Editor's Note: A recent Medscape survey found that less than two thirds of healthcare providers prescribe weight loss medications to eligible patients—those who are obese or are overweight and have weight-related health problems such as type 2 diabetes or hypertension. And those who do prescribe these drugs do so for only about one quarter of their obese or overweight patients.
Endocrinologist Laura Cowen is a willing prescriber of weight loss medications to the appropriate patients. Medscape interviewed her to find out her rationale and learn more about her experience.
Medscape: Many physicians are reluctant to prescribe—or are even adamantly opposed to prescribing—FDA-approved weight loss medications. Why are you willing to do so?
Dr Cowen: I would not send a patient home with a hemoglobin A1c of 14, or with persistently elevated blood pressure, without offering medical treatment. In the same manner, we know that obesity is a chronic medical condition associated with multiple serious comorbidities, and we should start treating it as such.
I'm a believer in pharmacologic therapy for obesity, and I prescribe these medications because I have had enough experience to see that they work. Although the drugs don't work for everyone, many patients have had life-changing results.
One of my most successful patients is JB, a 35-year-old woman with type 2 diabetes. When I met her, she weighed 235 pounds and her BMI was above 40. Her diabetes was poorly controlled on a combination of basal-bolus therapy, with an elevated hemoglobin A1c of 11.0.
This woman told me about her lifelong struggle with her weight. Her self-confidence was very low, and she used food in a destructive manner. During our visits, we focused equally on her diabetes management and her mental health. As she started to make positive changes in her diet, I stopped her mealtime insulin in favor of liraglutide 1.8 mg (Victoza®), and she started to lose weight in small but steady increments. Her motivation and sense of self-worth improved as she saw positive results. Together, we discussed options for pharmacologic therapy for her obesity and initiated phentermine/topiramate ER (Qsymia®).
The change I have seen in JB is astounding. After 1 year on the low dose (7.5 mg/46 mg), JB has lost 56 pounds, 9 inches from her hips, and 7.5 inches from her waist. When her weight loss plateaued, she started working with a trainer and continued to progress. She now runs 5K races and looks forward to exercising daily. She is off insulin completely, and she stopped liraglutide due to a change in her insurance. Her current hemoglobin A1c is 6.4 and she manages her diabetes with canagliflozin (Invokana®) alone.
Most of my patients who are successful on weight loss pharmacologic therapy say that it is the first time in years of trying to lose weight that they have seen positive results. They come back encouraged and empowered. In addition to noticing increases in their confidence and sense of well-being, I usually see improvements in their glycemic control, cholesterol, and hypertension.
I prescribe weight loss medications to make these results possible for more patients.
Medscape: Could those patients have been just as successful if you had just advocated a proper diet and exercise regimen?
Dr Cowen: Yes and no. For patients who are making minimal effort when I first see them, I think they would likely be as successful if they would truly commit to a proper diet and exercise regimen. However, there are many barriers that are outside of our control:
Healthy food is expensive. I have patients who rely on packaged food from the local dollar store and coupons from fast food restaurants to feed themselves and their families.
Lack of education is another barrier. For example, many patients drink fruit juice because they think it is healthy, or they drink other sugar-sweetened beverages to stay well hydrated. Some patients make misguided dietary changes that they think are healthy, such as switching from vanilla to strawberry ice cream because the latter "has fruit."
Exercise seems to be everyone's least favorite pastime, and inertia is a powerful force. Many patients work multiple jobs and have family responsibilities that do not allow them adequate time to exercise. Others live in areas where it's unsafe to exercise outside and do not have the means to pay for gym memberships.
Thus, barriers to a proper diet and exercise regimen are more complex than, "You're not trying hard enough."
That is not to say that patients who fit into the above categories cannot be successful on these medications. One of my patients, CO, is a 45-year-old African American woman who presented for management of hypothyroidism. She had tried multiple fad diets over the years, losing up to 30 pounds at a time but always gaining it back. Regular exercise never played a role in her weight loss.
This patient had been on phentermine and topiramate separately in the past, prescribed by a different provider, and she asked me to restart pharmacologic therapy. At baseline, she weighed 236 pounds with a BMI of 37.41. We opted for phentermine-topiramate ER because she had tolerated the separate components well and her insurance plan covered that medication.
Initially, she made an effort in terms of her diet and exercise, and she lost 10 pounds in the first 3 months and her BMI came down to 35.57. Unfortunately, as often happens, life took over. She commutes to work more than 2 hours a day, and she sustained an injury that limited her ability to exercise. She admitted that she had gotten lax with her diet. Still, with minimal effort on her part, she continued to lose weight slowly. Now at the 1-year mark, she weighs 213 pounds and her BMI is 34.9. She continues on the drug and has kept the weight off.
