Pharmacologic Management of Obesity: Endocrine Society’s New Guidelines

In January, 2015, the Endocrine Society issued an evidence-based clinical practice guideline for the pharmacologic management of obesity (co-sponsored by the European Society of Endocrinology and the Obesity Society).¹ The authors agree with the opinion of prominent medical societies that obesity is a disease.² They note that, while greater weight loss is most beneficial, even modest (5%–10%) weight loss has been shown to produce significant improvement in many conditions.^2,3

The rationale for pharmacologic treatment of obesity is that permanent weight loss cannot always be achieved or maintained exclusively with reductions in food intake and increases in energy expenditure. Weight loss medications “reinforce” behavioral changes by affecting appetite or blocking fat absorption. While pharmacotherapy does not lead to long-term thermogenesis, the medications increase satiety and decrease hunger, enabling long-term reduction of energy intake.^1-3,6

Care of the Patient Who is Overweight or Obese

Diet, exercise, and behavioral modification should be included in all obesity management approaches for those with body mass index (BMI) ≥25kg/m². Pharmacotherapy is recommended for patients with BMI ≥27kg/m² with comorbidity, or BMI >30kg/m². Bariatric surgery is recommended for patients with BMI ≥35kg/m² with comorbidity, or BMI >40kg/m². 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.” Advantages and disadvantages of weight loss medications are listed in Table 1.

Table One

Drug	Advantages	Disadvantages
Phentermine	Inexpensive  Weight loss >3–5%	Side effect profile  No long-term data (1–2 years)
Topiramate/phentermine	Weight loss >5%  Long-term data (1–2 years)	Expensive  Teratogen
Lorcaserin	Side effect profile  Long-term data (1–2 years)	Expensive
Orlistat prescription	Nonsystemic  Long-term data (1–2 years)	Weight loss 2–3%  Side effect profile
Orlistat OTC	Inexpensive	Weight loss 2–3%  Side effect profile
Naltrexone/bupropion	Weight loss >3–5%  Food addiction  Long-term data (1–2 years)	Side effect profile  Mid-level price range
Liraglutide	Side effect profile  Long-term data (1–2 years)	Expensive  Injectable