beyond dieting: new weight loss medications & treatments on the horizon daniel bessesen, md
TRANSCRIPT
Beyond Dieting: New Weight Loss Medications & Treatments on the Horizon
Daniel Bessesen, MD
Currently Available Options
• Accept weight where it is
• Diet/Exercise: 3-10% weight loss
• Drugs: 5-12% weight loss
• Medically Supervised/Combination
of Diet + Drug: 10-15% weight loss
• Surgery: 15-30% weight loss
Low
High
Effectiveness
Currently Available Options
• Accept weight where it is
• Diet/Exercise: 3-10% weight loss
• Drugs: 5-12% weight loss
• Medically Supervised/Combination
of Diet + Drug: 10-15% weight loss
• Surgery: 15-30% weight loss
Low
High
Risks/Time/Money
A Guide to Selecting Treatment
Treatment
Body Mass Index category
25-26.9 27-29.9 30-34.9 35-39.9 40
Diet, physical activity, and behavior therapy
Pharmacotherapy
Surgery
Withco-morbidity
Withco-morbidity
Withco-morbidity
+ + + +
+
+
+ +
NIH The Practical Guide. 2000 http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesityin Adults: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.citation
Obesity Treatment Pyramid
SurgerySurgery
PharmacotherapyPharmacotherapy
Lifestyle ModificationLifestyle Modification
DietDiet Physical ActivityPhysical Activity
PharmacologicalTreatment of Obesity
• Current medications 5-12% wt loss• Benefits only last as long as patient takes the
medication. Chronic treatment likely needed.• Drugs probably not paid for by insurance so
cost is a big issue for patients.• Issues of FDA approval, long term safety, and
efficacy. • Are medications an appropriate treatment
modality for obesity?
New and Emerging Medications
• FDA approved– Lorcasarin (Belviq)– Phentermine/topiramate ER (Qsymia)
• May be approved in near future– Liraglutide – Bupropion/naltrexone
Lorcasarin (Belviq)
• Serotonin 2C receptor agonist• Previous serotonin agonists fenfluramine
and dexfenfluramine caused cardiac valve disease, removed from market
• 2C receptor only in the brain not in heart• Studies in 1-2,000 people for up to 2
years do not show evidence if valvulopathy with lorcasarin.
Lorcasarin (Belviq)
• Weight loss: 3-5% no better than phentermine or orlistat
• Side effects: headache, dizziness and nausea
• Cost: $220/month• Unclear if physicians will prescribe off
label with phentermine (no data on safety or efficacy)
Lorcasarin: Weight Effects
N Engl J Med. 2010 Jul 15;363(3):245-56
Phentermine/Topiramate
• Combination gives greater effectiveness with fewer side effects
• Cost: $150.00/month• Side effects: dry mouth, numbness,
tingling, insomnia, dizziness, anxiety, irritability and disturbance in attention
Lancet. 2011 Apr 16;377(9774):1341-52
Topiramate/Phentermine (Qsymia) Effects on Weight
Phentermine/Topiramate
• Risk of birth defects: women need – pregnancy test on starting and monthly while using.
• Reduces blood pressure, glucose, insulin, triglycerides and raises HDL
• Unclear if physicians will prescribe off label using generic phentermine and topiramate.
• Most effective medication available 10-12% weight loss.
Gastric BypassLap Band
Effectiveness
Risk
Low High
Comparison of Operations• Lap band: 20% weight loss, very low
mortality, 1% serious or 2.4% any complication
• Sleeve gastrectomy: 25% weight loss, 0.1% mortality, 2.4% serious or 6.3% any complication
• Gastric bypass: 30% weight loss, 0.2% mortality, 2.5% serious or 10% any complication
Ann Surg 2013;257: 791–797; Flum DR, N Engl J Med. 2009 Jul 30;361(5):445-54
Benefits of Weight Loss Surgery the Swedish Obese Subjects Trial
Bariatric Surgery vs. Usual Care
• Nonrandomized prospective controlled study
• 2010 pts. had surgery compared to 2037 contemporaneously matched controls
• Began 1987
• Median follow up 14.7 years
Weight loss in the SOS
JAMA. 2012;307(1):56-65
Bariatric Surgery is Associated with aReduced Mortality: the SOS Study
Sjostrom L NEJM 2007: 357-741-752
30% lower riskOf dying
MI: 25 in controlGroup 13 in theSurgery group
Cancer: 47 inThe control group29 in the surgerygroup
Benefits of Bariatric Surgery for T2DM
N Engl J Med 2012;366:1567-76
• 150 patients randomized to intensive medical therapy, gastric bypass or sleeve gastrectomy for management of type 2 diabetes
• Average baseline A1C was 9.2% (diabetes >6.5, goal <7%)
• Followed for 12 months
Stampede Trial: Benefits of Surgery for Type 2 Diabetes
Parameter Medical Therapy (n=41)
Bypass(n=50)
Sleeve(n=49)
P Value
HbA1c<6 12% 42% 37% 0.008
HbA1C<6 without DM med
0% 42% 27% 0.003
% change in Tg -14% -44% -42% 0.08
% change in HDL 11% 28% 28% 0.001
N Engl J Med 2012;366:1567-76
Who is a Good Candidate?
• BMI>35 with co-morbidities or >40 without
• Age 20-60
• Co-morbidities: Diabetes, sleep apnea, reflux > Hypertension, DJD
• Failed other forms of therapy
• No serious, active cardiac, pulmonary, or psychiatric disease
Thank you