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Treating Obesity

CE / CME

Obesity Management: The Right Patient and the Right Treatment

Physician Assistants/Physician Associates: 0.25 AAPA Category 1 CME credit

Nurses: 0.25 Nursing contact hour

Physicians: maximum of 0.25 AMA PRA Category 1 Credit™

Released: December 07, 2023

Expiration: December 06, 2024

Jaime Almandoz
Jaime Almandoz, MD, MBA, MRCPI, FTOS
CME/CE Information

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Key Takeaways
  • Optimized treatment of obesity includes appropriate selection of anti-obesity medication therapies, regular follow-up, and clinical assessments (including lab and body composition monitoring), which are important to improve health outcomes and quality of life. 
  • Comorbidities should be considered in conjunction with relevant clinical trial data when selecting anti-obesity medications, including new and emerging incretin-based therapies.
  • For effective obesity management, patient engagement and a good relationship with their healthcare team improves the chances of reaching the outcomes desired by both the patient and the healthcare professional.

We are in an era where we have highly effective anti-obesity therapies that work differently compared with older anti-obesity medications. People lose significant amounts of weight in a relatively short period of time but that may not always lead to better health outcomes. To avoid this, health care professionals (HCPs) need to make sure that we are selecting the appropriate anti-obesity medication therapies and care pathways for our patients, which include regularly following up in person, especially with people who are losing large amounts of weight, ordering appropriate lab testing, and monitoring body composition. Because obesity treatment is not just about decreasing the number on the scale, our role in treating obesity is to improve obesity-related complications such as type 2 diabetes (T2D), reducing the risk for cardiovascular disease (CVD), and improving quality of life. For example, imagine a 75-year-old patient who started on a highly effective anti-obesity agent and lost 50 pounds in 6 months and is now feeling fatigued and weak. Moreover, this patient is on multiple blood pressure medicines that have not been adjusted. If that patient falls and breaks a hip due to low blood pressure, we have done them harm. We have not done what we set out to do, which was to improve their overall health while treating their obesity.

Some HCPs focus on getting people to lose large amounts of weight quickly with medications because we have not had very effective treatments until now. We need to focus on improving health and quality of life more than making the number on the scale smaller.

Selection of Patients Based on Comorbidities
When it comes to selection of the correct medication for patients, we should consider the magnitude of weight loss desired and the presence of obesity-related complications. We have had data for many years showing that glucagon-like peptide-1 receptor agonists (GLP-1 RA) are highly effective for treating T2D and decreasing body weight as part of that treatment. GLP-1 RA are also good for treating other complications with T2D and obesity such are cardiometabolic risk factors like hypertension and inflammation. I think CVD is in the forefront of everyone’s mind right now since the results of the SELECT trial showed that in people who are risk-optimized on standard of care therapies, including blood pressure medications and statin therapy saw a 20% reduction in cardiovascular death, non-fatal MI, and stroke following the addition of semaglutide 2.4 mg weekly. Therefore, in select patients we are not just treating the obesity but we are also providing lifesaving therapy by decreasing their residual cardiovascular risk. Along the lines of improving cardiometabolic-renal health, in people with T2D, the FLOW study recently showed that treatment with semaglutide significantly improved kidney outcomes.

There are so many new and emerging therapies on the horizon, and we are all anxiously awaiting the cardiovascular outcomes data for the glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 coagonist tirzepatide, outcomes studies for the combination of semaglutide and a long-acting amylin analog cagrilintide, glucagon/GLP-1 coagonist survodutide, and many others in development for treating obesity. Beyond weight loss and cardiovascular MACE reduction, outcomes of interest include other complications like obstructive sleep apnea and metabolic dysfunction–associated steatohepatitis (MASH). There are many ways in which these medications can improve health and quality of life. Although we believe that the majority of the effect may be due to weight loss, there are likely some direct impacts of these medications on cardiometabolic health and inflammation.

