Obesity Management Update 2023

As a nutrition support pharmacist, you can help obese patients manage obesity as New Year’s resolutions kick in. Continue to emphasize lifestyle changes, and review medication lists for possible causes of weight gain (antipsychotics, steroids, etc).

Updated Canadian guidelines recommend considering medications for patients with a BMI of 30 or more, or 27 or more plus an obesity-related condition (diabetes, hypertension, etc). When available, lean toward new Wegovy (semaglutide) 2.4 mg subcutaneously weekly. Using it for about a year leads to about 13% more weight loss than placebo or 13 kg for a 100 kg patient. This is at least double the weight loss of Saxenda (liraglutide) 3 mg subcutaneously daily per year, or around triple that of oral Contrave (naltrexone/bupropion) 16/180 mg BID or Xenical (orlistat) 120 mg TID.

NPS-adv

But Wegovy shortages are an issue. Don’t recommend using Ozempic (semaglutide) off-label unless your patient also has diabetes, since an Ozempic shortage is also a concern. Point out that GI side effects are common with Saxenda or Wegovy, but most patients can tolerate either with slow titration. And both come with a rare risk of gallbladder problems and pancreatitis.

If patients prefer an oral medication, lean toward Contrave. It may benefit patients who are also trying to quit smoking or those with depression. But avoid it in patients with seizures. Xenical may cause loose, oily stools and vitamin deficiencies. Point out differences in cost. Consider switching to another medication if patients don’t lose at least 5% of their body weight after 3 months on a therapeutic dose. But if patients are seeing results, explain that long-term use may be needed, to help maintain weight loss. Steer patients away from OTCs or supplements promoting weight loss, these don’t have much evidence of benefit. Learn more about the different medications in our notes, "Weight LOSS medications don't always work" and "New products to try to lose weight". For more data, read our guidance "7 Diet, a professional guide for weight loss".

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References

1. Pearce, N. Canadian Adult Obesity Clinical Practice Guidelines.
2. Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical practice guideline. CMAJ. 2020 Aug 4;192(31):E875-E891.
3. Grunvald E, Shah R, et al. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology. 2022 Nov;163(5):1198-1225.

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