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Clinical Practice Guideline

Clinical Practice Guideline published on obesity drugs

Endocrine Society recommends weight loss drugs and surgery as a supplement to lifestyle interventions

The Endocrine Society has issued a Clinical Practice Guideline (CPG) on strategies for prescribing drugs to manage obesity and promote weight loss. The CPG, entitled “Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline,” was published online and will appear in the February 2015 print issue of the Journal of Clinical Endocrinology and Metabolism (JCEM), a publication of the Endocrine Society. The recommends come after the FDA has approved four anti-obesity drugs (lorcaserin, phentermine/topiramate, naltrexone/bupropion and liraglutide) in the past two years.

As the first pharmacotherapy guideline for the treatment of obesity, the new resource expands upon the "Guidelines (2013) for Managing Overweight and Obesity in Adults," published in Obesity in November 2013 by TOS, the American Heart Association (AHA) and the American College of Cardiology (ACC). The CPG has been published with support from The Obesity Society (TOS) and the European Society of Endocrinology

"The pharmacotherapy guideline provides a roadmap for clinicians considering anti-obesity drug treatment for patients not finding success with diet and exercise alone," says Donna Ryan, MD, member of the development panel and professor emeritus at Louisiana State University's Pennington Biomedical Research Center, speaking on behalf of TOS. "The new guideline provides doctors with recommended medications and dosage based on obesity-related comorbidities, including type 2 diabetes and cardiovascular disease. Further, it gives specific recommendations for transitioning patients off drugs that cause weight gain, shifting the treatment paradigm from treating weight last, to treating weight first."

The Endocrine Society further highlights key recommendations from the guideline, including: implications for continuing and discontinuing medication, guidance for prescribing medications that promote weight loss or have no effect on weight, and disclosure of information about medication-related weight gain to patients to promote shared decision making.

"The 2013 Guidelines help health practitioners identify patients who may benefit from pharmacotherapy, and the new pharmacological guideline can help them decide on the best anti-obesity drug option," added Ryan. "Combined, both resources fill a gap in the treatment of obesity, a disease that puts individuals at risk for more than 30 other health conditions, including type 2 diabetes and cardiovascular disease."

Seeking the support of a healthcare practitioner for weight loss can make all the difference for people affected by obesity. As an adjunct to diet and exercise, medications approved by the FDA for the treatment of obesity can help those affected to lose weight, specifically if they have not found prior success with diet and exercise alone. Taken together, both guidelines provide an evidence-based tool to help physicians identify and treat patients struggling with their weight that may need the additional support.

“Lifestyle changes should always be a central part of any weight loss strategy,” said Dr Caroline M Apovian of Boston University School of Medicine and Boston Medical Center, and chair of the task force that authored the guideline. “Medications do not work by themselves, but they can help people maintain a healthy diet by reducing the appetite. Adding a medication to a lifestyle modification programme is likely to result in greater weight loss.”

In the CPG, the Endocrine Society recommends that diet, exercise and behavioural modifications be part of all obesity management approaches. Other tools such as weight loss medications and bariatric surgery can be combined with behavioural changes to reduce food intake and increase physical activity. Patients who have been unable to successfully lose weight and maintain a goal weight may be candidates for prescription medication if they meet the criteria on the drug’s label.

Other recommendations from the CPG include:

  • If a patient responds well to a weight loss medication and loses 5 percent or more of their body weight after three months, the medication should be continued. If the medication is ineffective or the patient experiences side effects, the prescription should be stopped and an alternative medication or approach considered.
  • Since some diabetes medications are associated with weight gain, people with diabetes who are obese or overweight should be given medications that promote weight loss or have no effect on weight as first- and second-line treatments. Doctors should discuss medications’ potential effects on weight with patients.
  • Certain types of medication, such as angiotensin converting enzyme inhibitors, angiotensin receptor blockers and calcium channel blockers, should be used as a first-line treatment for high blood pressure in obese people with Type 2 diabetes. These are effective blood pressure treatments that are less likely to contribute to weight gain than the alternative medication, beta-adrenergic blockers.
  • When patients need medications that can have an impact on weight such as antidepressants, antipsychotic drugs and medications for treating epilepsy, they should be fully informed and provided with estimates of each option’s anticipated effect on weight. Doctors and patients should engage in a shared-decision making process to evaluate the options.
  • In patients with uncontrolled high blood pressure or a history of heart disease, the medications phentermine and diethylpropion should not be used.

"We call on prescribing health practitioners from primary care physicians to bariatric surgeons to review both guidelines and take steps to put them into practice," concluded Ryan. "Broad, sweeping transformations in obesity management in the primary care setting can help identify patients most in need of this additional support."

The Society established the CPG Program to provide endocrinologists and other clinicians with evidence-based recommendations in the diagnosis and treatment of endocrine-related conditions. Each CPG is created by a task force of topic-related experts in the field. Task forces rely on scientific reviews of the literature in the development of CPG recommendations. The Endocrine Society does not solicit or accept corporate support for its CPGs, with all CPGs supported entirely by Society funds.

Other members of the Endocrine Society task force that developed this CPG include: Louis J Aronne of Weill-Cornell Medical College in New York, NY; Daniel H Bessesen of Denver Health Medical Center in Denver, CO; Marie E McDonnell of Brigham and Women’s Hospital in Boston, MA; Mohammad Hassan Murad of the Mayo Clinic in Rochester, MN; Uberto Pagotto of Alma Mater University of Bologna in Bologna, Italy; Donna H Ryan of Pennington Biomedical Research Center in Baton Rouge, LA; and Christopher D Still of Geisinger Health Care System in Danville, PA.

The CPG was co-sponsored by the European Society of Endocrinology and The Obesity Society.

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