Pharmacological Management of Obesity

Publication Date: January 2, 2015
Last Updated: April 11, 2022

Treatment

Endocrine Society (ES) recommends that diet, exercise, and behavioral modification be included in all obesity management approaches for BMI ≥25 kg/m2 and that other tools such as pharmacotherapy (BMI ≥27 kg/m2 with comorbidity or >30) and bariatric surgery (BMI ≥35 kg/m2 with comorbidity or >40) be used as adjuncts to behavioral modification to reduce food intake and increase physical activity when this is possible. Drugs may amplify adherence to behavior change and may improve physical functioning such that increased physical activity is easier in those who cannot exercise initially. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications. ( 1 , H )
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In order to promote long-term weight maintenance, ES suggests the use of approveda weight loss medication (over no pharmacological therapy) to ameliorate comorbidities and amplify adherence to behavior changes, which may improve physical functioning and allow for greater physical activity in individuals with a BMI2 ≥30 kg/m or in individuals with a BMI2 of ≥27 kg/m and at least one associated comorbid medical condition such as hypertension, dyslipidemia, T2DM, and obstructive sleep apnea.
( 2 , L )
a Approval in the United States is based on FDA determination. Approval in Europe is based on EMA determination.
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In patients with uncontrolled HTN or history of heart disease, ES recommends against using the sympathomimetic agents phentermine and diethylpropion. (1, M)
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ES suggests assessment of efficacy and safety at least monthly for the first 3 months, then at least every 3 months in all patients prescribed weight loss medications. (2, L)
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If a patient’s response to a weight loss medication is deemed effective (weight loss ≥5% of body weight at 3 months) and safe, ES recommends the medication be continued. If deemed ineffective (weight loss <5% at 3 months) or if there are safety or tolerability issues at any time, ES recommends the medication should be discontinued and alternative medications or referral for alternative treatment approaches considered. (1, H)
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If medication for chronic obesity management is prescribed as adjunctive therapy to comprehensive lifestyle intervention, ES suggests initiating therapy with dose escalation based on efficacy and tolerability to the recommended dose and not exceeding the upper approved dose boundaries. (2, L)
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In patients with T2DM who are overweight or obese, ES suggests the use of antidiabetic medications that have additional actions to promote weight loss (such as GLP-1 agonists or SGLT-2 inhibitors) in addition to the first-line agent for T2DM and obesity, metformin. (2, M)
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In patients with CVD who seek pharmacological treatment for weight loss, ES suggests using medications such as lorcaserin and/or orlistat that are not sympathomimetics. (2, VL)
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Drugs That Cause Weight Gain and Some Alternatives

ES recommends weight-losing and weight-neutral medications as first- and second-line agents in the management of a patient who is overweight or obese with T2DM. Clinicians should discuss possible weight effects of glucose-lowering medications with patients and consider the use of antihyperglycemic medications that are either weight neutral or promote weight loss. (1, M)
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In obese patients with T2DM requiring insulin therapy, ES suggests adding at least one of the following: metformin, pramlintide, or GLP-1 agonists to mitigate associated weight gain due to insulin. The first-line insulin for this type of patient should be basal insulin. This is preferential to using either insulin alone or insulin with sulfonylurea. ES also suggests that a preferential trial of basal insulin be considered prior to premixed insulins or combination insulin therapy. (2, M)
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ES recommends ACE inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers rather than β-adrenergic blockers as first-line therapy for hypertension in patients who are obese with T2DM. ( 1 , H )
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When antidepressant therapy is indicated, ES recommends a shared decision-making process that provides patients with quantitative estimates of the expected weight effect of the antidepressant to make an informed decision about drug choice. Other factors that need to be taken into consideration include the expected length of treatment. (1, M)
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ES recommends using weight-neutral antipsychotic alternatives when clinically indicated rather than those that cause weight gain, and the use of a shared decision-making process that provides patients with quantitative estimates of the expected weight effect of the alternative treatments to make an informed decision about drug choice. (1, M)
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ES recommends considering weight gain potential in choosing an antiepileptic drug for any given patient, and the use of a shared decision-making process that provides patients with quantitative estimates of the expected weight effect of the drugs to make an informed decision about drug choice. (1, M)
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In women with a BMI >27 kg/m2 with comorbidities or >30 kg/m2 seeking contraception, ES suggests oral contraceptives over injectable medications due to weight gain with injectables, provided that women are well-informed about the risks and benefits (i.e., oral contraceptives are not contraindicated).

( 2 , VL )
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ES suggests monitoring the weight and waist circumference of patients on antiretroviral therapy due to unavoidable weight gain, weight redistribution, and associated cardiovascular risk. (2, M)
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ES suggests the use of NSAIDs and disease-modifying antirheumatic drugs (DMARDs) when possible in patients with chronic inflammatory disease like rheumatoid arthritis, since corticosteroids commonly produce weight gain. (2, M)
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ES suggests the use of antihistamines with less central nervous system activity (less sedation) to limit weight gain. (2, L)
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Off-Label Use of Drugs Approved for Other Indications for Chronic Obesity Management

ES suggests against the off-label use of medications approved for other disease states for the sole purpose of producing weight loss. A trial of such therapy can be attempted in the context of research, and by health care providers with expertise in weight management dealing with a well-informed patient. (U, )
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Recommendation Grading

Overview

Title

Pharmacological Management of Obesity

Authoring Organization

Endorsing Organization

Publication Month/Year

January 2, 2015

Last Updated Month/Year

April 4, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To formulate clinical practice guidelines for the pharmacological management of obesity.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory

Intended Users

Diabetes educator, dietician nutritionist, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Treatment, Management

Diseases/Conditions (MeSH)

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

Keywords

obesity, overweight

Source Citation

Caroline M. Apovian, Louis J. Aronne, Daniel H. Bessesen, Marie E. McDonnell, M. Hassan Murad, Uberto Pagotto, Donna H. Ryan, Christopher D. Still, Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 100, Issue 2, 1 February 2015, Pages 342–362, https://doi.org/10.1210/jc.2014-3415