Most of my patients know that I am not a huge fan of the currently available weight loss medications. This is because I feel people need good long-term solutions for weight control, and unfortunately, the obesity medications that are safe and approved for long-term use are generally not covered by insurance companies. This means patients need to shell out $120-300/month to lose weight and keep it off. My experience has been that most people cannot add this expense to their monthly budget for very long. No obesity medication has proven to help maintain weight loss once the drug is discontinued. Despite their best efforts, even the most determined and steadfast patients find themselves gaining the weight back (and often adding more pounds) once they have come off the medication. “But, Dr. Phillips, if I could just get myself started, I really think I could keep the weight off. . . .” I really don’t want to seem unsupportive when I hear this, it’s just that I’ve heard it so many times, and I’ve dealt with the aftermath of disappointment and depression when the scale tips back in the wrong direction. This is a very unpleasant part of my job, and when I am the one that started the yo-yo cycle with a prescription, I often question whether I have helped that person. The pharmaceutical companies’ data coincides with my personal practice experience; most people gain back the weight they’ve lost once the drug is stopped.
Despite these reservations, I do sometimes prescribe these drugs. Why? Because even small amounts of weight loss (5-10% of body weight) offer a significant reduction in the risk of developing diabetes, hypertension, and cardiac disease, and I know many people are unable to make any progress with lifestyle interventions alone. The benefits of a healthy diet and regular exercise are well-established, but difficult to maintain. Right now we don’t have the “magic pill,” so I offer patients what I can, even if it has significant limitations. If a person meets the criteria for one of the medications and is interested in starting, I explain the drawbacks to the medications (especially the high likelihood of weight gain after the drug is discontinued), and we review the options. . .
This would be the best option, if it were not for the cost. Most insurance companies won’t cover it and it’s approximately $120-140/month. Sibutramine inhibits reuptake of norepinephrine, serotonin and other brain chemicals. This causes decreased food intake and early satiety (i.e. people feel less hungry and need less food to feel satisfied). Studies suggest that when sibutramine is combined with a diet and exercise plan, patients will lose about 5-10% of body weight (in the studies, this was approximately 22 lbs). Patients who work on diet and exercise alone will typically lose only about 2-4% of body weight. These changes occur over the course of about 6 months. Side effects include elevated blood pressure, heart racing, nausea, insomnia, and anxiety. This drug is FDA-approved for up to 2 years.
Phentermine (Adipex, Ionamin), Diethylpropion, and Phendimetrazine (Bontril)
These drugs also elevate norepinephrine levels, but they do so by directly stimulating its release in the brain. As with sibutramine, people taking these medications will have a decreased appetite and eat less. Although results are highly variable, people can expect a 25-30 pound weight loss if the drug is continued for 6 months and is combined with a diet and exercise plan. Due to safety concerns about valvular heart disease and lung problems with long term use, the drug is only FDA-approved for short-term use (widely accepted to be about 3 months). Side effects are similar to sibutramine, but I have found them to be more common on these medications. Because this drug is only approved for a short period of time, my experience has been that people almost never maintain weight loss after stopping this medication. These drugs have available generics, so many insurance plans will cover them. They cost about $25-35/month.
Orlistat (Xenical, OTC Alli)
This medication works in a completely different way. Orlistat inhibits an enzyme that breaks down fat in the intestine. This means the fat cannot be absorbed and is passed out in the stool. Potential side effects are related to this therapeutic mechanism and include loose, greasy stools, abdominal pain and/or fecal incontinence. These are more likely to occur if a high fat meal is eaten. This drug does not affect appetite, but if a patient takes it and eats a greasy meal, they will likely not be inclined to do so again! Patients taking Alli or Xenical should take a multi-vitamin every day because the absorption of vitamins can be blocked by this drug. Studies suggest that patients who take Xenical 120 mg three times per day will lose between 8-10% of body weight (approximately 18 lbs in the studies) after about 1 year. OTC Alli is dosed at 60 mg three times per day and results in loss of 5-10% of body weight. The FDA has approved this drug for up to 4 years. Again, most insurance companies will not pay for this drug; Alli cost about $50/month and Xenical costs between $250-300/month. Ouch.
I see various dietary and herbal supplements marketed to people for weight loss. Unfortunately, as with all supplements, they are not regulated by the FDA and do not have to prove their safety and efficacy, so data is extremely limited. In fact, these supplements often do not include any appreciable amount of the advertised active ingredient in the pills! Even if you take the leap of faith that these supplements are safe and they will work, you cannot be sure you are even getting the active ingredient.
Many new drugs with novel mechanisms of action are under investigation, but have a long way to go in proving their safety and efficacy. For now, the medicines listed above are our only options. Remember all of the weight loss data on these drugs is representative of patients following a strict diet and exercise plan along with taking the medication. Some patients have medical problems or take other medications that preclude their use of a weight loss drug, so be sure to have a discussion with your physician before starting any of these. For most of us who are waiting for the magic pill, the best option is to commit and repeatedly re-commit (when we fall off the wagon) to a healthy lifestyle.
Shari S. Phillips, M.D.
Your Lake Norman Physician