What are the recommendations for using appetite suppressant capsules in a patient with a history of cardiovascular disease, glaucoma, or hyperthyroidism who is considering weight loss options?

Appetite Suppressant Capsules in Patients with Cardiovascular Disease, Glaucoma, or Hyperthyroidism

Avoid phentermine, diethylpropion, and phentermine/topiramate in patients with cardiovascular disease, glaucoma, or hyperthyroidism—these sympathomimetic agents are explicitly contraindicated in these populations. 1

Contraindicated Medications

Sympathomimetic Appetite Suppressants

• Phentermine and diethylpropion must be avoided in patients with:
  • History of cardiovascular disease (including coronary artery disease, uncontrolled hypertension) 1
  • Hyperthyroidism 1
  • Glaucoma 1
• These agents increase norepinephrine, causing sympathomimetic effects that can precipitate cardiovascular events, worsen hyperthyroidism, and increase intraocular pressure 1

Phentermine/Topiramate ER (Qsymia)

• Contraindicated in cardiovascular disease and uncontrolled hypertension due to the phentermine component 1, 2
• Also contraindicated in glaucoma and hyperthyroidism 1

Safe Alternative Options

First-Line: Semaglutide 2.4 mg

• Semaglutide 2.4 mg is the preferred choice for patients with cardiovascular disease, as it reduces cardiovascular mortality by 20% and major adverse cardiovascular events (6.5% vs 8% with placebo) 2
• Provides 5.4-6.8% placebo-subtracted weight loss at 12+ months 2
• The American Heart Association and American College of Cardiology recommend this as first-line for patients with established cardiovascular disease 2
• Safe in patients with glaucoma and hyperthyroidism (no contraindications in these conditions) 2
• Start at 0.25 mg weekly, titrate gradually to 2.4 mg by week 16 to minimize gastrointestinal side effects 2

Second-Line: Liraglutide 3.0 mg

• Liraglutide 3.0 mg is the second-best option for cardiovascular disease patients, reducing major adverse cardiovascular events (HR 0.87,95% CI: 0.78-0.97) 2
• Achieves 5.4% placebo-subtracted weight loss 2
• Start at 0.6 mg daily, titrate to 3.0 mg by week 4 2
• Safe in glaucoma and hyperthyroidism 2

Third-Line: Naltrexone/Bupropion ER

• Can be used in patients with cardiovascular contraindications to sympathomimetics, though requires blood pressure monitoring 1
• Achieves 6.1% weight loss 1
• Avoid in patients with uncontrolled hypertension or seizure disorders 1
• Safe in glaucoma and hyperthyroidism 1

Safe but Less Effective: Orlistat

• Orlistat is the safest option for patients with cardiovascular contraindications, demonstrating lower cardiovascular event risk in long-term cohort studies 2
• Achieves only 2.8-4.8% weight loss with frequent gastrointestinal side effects 1
• The 2022 AGA guidelines conditionally recommend against orlistat due to modest efficacy and side effects, though it remains appropriate when other agents are contraindicated 1
• Requires daily multivitamin with fat-soluble vitamins (A, D, E, K) taken 2 hours apart from orlistat 1

Monitoring Requirements

For GLP-1 Receptor Agonists (Semaglutide, Liraglutide)

• Monitor for gastrointestinal side effects (nausea, vomiting) during titration 2
• Assess for pancreatitis and gallbladder disease risk 1
• Evaluate weight loss response at 12 weeks; continue if ≥5% weight loss achieved 2

For Naltrexone/Bupropion

• Monitor blood pressure and heart rate periodically, especially in first 12 weeks 1
• Avoid in patients on opiate medications 1

Clinical Algorithm

For patients with cardiovascular disease, glaucoma, OR hyperthyroidism:

1. First choice: Semaglutide 2.4 mg (proven cardiovascular mortality benefit) 2
2. Second choice: Liraglutide 3.0 mg (cardiovascular event reduction) 2
3. Third choice: Naltrexone/bupropion ER (if blood pressure controlled) 1
4. Last resort: Orlistat (safest but least effective) 2

Never use: Phentermine, diethylpropion, phentermine/topiramate, or any sympathomimetic agent 1, 2

Critical Pitfalls to Avoid

• Do not prescribe phentermine "off-label" for longer duration in these high-risk patients despite common practice—the cardiovascular, glaucoma, and hyperthyroidism contraindications remain absolute regardless of treatment duration 1
• Do not assume all appetite suppressants are contraindicated—GLP-1 receptor agonists actually provide cardiovascular protection 2
• Do not overlook the magnitude of benefit difference—semaglutide provides both superior weight loss AND mortality reduction compared to older agents 2