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Counseling Patients on Pharmacotherapy for Weight Loss


Advice to help healthcare professionals counsel patients about the safety profiles of pharmacologic therapies available for weight loss.

Chris Mazzolini: In terms of pharmacologic agents in general, are there any other risks, concerns or discussion points that you need to have with patients when discussing these treatments? Dr. Christofides, is there any general information that’s important for clinicians to know about regarding weight management via pharmacologic agents?

Elena A. Christofides, M.D., FACE: Thank you. There are a few key points that need to be addressed. Orlistat [Alli], being a fat-blocker medication, you need to make sure to caution the patient to not take it with other medications that are fatty, or with vitamins that are fat-absorbing requiring. For example, many patients who have metabolic or cardiovascular disease may take fish oils, and if you take something like orlistat, it’s going to cause oily stool because orlistat is going to block the absorption of the fish oil into the body and cause you to excrete it. Vitamin D deficiency is a massive epidemic everywhere around the world, and vitamin D is a fat-absorbed vitamin, so if you have somebody who is taking vitamin D to try to improve their levels, and they’re taking it with fatty food, they may block that absorption and worsen their vitamin D deficiency if they’re taking orlistat. That’s more of a nutritional medication problem. For patients who were on Qsymia [phentermine and topiramate] or Contrave [naltrexone and bupropion], because those are more neurologically active drugs., there could be some drug interactions with their antidepressants or other psychiatric agents. It seems like there’s a fair amount of those drug interactions that are out there. Sometimes I think that, as clinicians, especially if we’re treating obesity or we’re treating diabetes, we may not necessarily be as aware of what additional drugs that the patient is taking, so we need to make sure that we’re having a conversation about overlapping psychiatric medications. I wanted to touchpoint to something that Dr. Bays said. The class of incretin hormones, as a whole, where liraglutide and semaglutide fit in, are a class of hormones that are well known to be dysfunctional in the early phases of overweight and obesity, and they’re progressively dysfunctional as somebody progresses with diabetes. They are considered standard of care in diabetes management and they aren’t considered experimental. They’re not considered endgame. You are expected to be on these drugs as a diabetic, period. They cannot cause hypoglycemia on their own because it’s biologically impossible. It’s absolutely impossible. That’s why incretin hormones are approved for obesity management because they cannot cause hypoglycemia. None of the drugs that we’ve discussed can cause hypoglycemia. If a clinician is using drugs that are not considered standard of care, like sulfonylurea and insulin, which are endgame medications in diabetes, these drugs aren’t biologically relevant, and they’re not helpful in terms of remission for diabetes. They don’t benefit the patient’s biology in terms of what caused diabetes in the first place. Those aren’t expected medications that you would use at any stage in diabetes, unless you’ve exhausted the other 12 or 13 classes that came before. I wanted to make sure that one point was clear. Those are drugs that are physiologically replacing hormones that the body is defective in, which led to their overweight, their obesity, and their diabetes. Replacing these hormones is akin to replacing thyroid hormone after you’ve taken someone’s thyroid out surgically. It’s very comparable. I don’t want clinicians to leave with the idea that incretin hormones are super-powered, overpowered and dangerous or problematic. They are the least problematic drugs in that category, as far as I’m concerned, based on efficacy, safety and the replenishment of normal physiology that we already know to be dysfunctional, which led to a patient being overweight or having obesity or diabetes.

Transcript edited for clarity.

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