What is the recommended medication regimen for safe weight loss in patients with a body mass index (BMI) of 30 or higher or 27 or higher with at least one weight-related condition?

From the Guidelines

For patients with a BMI of 30 or higher, or 27 or higher with at least one weight-related condition, the recommended medication regimen for safe weight loss includes GLP-1 receptor agonists like semaglutide or tirzepatide, as they have shown significant efficacy in reducing body weight and improving weight-related conditions, as seen in recent studies 1. The choice of medication should be based on patient-specific factors, including comorbidities, potential side effects, cost, and insurance coverage. Some key points to consider when prescribing weight loss medications include:

• Starting with a low dose and gradually increasing as needed and tolerated
• Monitoring for potential side effects, such as gastrointestinal symptoms
• Discontinuing medication if 5% weight loss is not achieved within 3-6 months
• Encouraging lifestyle modifications, including calorie reduction and increased physical activity, alongside medication use
• Considering the mechanism of action of each medication, such as appetite suppression or reduced fat absorption, when selecting a treatment option.

Other options for weight loss medications include orlistat, phentermine-topiramate, naltrexone-bupropion, and liraglutide, which have also shown efficacy in clinical trials 1. However, the most recent and highest quality study 1 suggests that GLP-1 receptor agonists may be a preferred option due to their significant efficacy and relatively favorable side effect profile. It is essential to note that medication should be used in conjunction with lifestyle modifications and regular monitoring to ensure safe and effective weight loss. Ultimately, the decision to prescribe a particular medication should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances.

From the FDA Drug Label

Phentermine Hydrochloride, USP 15 mg and 30 mg is indicated as a short-term (a few weeks) adjunct in a regimen of weight reduction based on exercise, behavioral modification and caloric restriction in the management of exogenous obesity for patients with an initial body mass index greater than or equal to 30 kg/m 2, or greater than or equal to 27 kg/m 2 in the presence of other risk factors (e.g., controlled hypertension, diabetes, hyperlipidemia).

The recommended medication regimen for safe weight loss in patients with a body mass index (BMI) of 30 or higher or 27 or higher with at least one weight-related condition is phentermine.

• The usual adult dose is 15 mg to 30 mg at approximately 2 hours after breakfast for appetite control.
• Dosage should be individualized to obtain an adequate response with the lowest effective dose.
• Phentermine is indicated only as short-term (a few weeks) monotherapy for the management of exogenous obesity.
• The safety and efficacy of combination therapy with phentermine and any other drug products for weight loss have not been established, therefore coadministration is not recommended 2, 2, 2.

From the Research

Safe Weight Loss Medications

The following medications are recommended for safe weight loss in patients with a body mass index (BMI) of 30 or higher or 27 or higher with at least one weight-related condition:

• Orlistat: a non-systemic treatment for obesity that inhibits lipases in the gastrointestinal tract, preventing the absorption of approximately 30% of dietary fat 3, 4, 5
• Liraglutide: a medication for long-term weight loss, indicated for the treatment of patients with overweight (BMI ≥27 kg/m2 with ≥1 weight-related comorbidity) or obesity (BMI ≥30 kg/m2) 6
• Lorcaserin: a medication for long-term weight loss, indicated for the treatment of patients with overweight (BMI ≥27 kg/m2 with ≥1 weight-related comorbidity) or obesity (BMI ≥30 kg/m2) 6
• Naltrexone/bupropion extended-release: a medication for long-term weight loss, indicated for the treatment of patients with overweight (BMI ≥27 kg/m2 with ≥1 weight-related comorbidity) or obesity (BMI ≥30 kg/m2) 6
• Phentermine/topiramate extended-release: a medication for long-term weight loss, indicated for the treatment of patients with overweight (BMI ≥27 kg/m2 with ≥1 weight-related comorbidity) or obesity (BMI ≥30 kg/m2) 6, 7

Dosage and Efficacy

The recommended dosage and efficacy of these medications are:

• Orlistat: 120 mg three times daily, resulting in weight reduction of 7.9 to 10.2% in obese non-diabetic individuals 3
• Orlistat (60-mg over-the-counter dose): resulting in weight loss of ~5% of initial body weight over 16 weeks 4
• Phentermine/topiramate: resulting in an average weight loss of 7.73 kg (95% CI: 6.60-8.85) in general compared with placebo, with the weight loss related to the dose of phentermine/topiramate 7

Safety and Adverse Events

The safety and adverse events associated with these medications are:

• Orlistat: generally well tolerated, with the most commonly reported adverse events related to decreased fat absorption, including oily faecal spotting, flatus with discharge, faecal urgency, and oily stool 3
• Phentermine/topiramate: increased risk of nervous system-related adverse events, including dysgeusia, paresthesia, dry mouth, disturbance in attention, irritability, hypoesthesia, constipation, and dizziness 7