Transcript Slide 1

Beyond Dieting:
New Weight Loss Medications
& Treatments on the Horizon
Daniel Bessesen, MD
Currently Available Options
Effectiveness
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•
•
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Accept weight where it is
Diet/Exercise: 3-10% weight loss
Drugs: 5-12% weight loss
Medically Supervised/Combination
of Diet + Drug: 10-15% weight loss
• Surgery: 15-30% weight loss
Low
High
Currently Available Options
Risks/Time/Money
•
•
•
•
Accept weight where it is
Diet/Exercise: 3-10% weight loss
Drugs: 5-12% weight loss
Medically Supervised/Combination
of Diet + Drug: 10-15% weight loss
• Surgery: 15-30% weight loss
Low
High
A Guide to Selecting
Treatment
Body Mass Index category
Treatment
25-26.9 27-29.9 30-34.9 35-39.9
Diet, physical activity,
With
and behavior therapy co-morbidity
Pharmacotherapy
Surgery
40
+
+
+
+
With
co-morbidity
+
+
+
With
co-morbidity
+
NIH The Practical Guide. 2000 http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm
2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity
in Adults: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739.71477.ee.citation
Obesity Treatment Pyramid
Surgery
Pharmacotherapy
Lifestyle Modification
Diet
Physical Activity
PharmacologicalTreatment of
Obesity
• Current medications 5-12% wt loss
• Benefits only last as long as patient takes the
medication. Chronic treatment likely needed.
• Drugs probably not paid for by insurance so
cost is a big issue for patients.
• Issues of FDA approval, long term safety, and
efficacy.
• Are medications an appropriate treatment
modality for obesity?
New and Emerging Medications
• FDA approved
– Lorcasarin (Belviq)
– Phentermine/topiramate ER (Qsymia)
• May be approved in near future
– Liraglutide
– Bupropion/naltrexone
Lorcasarin (Belviq)
• Serotonin 2C receptor agonist
• Previous serotonin agonists
fenfluramine and dexfenfluramine
caused cardiac valve disease, removed
from market
• 2C receptor only in the brain not in heart
• Studies in 1-2,000 people for up to 2
years do not show evidence if
valvulopathy with lorcasarin.
Lorcasarin (Belviq)
• Weight loss: 3-5% no better than
phentermine or orlistat
• Side effects: headache, dizziness and
nausea
• Cost: $220/month
• Unclear if physicians will prescribe off
label with phentermine (no data on
safety or efficacy)
Lorcasarin: Weight Effects
N Engl J Med. 2010 Jul 15;363(3):245-56
Phentermine/Topiramate
• Combination gives greater effectiveness
with fewer side effects
• Cost: $150.00/month
• Side effects: dry mouth, numbness,
tingling, insomnia, dizziness, anxiety,
irritability and disturbance in attention
Topiramate/Phentermine
(Qsymia) Effects on Weight
Lancet. 2011 Apr 16;377(9774):1341-52
Phentermine/Topiramate
• Risk of birth defects: women need –
pregnancy test on starting and monthly
while using.
• Reduces blood pressure, glucose,
insulin, triglycerides and raises HDL
• Unclear if physicians will prescribe off
label using generic phentermine and
topiramate.
• Most effective medication available 1012% weight loss.
Lap Band
Low
Gastric Bypass
Effectiveness
Risk
High
Comparison of Operations
• Lap band: 20% weight loss, very low
mortality, 1% serious or 2.4% any
complication
• Sleeve gastrectomy: 25% weight loss,
0.1% mortality, 2.4% serious or 6.3%
any complication
• Gastric bypass: 30% weight loss, 0.2%
mortality, 2.5% serious or 10% any
complication
Ann Surg 2013;257: 791–797; Flum DR, N Engl J Med.
2009 Jul 30;361(5):445-54
Benefits of Weight Loss Surgery
the Swedish Obese Subjects Trial
Bariatric Surgery vs. Usual Care
• Nonrandomized prospective controlled
study
• 2010 pts. had surgery compared to 2037
contemporaneously matched controls
• Began 1987
• Median follow up 14.7 years
Weight loss in the SOS
JAMA. 2012;307(1):56-65
Bariatric Surgery is Associated with a
Reduced Mortality: the SOS Study
30% lower risk
Of dying
MI: 25 in control
Group 13 in the
Surgery group
Cancer: 47 in
The control group
29 in the surgery
group
Sjostrom L NEJM 2007: 357-741-752
Benefits of Bariatric
Surgery for T2DM
N Engl J Med 2012;366:1567-76
• 150 patients randomized to intensive
medical therapy, gastric bypass or sleeve
gastrectomy for management of type 2
diabetes
• Average baseline A1C was 9.2% (diabetes
>6.5, goal <7%)
• Followed for 12 months
Stampede Trial: Benefits of
Surgery for Type 2 Diabetes
Parameter
Medical
Therapy
(n=41)
Bypass
(n=50)
Sleeve
(n=49)
P Value
HbA1c<6
12%
42%
37%
0.008
HbA1C<6 without
DM med
0%
42%
27%
0.003
% change in Tg
-14%
-44%
-42%
0.08
% change in HDL
11%
28%
28%
0.001
N Engl J Med 2012;366:1567-76
Who is a Good Candidate?
• BMI>35 with co-morbidities or >40 without
• Age 20-60
• Co-morbidities: Diabetes, sleep apnea,
reflux > Hypertension, DJD
• Failed other forms of therapy
• No serious, active cardiac, pulmonary, or
psychiatric disease
Thank you