If you’re considering weight loss medication, you’ll certainly want to take an FDA approved medication, and you’ll want to know the pros & cons of the different options available to you. Before choosing the specific medicine that’s right for you, let’s first address whether or not ANY medication is appropriate.
If you have a body mass index (BMI) of 30 or higher, then medication may be an effective and appropriate way to manage your weight. For those of you with a BMI of 27 or higher, along with a medical diagnosis related to your weight (diabetes, high cholesterol, high blood pressure, sleep apnea…), you also qualify for weight loss medication. We now have a better understanding of obesity as a chronic disease that requires chronic management, much like diabetes or high cholesterol.
Of course your first stop should be to an Obesity Medicine specialist or to your own Primary Care Provider to talk about your individual situation. That person will take a look at any medications you’re already taking in order to confirm that there are no interactions with weight loss meds. They will also guide you regarding the safest medication choice for you, based on their knowledge of your past medical history and any allergies to medications.
Let’s start our review of the FDA approved medications for weight loss with phentermine, since it’s the most commonly prescribed weight loss medicine. Phentermine has been around for many decades and has a long history of short term use to reduce appetite. Because it has not been studied & FDA approved for long term use (alone), it may be problematic for your physician to prescribe it for chronic treatment, depending on the regulations in your state. Phentermine works by impacting the re-uptake of the neurotransmitters norepinephrine, serotonin, and dopamine. Side effects may include palpitations, dry mouth, constipation, insomnia, headache and irritability. Who should steer clear of phentermine? Those who have heart disease, poorly controlled high blood pressure, glaucoma, or an overactive thyroid gland.
Qsymia is a weight loss medication that was FDA approved in 2012. It’s made from a combination of two older (and well understood) medications: phentermine and topiramate. Qsymia reduces hunger, improves satiety (fullness) and helps to manage food cravings. It does this via its impact on norepinephrine, as well as through GABA and AMPA receptors. If there’s one critical thing you need to know about Qsymia it’s this: DO NOT take Qsymia if there is any chance you might be pregnant, or could become pregnant, because it can cause serious birth defects. In addition to the warnings mentioned above for phentermine, you should also avoid Qsymia if you have a history of kidney stones, severe depression, or if you have recently taken a medication called an MAO inhibitor. You already know the side effects to look out for with the phentermine component of Qsymia. One could also experience fatigue, some tingling in the hands or feet, a change in the taste of certain foods or drinks, which is called dysgeusia, or some memory or word finding problems. This might sound daunting, but in fact, most people tolerate Qsymia very well and have no problems with this highly effective, once a day medication. Qsymia is a good choice for those who won’t be getting pregnant, and for those with migraines, which typically improve on this medication. It may also help those who struggle with binging or cravings.
Belviq (locaserin) is another option that was also FDA approved in 2012. While there were some unknowns about it’s long term heart safety initially, a study published in the New England Journal Of Medicine in September of 2018 was reassuring. The study concluded that locaserin was effective for long term weight management, without a higher rate of major cardiovascular events, when compared to placebo. Unfortunately, in January 2020, the FDA issued a “safety communication” indicating that they are investigating whether or not there is a link between locaserin and cancer, based on further analysis of their data. With that, I’m holding off on writing any new locaserin prescriptions until that question is resolved.
Contrave, like Qsymia, is made up of two medications combined into one pill, both of which have been available for decades. Bupropion is used alone for depression and Naltrexone is used alone to combat addiction. Interestingly, when combined, these medications work well for weight loss by reducing appetite, increasing energy expenditure, and helping with cravings. Contrave works through it’s actions on dopamine, norepinephrine, POMC, and by blocking B-endorphin. It’s a good choice for people who also require treatment for depression or smoking cessation. Please note that Contrave BLOCKS opioid receptors, so if you require an opioid pain killer, this medication is not for you. It should also be avoided in those with a seizure disorder, bulimia, or uncontrolled high blood pressure. Since it’s best not to take Contrave with a high fat diet, I don’t reach for it if people are following a ketogenic diet which can contain up to 80% fat! Side effects to watch out for include mood or behavior changes, nausea, headache, insomnia, dry mouth, constipation, or dizziness.
Medication for weight loss doesn’t replace your effort to make your lifestyle as healthy as possible. Of course not! It’s a combination of medication, along with healthy nutrition and exercise, that we strive for in order to bring your weight to a healthier range. Medication for obesity now serves as chronic treatment for a chronic disease, much like medication for diabetes. One may need to be on treatment for years to help maintain weight loss, and that’s okay. When we treat excess weight with medication, we are trying to prevent the need for medication for related conditions like diabetes, high cholesterol, high blood pressure, arthritis, and so on. We’re treating the root of these other health problems, trying to prevent or manage them with weight loss.
Carrying excess weight is not a disease of willpower. Those who have faced a long term struggle with their weight know that this is a disease with a powerful biologic component, driven by genetic, hormonal, neurological, and environmental changes. That’s why medication helps.
We need to take away the stigma of using medication for weight management. We don’t judge those who take meds for diabetes or high cholesterol, right? We understand these are diseases with both genetic and environmental components. We further understand that it takes a lifetime of attention to diet, exercise and often medication to bring these diseases under control. Let’s eliminate the stigma around medication for the treatment of obesity. It shouldn’t be treated as a last resort or a sign of weakness. Medication is simply another tool in our toolbox to fight this chronic disease.
Please talk to your primary care doctor or a board certified Obesity Medicine specialist to learn more about using medications if your BMI is greater than 30 (or if it’s greater than 27 and you have diabetes, high cholesterol, sleep apnea, metabolic syndrome or high blood pressure).
Thanks for listening and I wish you the best of health!
Lisa Oldson MD