Pharmacological Interventions for Adults With Obesity

Publication Date: October 20, 2022
Last Updated: January 31, 2023

Summary of Recommendations

In adults with obesity or overweight with weight-related complications, who have had an inadequate response to lifestyle interventions, the AGA recommends adding pharmacological agents to lifestyle interventions over continuing lifestyle interventions alone. ( Moderate , Strong )
Implementation considerations:
  • AOMs generally need to be used chronically, and the selection of the medication or intervention should be based on the clinical profile and needs of the patient, including, but not limited to, comorbidities, patients' preferences, costs, and access to the therapy.
612
In adults with obesity or overweight with weight-related complications, the AGA suggests using semaglutide 2.4 mg with lifestyle modifications, compared with lifestyle modifications alone. ( Moderate , Conditional (weak) )
Implementation considerations:
  • Given the magnitude of net benefit, semaglutide 2.4 mg may be prioritized over other approved AOMs for the long-term treatment of obesity for most patients.
  • Semaglutide has glucoregulatory benefits and is also approved for the treatment of T2DM
  • Semaglutide may delay gastric emptying with adverse effects of nausea and vomiting. Gradual dose titration may help mitigate these adverse effects.
  • GLP-1 RAs have been associated with increased risk of pancreatitis and gallbladder disease
612
In adults with obesity or overweight with weight-related complications, the AGA suggests using liraglutide 3.0 mg with lifestyle modifications, compared with lifestyle modifications alone. ( Moderate , Conditional (weak) )
Implementation considerations:
  • Liraglutide has glucoregulatory benefits and is also approved for the treatment of T2DM
  • Liraglutide may delay gastric emptying with adverse effects of nausea and vomiting. Gradual dose titration may help mitigate these adverse effects.
  • Liraglutide has been associated with an increased risk of pancreatitis and gallbladder disease
612
In adults with obesity or overweight with weight-related complications, the AGA suggests using phentermine-topiramate ER with lifestyle modifications, compared with lifestyle modifications alone. ( Moderate , Conditional (weak) )
Implementation considerations:
  • Because topiramate is effective for treating migraine headaches, phentermine-topiramate ER may be preferentially used in patients with comorbid migraines.
  • Phentermine-topiramate ER should be avoided in patients with a history of cardiovascular disease and uncontrolled hypertension.
  • Topiramate is teratogenic. Women of childbearing potential should be counseled to use effective contraception consistently.
  • Blood pressure and heart rate should be monitored periodically while taking medications with phentermine.
612
In adults with obesity or overweight with weight-related complications, the AGA suggests using naltrexone-bupropion ER with lifestyle modifications, compared with lifestyle modifications alone. ( Moderate , Conditional (weak) )
Implementation Considerations:
  • Naltrexone-bupropion ER may be considered for the treatment of overweight or obesity in patients who are attempting smoking cessation, and in patients with depression.
  • Naltrexone-bupropion ER should be avoided in patients with seizure disorders and used with caution in patients at risk of seizures.
  • Naltrexone-bupropion ER should not be used concomitantly with opiate medications.
  • Blood pressure and heart rate should be monitored periodically while taking naltrexone-bupropion ER, especially in the first 12 weeks of treatment.
612
In adults with obesity or overweight with weight-related complications, AGA suggests against the use of orlistat. ( Moderate , Conditional (weak) )
Implementation Considerations:
  • Patients using orlistat should take a multivitamin daily. Vitamins should contain fat-soluble vitamins (A, D, E, K) and should be taken 2 hours apart from orlistat.
  • Comment: Patients who place a high value on the potential small weight loss benefit and low value on GI adverse effects may reasonably choose treatment with orlistat.
612
In adults with obesity or overweight with weight-related complications, the AGA suggests using phentermine with lifestyle modifications, compared with lifestyle modifications alone. ( Low , Conditional (weak) )
Implementation Considerations:
  • Phentermine monotherapy is approved by the FDA for short-term use (12 weeks). However, given the chronic nature of weight management, many practitioners use phentermine longer than 12 weeks in an off-label fashion.
  • Phentermine should be avoided in patients with a history of cardiovascular disease.
  • Blood pressure and heart rate should be monitored periodically while taking phentermine.
612
In adults with obesity or overweight with weight-related complications, the AGA suggests using diethylpropion with lifestyle modifications, compared with lifestyle modifications alone. ( Low , Conditional (weak) )
Implementation considerations:
  • Diethylpropion monotherapy is approved by the FDA for short-term use (12 weeks). However, given the chronic nature of weight management, many practitioners use diethylpropion longer than 12 weeks in an off-label fashion.
  • Diethylpropion should be avoided in patients with a history of cardiovascular disease.
  • Blood pressure and heart rate should be monitored periodically while taking diethylpropion.
612
In adults with BMI between 25 and 40 kg/m2, the AGA recommends using Gelesis100 oral superabsorbent hydrogel only in the context of a clinical trial. ( Evidence Gap , No recommendation )
612

Recommendation Grading

Overview

Title

Pharmacological Interventions for Adults With Obesity

Authoring Organization

Publication Month/Year

October 20, 2022

Last Updated Month/Year

February 13, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

Pharmacological management of obesity improves outcomes and decreases the risk of obesity-related complications. This American Gastroenterological Association guideline is intended to support practitioners in decisions about pharmacological interventions for overweight and obesity.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D009765 - Obesity, D019440 - Anti-Obesity Agents, D000073319 - Obesity Management

Keywords

obesity, obesity medications, adiposity

Source Citation

Grunvald E, Shah R, Hernaez R, Chandar AK, Pickett-Blakely O, Teigen LM, Harindhanavudhi T, Sultan S, Singh S, Davitkov P; AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022 Nov;163(5):1198-1225. doi: 10.1053/j.gastro.2022.08.045. Epub 2022 Oct 20. PMID: 36273831.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
171
Literature Search Start Date
March 23, 2021
Literature Search End Date
January 1, 2022