Weight Loss Med Guide

by Dr. Karl Nadolsky

As a physician who focuses on weight and body composition (along with overall health), I want to make sure I don’t prescribe medications that cause weight gain. As a bonus for my patients, I try to make sure the meds I prescribe might even be beneficial for weight LOSS.

With that being said I wanted to create a quick reference guide for:

1. FDA approved drugs for Obesity treatment

2. Certain medical conditions where different meds will either help or hinder weight loss

Now before we go further, make sure you talk with your OWN doc if you’re on some of these meds and would like to change or would like to start one.

Medications FDA Approved for weight loss

1. Short-term  – There are currently three drugs approved for short-term weight loss (12 weeks or less). The most popular of which is phentermine, but there are two others also used by weight loss doctors – diethylpropion and phendimetrazine. These drugs are what is termed sympathomimetic (mimics adrenaline-like transmitters). They help decrease hunger by activating certain receptors in the hypothalamus (exact mechanism is unknown). These drugs are relatively inexpensive, have a good safety profile, and work VERY well, but are only approved for short-term weight loss. Weight loss doctors rarely ever use these drugs according to their FDA approval (12 weeks) as their patients tend to stay on them long-term with what is called off-label use.

When I personally recommend to use these: These drugs should be reserved for hunger / craving issues – PERIOD. I don’t like to throw patients on these drugs automatically like many weight loss doctors do. At some weight loss centers you are put on an 800 calorie diet and then given one of these drugs right off the bat. You must tease out what the underlying issue is. Maybe it IS hunger or cravings, which would definitely be helped by one of these agents. By the way these drugs should really only be used for BMI over 30 or 27 with a comorbidity (hypertension, diabetes, sleep apnea, arthritis, etc).

When NOT to use these: Don’t use if you are pregnant, nursing, allergic to them, have cardiovascular disease, glaucoma, hyperthyroidism, and poorly controlled hypertension (high blood pressure). Just make sure you talk to your doctor. The side effects are mostly related to its adrenaline-like properties (dry mouth, constipation, insomnia, etc).

2. Long-term – Right now there are three approved drugs for long-term weight loss, Xenical (orlistat), Qsymia (phentermine/topiramate), and Belviq (lorcaserin). These drugs were meant to be used just like blood pressure and/or diabetes medications in that generally you can take them forever (this isn’t to say you couldn’t get off of them with proper lifestyle strategies). I will go through each.

– Xenical (orlistat) – This drug works by inhibiting pancreatic lipase, which basically means it stops you from breaking down the fat you eat. So essentially if you eat fat it will go right through you and you won’t absorb it, which means you get less calories and lose weight. The problem with this drug is that fat is not the enemy and also the side effects are flatulence and diarrhea, which make compliance very low. I don’t personally prescribe this drug.

– Qsymia (phentermine/topiramate) – This is one of the newest drugs approved for long-term obesity treatment. You can read about how phentermine works above so I will briefly touch on topiramate. Topiramate was first approved as an anti-convulsant and then also for migraine prophylaxis. When used, doctors/researchers noticed a weight loss effect side effect. Once this was discovered, bariatric physicians started using it off-label for its weight loss properties. Topiramate does work well with its anorectic (anti-hunger) and possibly calorie burning properties, but it does have some nasty side effects due to its dosing. The company Vivus decided to combine phentermine and a controlled-release topiramate in order to lessen the side effects of each drug. This combo is actually VERY potent and works well for weight loss long-term.

When I personally recommend this: I think this drug is fantastic however it is SUPER pricey. It generally costs 5 to 7 dollars a day (150-210 bucks a month!)! Right now only about 30% of insurances are paying for this, which is a shame. This is much more than many of my patients can afford so my recommendation would be to use this if patients do have hunger issues, BMI over 30 or 27 with comorbidity, and can afford it. If they can’t afford it I would likely use them separately (they are very cheap when purchased separately) especially if the patient has a diagnosis of migraines.

How to use separately (for my fellow physician audience): I start the patient on 1/2 tab of 37.5 mg of phentermine each morning along with the classic topiramate migraine starting recommendation which is 25 mg tab of topiramate at night for 10-14 days. Then switch to 25 mg BID for 10-14 days, then 25 mg in the AM and 50 mg at night for 10-14 days, then 50 mg BID. If there are still hunger issues you can go to full dose phentermine with this.

What to look out for: As mentioned above, topiramate has some nasty side effects, which Vivus tried to eliminate by making a controlled release topiramate. This is also why you should start low and slowly titrate up if using separately. The nasty side effects I am talking about include spaciness/forgetfulness, numbness and tingling in extremities, and dysguesia (things start tasting differently). These are all fine and dandy but the WORST effect is seen in pregnant women as their babys could get CLEFT lips/palates. Do not take this drug if you plan on getting pregnant and it is highly recommended to use 1 or more forms of contraception. Some people say to do monthly pregnancy screenings as well. Also because of topiramate’s mechanism of action, you will want to check potassium and bicarb beforehand and possibly monitor these things.

