Managing Obesity: More Than GLP-1s or Bust?

Obesity expert Dr Holly Lofton reviews three alternatives to GLP-1s to help patients drop excess weight. https://www.medscape.com/viewarticle/... -- TRANSCRIPT -- Hi. I'm Dr Holly Lofton. I'm a board-certified obesity medicine specialist, and I direct the medical weight management program at NYU Langone Health. There is so much information about glucagon-like peptide 1 (GLP-1) agonists as anti-obesity medications. I bet you can't think of a single person who hasn't heard of them, and many of your friends or family members may have even tried them. However, we also have what we call the first generation of medications for weight management, and I'll talk about some of those today. Phentermine. If your patient is not able to tolerate a GLP-1 agonist or is unable to access these medicines for various reasons, one option is phentermine, which has been around for decades. It is an oral medication that's usually taken once a day in the morning. It is a classic appetite suppressant. Phentermine makes people feel less hungry. It also gives people a little more energy, so they're able to increase their activity while creating a caloric deficit, and this leads to weight loss over time. Phentermine differs from the GLP-1 agonists, which are intended for chronic weight management. The FDA has approved phentermine for short-term weight loss; its use is recommended for no more than 12 weeks at a time. The medication comes in doses ranging from 8 mg to 37.5 mg and is usually slowly titrated up depending on tolerance and effect. Side effects that are most often reported include a racing heart, insomnia, agitation, and dry mouth. This drug is not for everyone. Phentermine is contraindicated in those with uncontrolled hypertension, with cardiac disease (such as a history of heart attack), or who are at high risk for heart attack or stroke. Some drug interactions can occur, which should be considered on a case-by-case basis. Phentermine may be an option for your patients if an elevated appetite is keeping them from losing weight. It should be used as an adjunct to lifestyle recommendations, which means eating fewer calories and increasing activity. Phentermine-Topiramate. Another non–GLP-1 agonist medication indicated for obesity is phentermine-topiramate [Qsymia]. This is another oral medication. The idea behind combining these two medications is that they can generate more appetite suppression without the high potential for side effects of phentermine alone, such as agitation, increased heart rate, or increased blood pressure. Topiramate is used for migraine or seizure prevention. One side effect of topiramate is unintentional weight loss, so they decided to combine phentermine with topiramate in one pill. Phentermine-topiramate comes in four different doses and is usually titrated up from the lowest to the highest dose. People who can't tolerate the higher doses of phentermine are able to tolerate Qsymia because the dose of phentermine is lower. This medication came to the market in 2012, after the SEQUEL trial, which demonstrated its safety and efficacy, achieved about 12% weight loss, which for many years was the highest weight loss seen with any other anti-obesity medications on the market. Because this is a combination medication, it has some potential side effects and contraindications. For example, we don't give phentermine-topiramate to people with uncontrolled hypertension or anxiety, and it is contraindicated in those with glaucoma. We don't give this medication to anyone who has had adverse reactions or hypersensitivity to either of the ingredients. Because the combination contains topiramate, it should not be prescribed to anyone with childbearing potential unless they are using an effective form of hormonal contraception or even two effective forms. Topiramate can increase the risk of having a baby with a cleft palate by five times if they become pregnant while taking this medication. Phentermine-topiramate is dosed once daily. One commonly reported side effect is paresthesia: numbness and tingling of the fingers and toes that can manifest as feeling very cold when it's cold outside. Although some patients report paresthesia, most say that it's not so intolerable that they want to discontinue the medication. There have been reports of vision changes in people taking phentermine-topiramate; if severe vision changes occur, it is recommended to discontinue the medication. Transcript in its entirety can be found by clicking here: https://www.medscape.com/viewarticle/...