Treatment
Î In patients with uncontrolled HTN or history of heart disease, ES
recommends against using the sympathomimetic agents phentermine and
diethylpropion. (1|⊕⊕⊕
)
Î 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|⊕⊕
)
Î 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|⊕⊕⊕⊕)
Î 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|⊕⊕
)
Î 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|⊕⊕⊕
)
Î 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|⊕
)
Drugs That Cause Weight Gain and Some Alternatives
Î 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|⊕⊕⊕
)
Î 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|⊕⊕⊕
)
