We recommend the use of measures of central adiposity (using sex- and ethnicity-specific cut-offs if applicable), such as waist circumference, waist-to-hip ratio, or waist-to-height ratio, in addition to ethnicity-specific BMI thresholds or adiposity-related complications, to guide the decision to initiate pharmacotherapy. Level 3; grade C
We suggest that the initiation of obesity pharmacotherapy, in conjunction with health behaviour changes, for adults with excess adiposity be personalized to meet individual values, preferences, and treatment goals to support an approach that is safe, effective, culturally acceptable, and affordable for long-term adherence. Level 3; grade D consensus
Pharmacotherapy for obesity management, in conjunction with health behaviour changes, should be offered to people with BMI ≥ 30,* or BMI ≥ 27* with adiposity-related complications:
- Semaglutide 2.4 mg weekly (BMI ≥ 27*) (level 1a; grade A)
- Tirzepatide 5 mg, 10 mg, or 15 mg weekly (BMI ≥ 27*) (level 1a; grade A)
- Liraglutide 3 mg daily (BMI ≥ 27*) (level 2a; grade B)
- Naltrexone–bupropion 16 mg/180 mg twice daily (BMI 27–45*) (level 2a; grade B)
- Orlistat 120 mg 3 times daily (BMI 28–47*) (level 2a; grade B)
Pharmacotherapy for obesity management, in conjunction with health behaviour changes, should be used long term, when effective, to:
- Avoid weight regain and regression of health benefits achieved with pharmacotherapy:
- Semaglutide 2.4 mg weekly (level 1a; grade A)
- Tirzepatide 10 mg or 15 mg weekly (level 1a; grade A)
- Orlistat 120 mg 3 times daily (level 2a; grade B)
- Maintain weight loss and prevent weight regain following health behaviour changes alone:
- Liraglutide 3 mg daily (level 2a; grade B)
- Orlistat 120 mg 3 times daily (level 2a; grade B)
- Tirzepatide 10 mg or 15 mg (level 2a; grade B)
Pharmacotherapy should be offered, in conjunction with health behaviour changes, to reduce the occurrence of major adverse cardiovascular events in people with established ASCVD and BMI ≥ 27,* in addition to standard of care for ASCVD:. Semaglutide 2.4 mg week. Level 2a; grade B
Pharmacotherapy should be offered, in conjunction with health behaviour changes, to people living with heart failure with preserved ejection fraction and BMI ≥ 30,* in addition to standard of care, for weight loss and:
- A composite of reduction in cardiovascular death or a worsening heart failure event:
- Tirzepatide 15 mg weekly
- Improvement in heart failure symptoms:
- Semaglutide 2.4 mg weekly
- Tirzepatide 15 mg weekly
- Level 1a; grade A
Obesity pharmacotherapy, in conjunction with health behaviour changes, for people living with prediabetes should be offered for weight loss and to:
- Reduce the risk of progression to type 2 diabetes:
- Liraglutide 3 mg daily (BMI ≥ 27*) (level 2a; grade B)
- Orlistat 120 mg 3 times daily (BMI ≥ 30*) (level 2a; grade B)
- Tirzepatide 5 mg, 10 mg, or 15 mg weekly (BMI ≥ 27*) (level 2a; grade B)
- Achieve normoglycemia:
- Semaglutide 2.4 mg weekly (BMI ≥ 30*) (level 1a; grade A)
Obesity pharmacotherapy should be offered, in conjunction with health behaviour changes, to people living with type 2 diabetes for weight loss and improvement in glycemic control:
- Semaglutide 2.4 mg weekly (BMI ≥ 27*) (level 1a; grade A)
- Tirzepatide 10 mg or 15 mg weekly (BMI ≥ 27*) (level 1a; grade A)
- Liraglutide 3 mg daily (BMI ≥ 27*) (level 2a; grade B)
- Naltrexone–bupropion 16 mg/180 mg twice daily (BMI 27–45*) (level 2a; grade B)
- Orlistat 120 mg 3 times daily (BMI 27–43*) (level 2a; grade B)
Pharmacotherapy may be offered, in conjunction with health behaviour changes, in treating people living with MASH, for weight loss and:
- Resolution of MASH without worsening of fibrosis:
- Semaglutide 2.4 mg weekly (level 2a; grade B)
- Liraglutide 1.8 mg daily (BMI ≥ 25*) (level 3; grade C)
- Tirzepatide 5 mg, 10 mg, or 15 mg weekly (BMI 27–50*) (level 3; grade C)
- Improvement in fibrosis without worsening of MASH:
- Semaglutide 2.4 mg weekly (level 2a; grade B)
- Tirzepatide 5 mg, 10 mg, or 15 mg weekly (BMI 27–50*) (level 3; grade C)
Pharmacotherapy should be offered, in conjunction with health behaviour changes, for weight loss and improvement in apnea-hypopnea index in people who are living with moderate to severe obstructive sleep apnea and BMI ≥ 30,* and who are:
- Unwilling or unable to use positive airway pressure therapy:
- Tirzepatide 10 mg or 15 mg (level 1a; grade A)
- Liraglutide 3 mg daily (level 2a; grade B)
- Using positive airway pressure therapy:
- Tirzepatide 10 mg or 15 mg (level 1a; grade A)
Pharmacotherapy for obesity management should be offered, in conjunction with health behaviour changes, for people living with knee osteoarthritis and BMI ≥ 30* for weight loss and reduction in knee pain: Semaglutide 2.4 mg weekly.Level 1a; grade A
Setmelanotide up to 3 mg daily may be offered for weight management for people with BMI ≥ 30* and:
- Bardet–Biedl syndrome (level 2a; grade B)
- Genetically confirmed biallelic pro-opiomelanocortin, proprotein convertase subtilisin/kexin type 1, or leptin receptor deficiency due to variants interpreted as pathogenic, likely pathogenic, or of uncertain significance (level 3; grade C)
We recommend against the use of compounded medications, prescription medications, or over-the-counter medications other than those approved in Canada for weight loss in people with excess adiposity. Level 4; grade D consensus