Manage patient expectations about diet medications

Obesity defined as having a body mass index (BMI) of 30 or more is a national epidemic in the United States, affecting 1 in 4 people.1 For years, doctors have emphasized the importance of eating less, exercising more, and making good dietary choices as the cornerstone of a reliable weight loss program.

Today, however, researchers are increasingly aware that weight gain is driven by more than the difference between caloric intake and expenditure (the pattern of energy balance). They include the influence of brain signals on the endocrine, metabolic and nervous systems in response to individual energy needs and environmental factors.2

It is clear that genetic differences play a significant role in this more accurate definition, with heredity accounting for approximately 75% of the BMI variability.3.4

Getting involved

Given the information and misinformation exploding on social media about off-label semaglutide use,5 pharmacists need to learn more about weight-loss drugs, which will become progressively more important as researchers continue to identify the molecular pathways that contribute to weight gain. Table 15-9 lists the strengths, weaknesses, opportunities and threats (SWOT) associated with obesity treatments, highlighting those that are most important for pharmacy professionals to be aware of.

Mechanisms of action

Prescribed antiobesity drugs have different mechanisms of action. Most are approved for adults with BMIs greater than 30 or 27 in patients prone to comorbidities, such as hypertension and type 2 diabetes. All come with advice on how to make simultaneous lifestyle changes for best results. Commonly used drugs appear in Table 2.10-14 The FDA has also approved benzphetamine (Regimex), diethylpropion, phendimetrazine and phentermine, but they are used less frequently for this indication. Additionally, the FDA recently approved setmelanotide (Imcivree) for children over age 6 whose obesity is caused by rare genetic deficiencies.15

Implications for the pharmacy team

Fewer than 2 percent of eligible patients receive prescriptions for weight-loss drugs, and those who are female, heavier, more insured, and younger are more likely to be treated.16 Insurance coverage has been a particular barrier to access for patients needing weight-loss drugs, but insurers cover them more often and sometimes offer a discounted cash price.7 Pharmacy staff members can also help patients find assistance programs.

As indicated in Table 1, clinicians often need help monitoring patients. Pharmacists should be alert for drug interactions or signs that patients need closer supervision. They can also correct misinformation and educate other doctors and patients on the appropriate use of these drugs.

Conclusion

There are more options than ever for managing obesity, but unless barriers are addressed, patients will experience inequities when seeking treatment. Pharmacists can raise awareness about weight issues and appropriate treatments, and teach others about the ins and outs of medications.

References

1. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017-2018. NCHS Data Brief, no. 360. National Center for Health Statistics; 2020. Accessed March 17, 2023. www.cdc.gov/nchs/products/databriefs/db360.htm

2. Hall KD, Farooqi IS, Friedman JM, et al. The energy balance model of obesity: beyond calories in, calories out. I’m J Clin Nutr. 2022;115(5):1243-1254. doi:10.1093/ajcn/nqac031

3. Elks CE, den Hoed M, Zhao JH, et al. Variability in the heritability of body mass index: a systematic review and meta-regression. Front Endocrinol (Lausanne). 2012;3:29. doi:10.3389/fendo.2012.00029

4. Hainer V, Stunkard A, Kunesov M, Parzkov J, Stich V, Allison DB. A twin study of weight loss and metabolic efficiency. Int J Obes Relat Metab Disorder. 2001;25(4):533-537. doi:10.1038/sj.ijo.0801559

5. Johnson A. Ozempic’s face explained: why it happens and how to fix it. Forbes. February 1, 2023. Accessed March 22, 2023. https://www.forbes.com/sites/ariannajohnson/2023/02/01/ozempi-face-explained-why-it-happens-and-how-to-fix-it /

6. Marlene C, Christos MS. Advances in physiology, design and development of new drugs are changing the landscape of obesity pharmacotherapy. Metabolism. 2023;142:155531. doi:10.1016/j.metabol.2023.155531

7.Fujioka K, Harris SR. Barriers and solutions for prescribing pharmacotherapy of obesity. Endocrinol Metab Clin North Am. 2020;49(2):303-314. doi:10.1016/j.ecl.2020.02.007

8.Simon R, Lahiri SW. Provider practice habits and barriers to care in the management of obesity in a large, multi-center health care system. Endocr Pract. 2018;24(4):321-328. doi:10.4158/EP-2017-0221

9. Palanca A, Ampudia-Blasco FJ, Caldern JM, et al. Real-world assessment of persistence, adherence, and therapeutic inertness of GLP-1 receptor agonist therapy among obese adults with type 2 diabetes. Diabetes Ther. 2023;14(4):723-736 . doi:10.1007/s13300-023-01382-9

10. Xenical. Prescribing information. Roche pharmaceutical products; 2009. Accessed April 24, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020766s026lbl.pdf

11. Qsimia. Prescribing information. Vivus Inc; 2012. Accessed April 24, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022580s000lbl.pdf

12. Contrary. Prescribing information. Takeda Pharmaceuticals America, Inc; 2014. Accessed April 24, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/200063s000lbl.pdf

13. Saxenda. Prescribing information. NovoNordisk AS; 2010. Accessed April 24, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/206321s007lbl.pdf

14. Wegovy. Prescribing information. NovoNordisk AS; 2021. Accessed April 23, 2023. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/215256s000lbl.pdf

15. Imcivree. Prescribing information. Rhythm Pharmaceuticals, Inc; 2022. Accessed March 20, 2023. https://rhythm-vault-digital-publishing-production.s3.amazonaws.com/IMCIVREEPrescribingInformation.pdf

16. Zhang S, Manne S, Lin J, Yang J. Characteristics of patients potentially eligible for weight loss pharmacotherapy in primary care practice in the United States. Obes Ski Practice. 2016;2(2):104-114. doi:10.1002/osp4.46

About the author

Jeannette Y. Wick, MBA, RPh, FASCP, is the director of pharmacy professional development in the Department of Pharmaceutical Practice at the University of Connecticut School of Pharmacy at Storrs.

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