• Diet drugs

    by Brian Flyer, MD
    on Dec 30th, 2016

Obesity is the major factor contributing to substantial adverse health conditions and premature death.  It is defined as having a BMI of equal to or greater than 30 Kg per meter squared.  Roughly 35% of Americans fit this category and over 300,000 deaths per year occur directly related to obesity.  Obesity leads to coronary artery disease, diabetes, strokes, some cancers, sleep apnea, hypertension, gastroesophageal reflux disease, knee arthritis, and a higher incidence of accidents. Although weight gain is typically assumed to result from eating more calories than expended, there are certainly other variables, including genes, cultural background, and socioeconomic status.  One study which intentionally overfed volunteers an extra 1000 calories per day for two months resulted in a wide divergence of weight gain; some volunteers gained 12-14 pounds, while others gained only 1-2 pounds.

Diet drugs have been around since the 1950s, but never had such a profound impact until the early 1990s, when fenfluramine/phentermine (Fen-Phen) became popular.  This combination typically resulted in over 40-50 pound weight loss and near complete control of associated hunger.  Due to lawsuits, the fenfluramine component was removed by the FDA in 1997, although subsequently, less than 7% of users suffered potentially serious side effects.  The remaining phentermine, also known as Adipex, is still available, cuts appetite and typically leads to a 5-8% weight loss, but is limited by the eventual plateau effect and lack of sustainability, if this medication is stopped.

Topamax is the other main drug that can be highly beneficial in certain individuals.  This medication has been around since the mid 1990s, initially FDA approved for control of seizures. However, since the early 2000s, there has been substantial utility among psychiatric patients; eg those with bipolar disorder or schizophrenia, who typically gain significant weight from various psychiatric medication.  Specifically, the associated weight gain from those drugs is nullified by also taking Topamax.  Among internal medicine patients, it appears that the greatest benefit occurs in patients with 'binge eating'.  Binge eating is also understood as unconscious eating and includes snacking behavior apart from regular meals; this may occur during social situations, sports games, or TV watching.  Topamax does not decrease one's appetite, but does assist with improved personal awareness of what is being consumed.  Potential side effects include word-finding difficulties, which in my experience appears to be more noticeable among writers and attorneys.

Among patients with diabetes, some of the specific medications for that condition have an added benefit for weight loss.  This is true for the recommended starting medication for type 2 diabetes, Metformin, as well as the SGLT2 inhibitors (Farxiga, Jardiance, Invokana), which facilitate sugar spillage from the kidney and the associated loss of calories from the body. The combination of these two medications is an effective tool for also losing weight, but unfortunately, also has a plateau effect, where the weight loss achieved  reaches a limit.  It is believed that this plateau is due to an associated increased appetite.  Therefore, it is logical to add Phentermine at that point, to continue progress with weight reduction.  Some of the injection drugs for diabetes, including Trulicity and Byetta, may also lead to weight loss through various mechanisms. Whereas, insulin containing injection drugs typically result in further weight gain.

More recently, the FDA approved a combination pill, including Naltrexone, an opioid antagonist, and Bupropion (Wellbutrin), an anti-depressant known as a dopamine reuptake inhibitor.  Although, it isn't well established what the mechanism is for this weight loss effect, it is postuated that it has something to do with the brain's meso limbic reward system.  Studies report associated weight reduction between 5-15% of body weight.

While my favorite advice is to motivate patients to accept the right exercise program and proper eating behaviors, the addition of the right diet pill has been a very useful tool to assist in the battle against this growing epidemic of obesity.

Author Brian Flyer, MD Dr. Brian Flyer is an internist located in Beverly Hills, CA.

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