What oral weight loss medication can be prescribed for a patient with a history of seizure and no insurance coverage for injectables?

Oral Weight Loss Medication Options for a Patient with History of Seizure

For a patient with a history of seizure who cannot take Wellbutrin and lacks insurance coverage for injectable medications, phentermine or orlistat are the most appropriate oral weight loss medication options. 1

First-Line Option: Phentermine

Phentermine is an adrenergic agonist that promotes weight loss by:

• Activating the sympathetic nervous system
• Increasing norepinephrine release
• Enhancing resting energy expenditure
• Suppressing appetite

Dosing and Administration:

• Standard dosage: 15-37.5 mg orally once daily 1
• Start with lowest effective dose (can begin with 9.375 mg or 18.75 mg)
• Take in the morning to avoid insomnia
• Split dosing option: half tablet twice daily

Efficacy:

• Average weight loss: 5.5-6.1% of baseline weight at one year 1
• More effective than placebo (1.7% weight loss)

Safety Considerations for Seizure History:

• No contraindication for patients with remote seizure history (40 years ago)
• Primarily contraindicated in uncontrolled hypertension, coronary artery disease, glaucoma, and substance use disorders 1
• Unlike bupropion (Wellbutrin), phentermine does not lower seizure threshold

Monitoring:

• Regular blood pressure and heart rate checks
• Evaluate for side effects: dry mouth, insomnia, dizziness, irritability

Alternative Option: Orlistat

If phentermine is not tolerated or contraindicated, orlistat is a viable alternative:

Mechanism and Dosing:

• Pancreatic and gastric lipase inhibitor that blocks ~30% of fat absorption
• Available as prescription (Xenical 120 mg) or over-the-counter (Alli 60 mg)
• Dosing: One capsule three times daily with meals containing fat 1

Efficacy:

• Average weight loss: 2.8-4.8% beyond placebo at one year 1
• May be particularly beneficial for patients with constipation 1

Safety Profile:

• No effect on seizure threshold
• No central nervous system effects
• No cardiovascular concerns

Side Effect Management:

• Advise patient to follow a diet with approximately 30% of calories from fat
• Recommend daily multivitamin taken 2 hours apart from orlistat
• Warn about gastrointestinal side effects (steatorrhea, flatulence, fecal urgency)

Decision Algorithm:

1. First assess contraindications to phentermine:

   • Current cardiovascular disease
   • Uncontrolled hypertension
   • Hyperthyroidism
   • Glaucoma
   • Active substance use disorder
   • Use of MAO inhibitors

2. If no contraindications:

   • Start with phentermine at lowest effective dose (15 mg daily)
   • Titrate as needed based on response and tolerability
   • Discontinue if <3% weight loss after 12 weeks

3. If phentermine contraindicated or not tolerated:

   • Switch to orlistat 120 mg three times daily with meals
   • Provide dietary counseling to limit fat intake to ~30% of calories
   • Add multivitamin supplementation

Important Caveats:

• Remote history of seizure (40 years ago) is not a contraindication to phentermine
• Phentermine is FDA-approved for short-term use (12 weeks), though many clinicians use it for longer periods 1
• Orlistat has modest efficacy but excellent safety profile for patients with neurological concerns
• Both medications require lifestyle modifications (diet and exercise) for optimal results
• Regular monitoring for efficacy and side effects is essential
• Consider discontinuation if 5% weight loss is not achieved after 3 months of treatment