Malady Wise

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Obesity Drugs

Maladywise

SUMMARY: Quick overview of obesity medications from the HPMI Obesity Weekend Conference 2022.

Reference

Introduction

  • 67% of adults are overweight or obese

  • 1 in 4 children and adolescents are overweight or obese

  • 9% of disease burden and death is attributable to obesity

Consequences

  • Obesity linked to >195 complications

  • Metabolic: Diabetes, HTN, PCOS, Dyslipidemia

  • Pulmonary: OSA, Asthma

  • MSK: OA, back pain, immobility, sarcopenia, falls

  • Reproductive: menstrual irregularity, continence, infertility

  • Cardiovascular: CCF, IHD, Stroke, varicose veins

  • Mental health: Social isolation, depression, eating disorders

  • Nutrition: malnutrition

  • Cancer: Endometrial, breast, pancreas, prostate

Central Regulation

  • Adipose tissue > Leptin (appetite suppressing)

  • Stomach > Ghrelin (appetite increasing)

  • Pancreas > Insulin (appetite suppressing)

  • Intestines > CCK, GLP-1, PYY, OXM (appetite suppressing)

Contrave

  • Cost $250

  • Works on BOTH mesolimbic reward system and hypothalamic hunger system

  • Naltrexone / Buproprion

  • Indication BMI > 30 or BMI > 27 with comorbidity

  • Check weight loss at 16 weeks, needs to be > 5% other cease

  • 2 tablets twice daily, uptitrate over 4 weeks

  • Weight loss 5 to 7%, can be up to 12% with behaviour modification therapy

  • 53% lost 5% or more at week 56

  • Good time to quit smoking or alcohol as well

  • Contraindications: Opiates, Seizure disorders

  • Adverse effects: No convincing evidence of increased cardiovascular events, lower dose if GFR <60

  • Drug interactions: Increase levels of Antipsychotics, B blockers, Antidepressants, limit to max 2 tablets if on clopidogrel

  • Contrave Prescribing Checklist - https://contravehcp.com/wp-content/uploads/2017/06/Prior_Authorization_Checklist.pdf

Saxenda / Liraglutide / GLP-1 analogues

  • Cost $375

  • Indication BMI > 30 or BMI > 27 with comorbidity

  • Weight loss is 8% at 56 weeks

  • Those who lost >5% at 16 weeks, lost 11% at 56 weeks

  • Can be used with VLED

  • Side effects: 25% has significant nausea, peaks around week 6. Titrate up slower over 3 months to reduce

  • Titrate weekly, 0.6mg, 1.2mg, 1.8mg, 2.4mg up to 3mg

  • Adverse events: Slight increase gall stones

Ozempic / Semaglutide

  • Once weekly dosing

  • 1mg gets 10% weight loss, 2.4mg dose achieves 13% weight loss

Topirimate and Phentermine (Duromine)

  • Up to 14% weight loss

  • Adverse effects: Dry mouth, constipation, change in taste

Tirzepatide

  • Not available yet

  • Weekly injection

  • Weight loss around 20 to 22% weight loss

  • 2.2% HBA1c reduction in T2DM, compared to 1.8% loss with Ozempic

  • Newer triple agonist medication also in works looking at 30% weight loss

End point

  • All drugs wear off and weight regain happens due to set point

  • At start, consider discussion regarding end point or continuation indefinitely

Reference