– Belviq (lorcaserin) – This is the other new FDA approved drug for obesity treatment. It is actually NOT yet available but I will update this when it is to talk about how effective it is in my clinic. Lorcaserin is a serotonin receptor agonist (5-HT2C), which helps with satiety signaling in the brain. Now there was a lot of concern since the drug fenfluramine, which was a 5-HT2B agonist, caused heart valve issues. Well in the trials the makers were very careful to monitor for this and found that the difference was in the receptors. This drug has been shown to be safe as far as we know. In the first trials though it didn’t work quite as well as the phentermine/topiramate combo. Again I will update this when I have used it.

Leaner Meds vs. Weight Gain Meds

I will quickly go through some common medical conditions where using different medications can have vastly different effects on weight.

Diabetes  – By now most physicians should be using metformin as first-line treatment for diabetes. Second-line is another story. A very popular class of drugs for diabetes among family physicians are the sulfonylureas. Sulonylureas (e.g. glyburide, glipizide, etc) work by making the pancreas release more insulin. This would seem like a good thing but in the end it doesn’t treat the underlying insulin resistance and in fact will make it worse by increasing fat gain. So what is a better option?

• GLP-1 Agonists (e.g. Byetta, Victoza, Bydureon, berberine) – The GLP-1 agonists will help diabetics not only get their sugars down but also help them lose some big time weight! I have had MANY patients add one of these along with their Leaner Living Diet plan and lose about 20 pounds and get to their A1c goal. You can learn more about how they work by watching my video at How Diabetes and Berberine Work – Part 3. Now the problem with the pharmaceuticals is that they are injectable. If the patient is not willing to inject then obviously they aren’t an option. Berberine has similar properties and is available in a pill.
• DPP-IV Inhibitors (e.g. Januvia, Onglyza, Tradjenta) – These are pills that work by decreasing the body’s own breakdown of GLP-1. You get similar benefits but not really any weight loss. They are still a better option than the sulfonylureas. They are also in pill form.

Depression – Most doctor’s go to drugs are SSRIs (Selective Serotonin Reuptake Inhibitors) for depression however I just want to throw some things out there to consider. SSRIs (e.g. Paxil, Prozac, Zoloft, Celexa, Lexapro, etc) can do some funny things to people’s weight. Many people might lose weight at first and then all of a sudden start gaining weight. Be very wary of this effect. Another class of drugs that many docs used to use for depression are the TCAs (Tricyclic Antedepressants). TCAs (e.g. Amitriptyline) will cause definite weight/fat gain so beware! Another antidepressant that causes weight gain is Remeron (mirtazapine). Doctors will actually prescribe mirtazapine to those who NEED to gain weight. Let’s just explore a couple other options before jumping to these.

• Cognitive Behavioral Therapy – Yep this non pharmaceutical option could be all the patient needs and has been shown to be as effective as a pharmaceutical. Drug-free would be a pretty good way to go if possible.
• Wellbutrin (bupropion) – This drug would be a great option to start someone on for depression especially if they need to lose weight. In fact, bupropion is trying to be approved in a combo drug that treats obesity (will update this page once approved). It works by inhibiting norepinephrine and dopamine reuptake. It has been shown to work just as well as SSRIs and can even be ADDED to an SSRI if the SSRI is not working well. Just make sure the patient doesn’t have a history of seizures. This drug has also been approved for smoking cessation so it could be used for those with tobacco abuse as well.

Hypertension (High Blood Pressure) –  Many people are antihypertensives (blood pressure meds) because their blood pressure is high due to their weight. Well would it make sense to then put someone on a blood pressure med that might make someone gain weight? Probably not. Beta Blockers (e.g. Coreg, metoprolol, atenolol, etc) have some of the worst effects when it comes to weight/fat since they not only block our adrenalin from helping us burn fat, they also make us not tolerate exercise very well. Double whammy. Make sure you talk to your doctor first since you may be on a beta blocker for reasons other than high blood pressure but here are other options.

• Ace Inibitors / Angiotensin Receptor Blockers (e.g. lisinopril, enalapril, losartan, etc) – These drugs are not associated with weight gain and even might have some insulin sensitizing properties.
• Low Carb / Low Salt Diet – It would be nice to just have your patient lose weight and not have to take a drug. Also lowering salt intake along with carbohydrate intake will help diurese the excess volume that makes your blood pressure high. Be careful with this though because it can work almost too well and people have orthostatic hypotension (when they stand up they pass out).
• Rule Out Sleep Apnea – Sleep apnea is a major cause of resistant hypertension. If the patient snores and has some daytime sleepiness, get a sleep study to make sure they don’t have sleep apnea. It can be fixed with weight loss and a cpap. Sometimes it requires surgery.
• Breathing Techniques / Stress Reduction