COMMENTARY

Weight-Loss Drugs: Risks vs Benefits

Richard M. Plotzker, MD

Disclosures

April 13, 2015

Juggling Competing Risks and Goals

Richard M. Plotzker, MD

While trying to fulfill my CME requirements, I recently completed a wonderful program on dealing with complex multisystem disease in the elderly. It dealt with the dilemma that many of us face: trying to follow treatment guidelines for individual diseases while sometimes undermining more overriding goals of the patient, such as keeping their driver's license or living independently. The CME program drew on some fundamental principles of how doctors are taught to think, a process that can be transposed not only to a geriatric population but also to more generalized patient care, and perhaps even to personal decisions.

For instance, if I serve on a committee that I find annoying, should I divest myself of that committee and watch events take place without my input, or continue to hack away at the various tasks to avert regrettable outcomes? In patient care, intermediate goals should help us reach the best ultimate outcome, but that is not always the case. And, as this article suggested, what constitutes the best outcome may not be entirely clear and may differ from one individual to the next.

Competing goals and risks have always been present when dealing with weight-loss medications. In fact, there is a small historical graveyard for agents whose prescribing misadventures outweighed their efficacy. It was not that long ago when many women were getting amphetamines for weight loss from a doctor in an adjacent state (always someplace else). This eventually became part of their past medical histories, as the lack of efficacy did not justify the expense or inconvenience, to say nothing of the jitters that some of them experienced.

Over the years we have seen the development and commercialization of decent but not ideal options available to any licensed provider with a prescription pad, such as sibutramine, dexfenfluramine, and rimonabant (had been approved in Europe, was never approved in the United States). People wanted these drugs as soon as they were available, and doctors would prescribe them. Health spas even advertised in the newspaper that they had physicians on contract to prescribe dexfenfluramine for their clients.

Unfortunately, the reality of new medications is that rare but serious adverse effects often do not appear until a drug is in common use. So, if you weigh 400 pounds and have insulin resistance and are immobile, rolling the dice with a new appetite suppressant may represent a reasonable medical balance of risk and benefit. If the goal is to go down a dress size for the next office party, however, the risk of prompting a call to the Suicide Hotline probably isn't warranted. (Rimonabant's European approval was withdrawn in 2009 after it was linked to depression and suicidality. Dexfenfluramine and sibutramine were pulled from the market in 2010 due to concerns about cardiovascular risks.)

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