Mount Carmel Health Partners Clinical Guidelines Adult Obesity | Page 3

Table 2: Drugs available as adjuncts to diet and exercise for the treatment of obesity
Generic name
US DEA
(Brand Name)
Usual dosing (adults)
Schedule
Pancreatic lipase inhibitor approved for long term use (12 months— 2 years)
Orlistat
(Xenical, Alli)
120 mg three times daily with fat containing meals. Not a
A reduced dose of 60mg is an option for patients controlled
who do not tolerate 120mg.
substance
Adverse effects/precautions
Cramps, flatulence, fecal incontinence, oily spotting, absorption of fat-soluble vitamins
may be reduced. Rarely reported: severe liver injury, oxalate-kidney injury.
Contraindicated during pregnancy. Advise patients to take multivitamins at bedtime.
Warfarin dose reduction may be required.
Serotinin-2C receptor agonist approved for long term use (12 months—2 years)
Lorcaserin
(Belviq)
10mg twice daily; re-evaluate after 12 weeks.
C-IV
If 5% weight loss has not been achieved after 12
weeks, alternative drug therapies can be
considered.
Headache, dizziness, dry mouth, constipation (non-diabetic patients). Hypoglycemia,
headache, back pain, cough (diabetic patients).
Avoid in patients with severe hepatic or renal insufficiency (CrCl <30 mL/min).
Preferably avoid use with other serotoninergic agents (including most antidepressants
triptan anti-migraine medications 5HT3-antagonsist antiemetics, tramadol,
dextromethorphan and some muscle relaxants) due to risk of serotonin toxicity.
Neuropsychiatric side effects and valvulopathy were not significantly increased in
clinical trials, but few long term safety data are available.
Contraindicated with ergot derivatives (e.g., ergomatine) and during pregnancy.
May cause psychic dependence and/or euphoria at higher than recommended doses.
Possible increase in cancer risk based on murine model data.
Combination of phentermine/topiramate approved for long term use (12 months—2 years)
Phentermine/
topiramate
(Qsymia)
Initial: 3.74 mg phentermine/23 mg topiramate
C-IV (due to Dry mouth, taste disturbance, constipation, paresthesia, depression, anxiety, elevated
once daily in the morning for 14 days.
phentermine heart rate, cognitive disturbances, insomnia (higher dose).
Then titrate based upon response: 7.5 mg
component) Abuse potential due to phentermine component.
phentermine/46 mg topiramate daily for 12 weeks,
Topiramate is teratogenic (increased risk of oral cleft defects, T1); negative pregnancy
then 11.25 mg phentermine/69 mg topirimate
test prior to and during treatment and two forms of contraception necessary for
daily for 14 days.
women of child bearing potential.
Maximum dose: 15 mg phentermine/92 mg
Actions of topiramate component include inhibition of carbonic anhydrase; rarely
topiramate daily: re-evaluate after 12 weeks.
metabolic acidosis and kidney stones may result from renal bicarbonate loss.
Maximum dose with moderate hepatic or renal impairment (CrCl <50 mL/min) 7.5 mg
If 5% weight loss has not been achieved after 12
phentermine/46 mg topiramate daily. Upon discontinuation, tapering of dose over at
weeks, alternative drug therapies can be
least one week using every other day dosing is recommended.
considered.
Contraindicated during pregnancy, hyperthyroidism, glaucoma, patients taking MAO
inhibitors.
Combination of buproprion /naltrexone (indefinite duration)
Buproprion/
naltrexone
(Contrave)
Week 1: One tablet (8mg naltrexone/90mg
Not a
bupropion) once daily.
controlled
Week 2: Once table twice daily.
substance
Week 3: Two tablets in the morning and one tablet
in the evening.
Week 4: Two tablets twice daily.
Maximum daily dose: Four tablets (32 mg
naltrexone/360 mg bupropion); re-evaluate after
12 weeks.
If 5% weight loss has not been achieved after 12
weeks, alternative drug therapies can be
considered.
Nausea, constipation, headache, vomiting, dizziness, insomnia, dry mouth.
Transient increase in blood pressure (1 to 2 mmHg on average) during initial 12 weeks
of treatment; heart rate may also be increased.
Contraindicated in patients with uncontrolled hypertension, seizure disorder, eating
disorder, use of other bupropion-containing products, chronic opioid use, use within
14 days of MAO inhibitors, pregnancy or breastfeeding.
*Not a first-line pharmacologic therapy. A trial showed the active treatment group
experienced more adverse cardiovascular events. The trial was terminated early,
cardiovascular safety remains unknown.
GLP-1 agonist approved for long term use (12 months—2 years)
Liraglutide
(Saxenda)
Initial: 0.6 mg subcutaneously daily.
Not a
Increase at weekly intervals (1.2, 1.8, 2.4 mg) until controlled
the recommended dose of 3 mg daily; reevaluate substance
after 16 weeks.
If 4% weight loss has not been achieved after 16
weeks, alternative drug therapies can be
considered.
Nausea, vomiting, diarrhea, constipation, anorexia, headache, fatigue, increased
lipase, increased heart rate. Rarely reported: pancreatitis, gallbladder disease, renal
impairment, suicidal thoughts.
Monitor blood glucose in diabetic patients and adjust co-administered sulfonylureas
and other anti-diabetic medications as needed to prevent potentially serious
hypoglycemia.
Causes a modest delay of gastric emptying.
Safety data in renal and hepatic impairment are lacking, use with caution or avoid use.
Possible increase in thyroid cancer risk based on murine model data.
Contraindicated in pregnancy and in patients with a personal or family history of
medullary thyroid cancer or multiple neoplasia 2A or 2B.
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Adult Obesity - 3