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When should I consider using a medication to assist with weight loss?

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Lisa is a 53-year-old woman who has struggled to maintain a healthy body weight for many years — really since her first pregnancy when she was 30 years old.

She always does well when she has a specific program to follow — for example, a food plan — or when she joins an exercise class. But as soon as the program is done, she gradually regains the weight. The multiple ups and downs in her weight are frustrating to her emotionally, and the weight is also causing her to have more health problems. She now has to take medicine for high blood pressure, is on treatment for sleep apnea and just found out she has borderline diabetes.

As a specialist who works with many women and their health issues around weight, I know Lisa’s story is not unique. The weight-loss journey can be a lonely and frustrating process, and Lisa’s story is one that many people can relate to.

Even though losing weight takes time and effort, maintaining weight can sometimes be more difficult because of how the body is designed to fight back. When the body senses that there is “less of itself,” it increases those signals that lead to food consumption. In other words, a person who has lost weight is more likely to be hungry and to have cravings. Having to resist these feelings can be quite exhausting. And over time, as the fight becomes harder and harder to sustain, there is regain of weight.

There is some thought that using certain food plans, such as a low-carbohydrate diet or a high-protein diet, can make the body less likely to put out these strong food-seeking signals. However, as it stands, the science backing long-term use of such dietary plans is lacking.

For some women, weight-loss medications may be an option. Almost all the current weight-loss medications approved by the U.S. Food and Drug Administration (FDA) are appetite suppressants. Appetite suppressants are designed to influence hunger, cravings and thoughts of food that occur when there is an attempt at weight loss. There is no medication on the market currently that changes metabolism or the body’s ability to burn calories. All approved appetite suppressants are effective enough to produce meaningful weight loss. This averages out to be about 5% to 15% of a person’s body weight, which can be enough to improve prediabetes and joint discomfort, as in Lisa’s case.

The different appetite suppressants come with their own set of side effects and potential interactions with other medications, and so those things must be weighed carefully before deciding on a medication. These drugs can also be expensive.

Weight-loss medications include:

  • Phentermine (Adipex-P, Lomaira). This medication is the oldest of the weight management drugs. Some people may be wary of this drug, as the former drug combination fenfluramine and phentermine (fen-phen) was pulled off the market due to concerns about valvular heart disease. However, the other drug, fenfluramine, was the cause — but phentermine retains a warning about valvular heart disease. This is a stimulant that works by reducing hunger. It is best used in someone with no high blood pressure, not much anxiety and no sleep issues who is not able to lose weight because of appetite. This drug is approved for short-term use of less than 12 weeks.
  • Phentermine-topiramate (Qsymia). This is a newer combination pill on the market. It combines phentermine with topiramate, which is a drug used to treat migraines and seizures. Different doses are needed for those with kidney disease. And the drug cannot be stopped abruptly, as this can lead to seizures. A loss of 5% of your body weight after three months of starting treatment is the initial goal.
  • Bupropion-naltrexone (Contrave). This medication is a combination of an antidepressant and a medication for treating addiction to opioids and alcohol. It’s important to note that this drug can increase suicidal thoughts, especially in young adults. Bupropion-naltrexone can raise blood pressure, and monitoring is necessary at the start of treatment.
  • Liraglutide (Saxenda). This is a rebranded diabetes medication (Victoza) that was later approved for weight management at a higher dose. It is given as a daily injection. It can cause pancreatitis and must be avoided in people with a personal or family history of a certain thyroid cancer.
  • Semaglutide (Wegovy). This is another former diabetes medication that was very recently approved by the FDA for weight management at a higher dose. This is a weekly injection, and it has the same pancreatitis and thyroid warnings as liraglutide.
  • Orlistat (Xenical). Unlike other weight-loss drugs that decrease appetite or increase feelings of fullness, this drug works by interfering with absorption of fat. Orlistat is also available in a reduced-strength form without a prescription (Alli). You need to follow a low-fat diet when taking this medicine. Rare cases of serious liver injury have been reported with orlistat. However, no cause-and-effect relationship has been established.

The people who would benefit most from an appetite suppressant are those who have already established a food and activity plan. I encourage people to meet with a dietitian, especially if it has been some time since they discussed specific food choices and meal planning.

People often wonder how long they can stay on an appetite suppressant. Some medications are approved for long-term use. And for a lot of people, they help not just in the weight-loss phase but also in the weight-maintenance phase. This will be an ongoing conversation with your health care provider. Assessing if the medication can be stopped is something to do periodically.

Meera Shah, M.B., Ch.B.

Dr. Shah is an endocrinologist specializing in helping patients manage weight at Mayo Clinic, Rochester. She serves on the editorial board of Metabolic Diseases and Related Disorders and has authored several book chapters and peer-reviewed articles on topics relevant to the subject. She believes that as our understanding of weight and weight management improves, patients can benefit from a greater variety of tools to manage what is now recognized as a chronic disease.

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