What alternative medication can be recommended for a patient who cannot take Wellbutrin (bupropion) and whose insurance does not cover injectable weight loss medications?

From the Guidelines

For a patient who cannot take Wellbutrin and lacks insurance coverage for injectable weight loss medications, I would recommend considering phentermine as an alternative weight loss medication, given its modest weight loss efficacy of 3.6 kg at 6 months, as reported in a meta-analysis 1. Phentermine is a sympathomimetic amine that suppresses appetite by increasing norepinephrine in the hypothalamus. It is typically prescribed at 15-37.5mg once daily in the morning. Some key points to consider when prescribing phentermine include:

• Monitoring for side effects such as potential increases in heart rate and blood pressure
• Contraindications in certain conditions including glaucoma, hyperthyroidism, and recent MAO inhibitor use
• The need for a thorough medical history before prescribing
• The importance of accompanying phentermine with lifestyle modifications, including caloric restriction and increased physical activity, to enhance efficacy and promote sustained weight loss. It's also important to note that while phentermine can be an effective weight loss medication, it should be used in conjunction with lifestyle modifications and under the guidance of a healthcare professional, as the long-term safety and efficacy data are limited 1.

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 patient can be recommended phentermine as an alternative medication for weight loss, given that they cannot take Wellbutrin and injectable weight loss medications are not covered by their insurance. However, it is essential to consider the patient's medical history, BMI, and other risk factors before prescribing phentermine. The dosage should be individualized, and the patient should be monitored for potential side effects and contraindications 2.

• Key considerations:
  • Patient's BMI and presence of other risk factors
  • Medical history, including cardiovascular disease, hyperthyroidism, and glaucoma
  • Potential for abuse and dependence
  • Need for regular monitoring and follow-up appointments
  • Importance of a comprehensive weight reduction program that includes exercise, behavioral modification, and caloric restriction.

From the Research

Alternative Weight Loss Medications

Given that the patient cannot take Wellbutrin and insurance does not cover injectable weight loss medications, alternative options can be considered. The following medications are approved for weight loss therapy in the USA:

• Orlistat
• Phentermine/topiramate
• Naltrexone/bupropion
• Liraglutide

Efficacy of Alternative Medications

Studies have shown that these medications can result in significant weight loss:

• Phentermine/topiramate: 6.8% weight reduction 3
• Liraglutide: 5.4% weight reduction 3
• Naltrexone/bupropion: 4.0% weight reduction 3
• Orlistat: 2.9% weight reduction 3

Considerations for Medication Selection

When selecting a medication, it is essential to consider the patient's individual needs and comorbidities:

• Medications should be tailored to the patient's specific conditions and preferences 3, 4
• The benefits and risks of each medication should be weighed carefully 3, 4

Recent Developments in Weight Loss Medications

New medications, such as semaglutide, have shown promise in clinical trials:

• Semaglutide: 15% weight loss at 1 year 5
• Tirzepatide and cagrilintide/semaglutide combination: showing promise for even greater weight loss efficacy 5