014, an FDA advisory committee recommended approval of liraglutide (Victoza) for chronic weight management. This would be the first injectable prescription medicine for treatment of obesity. Liraglutide, which is already approved for treatment of type 2 diabetes, comes as a solution in a prefilled dosing pen to inject subcutaneously.
“Liraglutide sounds really interesting and we have experience prescribing it. I prescribe it routinely so it is just a different dose,” said Clare Lee, MD, of Johns Hopkins University School of Medicine’s Division of Endocrinology, Diabetes & Metabolism in Baltimore.
Approaches to Treatment
Dr. Lee said currently there is no paradigm to follow when sequencing the new agents approved for obesity. However, she said that the approval of more agents over the next 12 to 24 months will allow clinicians to better tailor therapy.
“The new drugs are making a difference. The issue of which individual medication to use has to be individualized and based on the mechanism of action and what other drugs the patients are taking. Cost is a big issue because they are not always covered,” said J. Michael Gonzalez-Campoy, MD, PhD, who is Medical Director and CEO of the Minnesota Center for Obesity, Metabolism and Endocrinology in Egan.
Dr. Gonzalez-Campoy said obese patients have a chronic medical condition, and it has to be treated the same way clinicians now treat hypertension and diabetes.