Care in Treatment Selection Compared With Trial Patient Populations
When trying to select the best treatment for a patient, I think it is important to pay attention to the populations in the studies. For example, participants in the SELECT trial had a history of CVD, more than three fourths had preexisting coronary artery disease, about one fourth had a history of stroke, and around 10% had a history of peripheral arterial disease. This trial was done in a selected high-risk population and shows a decreased risk of heart attack and stroke of 20% in people without a history of CVD. 
I also think it is important to note the unfortunate lack of diversity in many obesity trials. For example, the study population in the SELECT trial was 84% White, 8.2% Asian, 3.8% Black, and 3.0% other. Hispanic or Latino/a ethnicity accounted for only 10.3% of participants. In the United States, we serve a diversity of people and race/ethnicity minority groups tend to be more severely impacted by obesity. Therefore, we need to push for diversity in clinical trials to make sure that we are, in fact, choosing the best treatment for our diverse patient populations.

Cost and Coverage
Cost and coverage for obesity treatments can also be an issue. We know that incretin-based therapies improve outcomes in obesity but the cash-pay costs, if they are not covered by insurance can be more than $1000 per month. These high costs can really impact access to evidence-based treatments and can worsen disparities in obesity care. A 5% to 10% weight loss that we can see with older generations of anti-obesity medications is still a clinically meaningful weight loss, vs the average ≥15% weight loss seen with highly effective medications like semaglutide and tirzepatide. In situations where these newer, more expensive medications are not covered, we need to consider how we can help people achieve clinically meaningful weight reduction by using and combining more affordable generic or off-label medications for weight loss. 

Considerations for Selecting an Older Class of Medication Over an Incretin-based Therapy
In addition to cost considerations, when selecting an anti-obesity medication, we should also consider other comorbidities that may be improved with non–incretin-based therapies. For example, the off-label use of a medication such as metformin could benefit a woman with polycystic ovary syndrome who desires weight loss. In addition to semaglutide, liraglutide, and now tirzepatide, FDA-approved anti-obesity medications include bupropion-naltrexone, phentermine-topiramate, phentermine, and orlistat, and we need to think about which health conditions could be directly impacted by their on-label use. For health conditions such as mood disorder, alcohol use disorder, or the need for smoking cessation, we can consider the use of bupropion-containing regimens. For people with a history of migraine headaches, the addition of topiramate could be beneficial. In general, the magnitude of weight reduction seen with the older classes of medications is lower compared to the newer incretin-based therapies. For most people living with obesity and serious complications, like T2D or MASH, achieving a weight reduction of ≥15% may be difficult with lifestyle modification and these older medications. Not achieving these goals or health outcomes may make the patient and the healthcare provider feel frustrated and disappointed. Managing the expectations of patients and healthcare providers is an important factor in treating obesity and its complications.

Oral Medications Preferred vs Injectables
Most people would say that they prefer taking a pill over giving themselves an injection. However, given the popularity, rapid uptake, and acceptability of injectable anti-obesity medications, this may not necessarily be the case. These treatments have been popularized on social media and the news to the point that many patients come into the office prepared to have that discussion if not asking for them by name. Although the unexpected demand for anti-obesity medications has created shortages and some interesting media coverage, it is exciting that people are talking about treating obesity.

Patient Treatment Selection
Beyond lifestyle and medication therapies, bariatric surgery is a highly effective but underutilized tool for treating obesity and its complications. Until recently, surgery was the most effective treatment available for obesity but we are now seeing medical therapies that on average achieve bariatric-range weight loss. We need to keep in mind that neither medications nor surgery is curative for obesity. There are many factors beyond body weight to consider when choosing the best treatment for obesity for our patients. We should individualize care according to the best available evidence, obesity-related complications, and factors like cost and coverage; all while acknowledging patient autonomy and choice in their treatment options. Ultimately HCPs who treat obesity are doing chronic disease management and must develop a relationship with their patient to support the patient engagement needed to facilitate the outcomes desired by both the patient and the HCP. We must ensure that we are not just here to help patients lose weight, we are here to treat their obesity and improve their health and quality of life.

Your Thoughts?
In your practice, what is the greatest concern that your patients have about anti-obesity medications? Join the conversation by leaving a comment in the discussion section and answering the question below.

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In your practice, when discussing anti-obesity medications your patients are most concerned about:

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