Treat weight problems first, then deal with comorbidities like dyslipidemia, hypertension, and impaired glucose tolerance, a new guideline urges.
It’s an entirely new approach to the treatment of disease, said Caroline Apovian, MD, of Boston University, the lead author of a new guideline for treating obesity with medications, published online in the Journal of Clinical Endocrinology and Metabolism.
“The old paradigm was to treat each comorbidity with medications … then manage obesity, which caused most of the original problems in the first place,” Apovian said during a press briefing. “The new paradigm is to manage the obesity first, with lifestyle change and medications, then manage the remainder of the comorbidities that have not responded.”
The guideline focuses on medical management of obesity, a component left out of earlier guidelines released by the American Heart Association, the American College of Cardiology, and the Obesity Society, since they were written before many of the new weight-loss drugs were approved.
Those drugs, coupled with extensive lifestyle counseling and clinician visits, are poised to help patients who’ve struggled to lose weight for years by enhancing their ability to make behavioral change, Apovian said.
That, in turn, should diminish their need for medications to manage other conditions that are tied to obesity, including diabetes, hypertension, and dyslipidemia, she said.
Several obesity experts contacted by MedPage Today said they agreed with the new guidance, that treating overweight and obesity could resolve many of the conditions that commonly occur with it.
“Treating obesity is good,” said Joel Zonszein, MD, of Albert Einstein College of Medicine in New York. “It is at the core of the hypertension, dyslipidemia, insulin resistance, and diabetes that we see.”
Four new obesity drugs have been approved in the last few years: Belviq, Qsymia, Contrave, and Saxenda. Many of these medications work by amplifying the effects of behavioral changes, Apovian said, and they have the greatest effect when they’re reinforced with face-to-face visits – the literature says at least 16 visits per year, a figure that federal insurers reimburse for.
“Adding the medications to a diet and lifestyle program leads to a greater enhancement of their effects,” she said. “And we recommend that if you’re going to treat weight management patients that you see them frequently.”
Apovian noted that the Endocrine Society still stands by the AHA/ACC/TOS guidelines on weight management, and that the current guidelines simply fill a gap that wasn’t addressed in the 2013 guidance.
The new guidelines are the first to mention specific obesity drugs and give some guidance on how to prescribe them.
In patients with uncontrolled hypertension or a history of heart disease, the guidelines recommend against using the sympathomimetic agents phentermine (a component of Qsymia) and diethylpropion.
Patients with cardiovascular risk, for instance, should be put on the drugs with the lowest cardiovascular risk, which include orlistat (Alli, Xenical) or lorcaserin (Belviq), Apovian said.
Patients should be put on the drugs for a 3-month trial period, starting at the lowest dose and titrating up, the guidelines state. If they don’t lose at least 5% of their body weight in that time, they should be switched to another drug.
“You have to give your best guess as to which drug the patient should go on based on their lifestyle characteristics that make them amenable to that particular drug,” Apovian said. “Unless you have a very clear idea of what drug you think the patient will do best on, it’s going to be trial and error.”
The guidelines also offer specifics on dietary recommendations – taking down saturated fats and trans fats for those with lipid problems, lowering salt and going on the DASH diet if they have hypertension – and calling for 150 minutes per week of moderate-intensity exercise.
They also cover how to treat patients who have both obesity and diabetes, urging clinicians to wean patients off diabetes drugs that make them gain weight, such as insulin, sulfonylureas, and thiazolidinediones, and replacing them with drug classes that promote weight loss, including GLP-1 agonists and SGLT2 inhibitors.
The question remains whether insurance will cover these medications, Zonszein said.
“Many insurances do not want to pay for obesity drugs,” he told MedPage Today. “And they’re expensive. They can cost between $4,000 and $6,000 per year.”
With more clinicians focused on the treatment of obesity as a disease – which is what the American Medical Association called it in 2013 – experts say that could change.
Journal of Clinical Endocrinology and Metabolism
Source Reference: Apovian CM, et al “Pharmacological management of obesity: An Endocrine Society clinical practice guideline” J Clin Endocrinol Metab 2015; DOI: 10.1210/jc.2014-3415.