Long-term Drug Treatment for Obesity A Systematic and Clinical Review
- Autores: Susan Z. Yanovski, Jack A. Yanovski
- Localización: JAMA: the journal of the American Medical Association, ISSN 0098-7484, Vol. 311, Nº. 1, 2014, págs. 74-86
- Idioma: inglés
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Resumen
Importance Thirty-six percent of US adults are obese, and many cannot lose sufficient weight to improve health with lifestyle interventions alone.
Objective To conduct a systematic review of medications currently approved in the United States for obesity treatment in adults. We also discuss off-label use of medications studied for obesity and provide considerations for obesity medication use in clinical practice.
Evidence Review A PubMed search from inception through September 2013 was performed to find meta-analyses, systematic reviews, and randomized, placebo-controlled trials for currently approved obesity medications lasting at least 1 year that had a primary or secondary outcome of body weight change, included at least 50 participants per group, reported at least 50% retention, and reported results on an intention-to-treat basis. Studies of medications approved for other purposes but tested for obesity treatment were also reviewed.
Findings Obesity medications approved for long-term use, when prescribed with lifestyle interventions, produce additional weight loss relative to placebo ranging from approximately 3% of initial weight for orlistat and lorcaserin to 9% for top-dose (15/92 mg) phentermine plus topiramate–extended release at 1 year. The proportion of patients achieving clinically meaningful (at least 5%) weight loss ranges from 37% to 47% for lorcaserin, 35% to 73% for orlistat, and 67% to 70% for top-dose phentermine plus topiramate–extended release. All 3 medications produce greater improvements in many cardiometabolic risk factors than placebo, but no obesity medication has been shown to reduce cardiovascular morbidity or mortality. Most prescriptions are for noradrenergic medications, despite their approval only for short-term use and limited data for their long-term safety and efficacy.
Conclusions and Relevance Medications approved for long-term obesity treatment, when used as an adjunct to lifestyle intervention, lead to greater mean weight loss and an increased likelihood of achieving clinically meaningful 1-year weight loss relative to placebo. By discontinuing medication in patients who do not respond with weight loss of at least 5%, clinicians can decrease their patients’ exposure to the risks and costs of drug treatment when there is little prospect of long-term benefit.
Obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] ≥30) is highly prevalent in the United States; 36% (>78 million) of US adults are estimated to be obese.1 Almost all US health professionals in the United States treat patients with obesity and are well aware of its medical consequences.
Weight loss of 5% to 10% of initial weight, achieved through intensive lifestyle intervention, reduces cardiovascular disease (CVD) risk factors, prevents or delays the development of type 2 diabetes, and improves other health consequences of obesity.2,3 Although improvements in some CVD risk factors can be seen with sustained weight loss as small as 3%, weight loss of 5% or more is generally considered to be clinically meaningful.4,5 Even larger weight losses produce greater reductions in cardiometabolic risk.6 With intensive lifestyle treatments, a majority of obese participants in clinical trials lose 7% to 10% of their initial weight at 1 year.5 However, results from these efficacy trials are far better than those attained by patients in primary care settings, where studies using low-intensity counseling have not demonstrated clinically meaningful mean weight loss.7 Regardless of initial weight loss success, longer-term weight maintenance is difficult. With continued lifestyle treatment, weight regain can be ameliorated but not eliminated.8 The need for constant vigilance to sustain behavior changes in the face of biologic and environmental pressures to regain weight emphasizes the challenges faced by even the most motivated patients who have achieved weight loss. Thus, there is a need for adjunctive therapies that can help patients who are not able to lose or sustain sufficient weight loss to improve health with lifestyle interventions alone.
This article systematically reviews the literature for long-term use of medications currently approved by the US Food and Drug Administration (FDA) for obesity treatment in adults (Table 1). We also discuss off-label use of medications approved for other purposes that have been studied for obesity treatment or drug-induced weight gain, and provide considerations for use of obesity medications in clinical practice.