It is difficult to say how this patient would have fared without the medication; she probably would have seen similar results by sticking to her diet and exercise program. She is encouraged by her weight loss results, but I continue to stress to her how much better she would be doing with appropriate effort.
The patients who do best on these medications, in my experience, are those who are making a concerted effort to lose weight but are not seeing the desired results on their own.
One such patient is DK, a 59-year-old woman with prediabetes and hypothyroidism. Her weight at presentation was 176 pounds, with a BMI of 31.26. She related a history of exercising for 45-60 minutes 4 days per week. She was actively calorie counting and limiting her intake to 1300-1400 calories per day. She wasn't gaining weight, but she expressed frustration at not losing weight.
We discussed options for pharmacologic therapy, and she opted for lorcaserin (Belviq®) because this was the only option covered by her insurance plan. I saw her 6 weeks later and she had already lost 13 pounds. She continued to be vigilant about her diet and exercise habits. She was very happy and reported to me that her positive results made her want to work even harder.
Medscape: Do these drugs work for everyone who is overweight? Would you be willing to prescribe them to any patient who requested them?
Dr Cowen: No, these drugs do not work for everyone who is overweight, and I do not prescribe them to everyone who asks. Patients who do not have good exercise and dietary habits are most likely to be unsuccessful on these medications, and they are also more likely to gain the weight back once they stop taking the medication.
I spend time assessing patients' motivation, and if they demonstrate none, I do not prescribe. I let them know that they will regain the weight if they are not vigilant, and that it is not worth wasting their time or money if they are not going to put forth an effort. The patients who view the weight loss drug as a "magic pill" tend to do poorly because they become complacent with their lifestyle habits. These patients usually do not meet the recommended weight loss at the 3-month mark as described in guidelines and package inserts.
Other patients have a psychological dependence on food. One of my patients says he knows he's full but cannot leave uneaten food on the table. Another patient cited her use of food for comfort and eating past the point of satiety for fear of being hungry later. I give patients a 3-month trial, and if they have not met the recommended percentage of weight loss at that time, I either uptitrate the dose or discontinue completely per the prescribing guidelines specific to each drug.
Medscape: You know other physicians who will not prescribe these drugs, and you know of practices that are now marketing themselves solely as "weight loss clinics"; what do you think about physicians on either end of the spectrum?
Dr Cowen: Every physician has the right to practice medicine the way he or she feels fit. If one does not believe in prescribing weight loss drugs, that is his or her prerogative. However, if a prescriber is being critical because he or she considers the drugs just a "simple fix," I would encourage them to give the drugs a chance and see for themselves. I was skeptical at first too, but I have seen enough patients do impressively well on these medications that I continue to believe in prescribing them.
Also, if a physician is uncomfortable with these drugs simply because of a lack of experience, I encourage them to refer patients to other physicians with interest and expertise in the area.
On the opposite end of the spectrum, some practices market themselves as weight loss clinics with the aim of making a profit. I think this type of practice is detrimental to the goals of the antiobesity movement. Some of these practices are dispensaries only, with no nutritional or psychosocial support for the patients.
Obesity is a complex issue, and we're doing our patients a disservice if we do not offer them multidisciplinary support to meet their goals.
Medscape: What do you see as the biggest challenges ahead for obesity treatment?
Dr Cowen: The biggest challenge I face is lack of insurance coverage for these drugs. I see many low-income patients in an inner city, with a majority covered under Medicare and Medicaid. None of the weight loss medications are covered on these plans. These patients cannot afford to pay cash for their prescriptions, and without formulary coverage, these medications are very costly.
Similarly, in my patients with commercial insurance, many plans specifically exclude these drugs from their formularies. It is difficult to feel motivated to prescribe these drugs when you know that you are going to get a time-consuming call back from the patient and the pharmacy stating that the drug is not covered or is too expensive.
The majority of patients I have on these drugs are still paying cash, and the reality of the matter is that not everyone has an extra $50-$150 per month lying around. I prescribed liraglutide 3.0 mg for a patient with commercial PPO coverage, and she returned from the pharmacy with a price quote even higher: $974 per month, even with a savings card.
I have been a big proponent of phentermine/topiramate ER since it came out, but recently I have had to curtail my prescribing practices secondary to cost. Lorcaserin and naltrexone SR/bupropion SR are significantly less expensive for cash-paying patients.
As a prescriber, I am awaiting increased formulary coverage for these drugs so that I can choose the best drug for a particular patient profile and not just the one they can afford. Coverage is improving, but we still have a long way to go. Accessibility of these drugs due to high out-of-pocket costs remains the biggest challenge in my practice.
I am also concerned about the weight gain that occurs when patients stop the drugs. In a perfect world, every insurance plan would cover these medications and all patients could afford them. Given the significant out-of-pocket cost for many patients, however, it is less feasible that patients will be able to afford long-term therapy.
Table. FDA-Approved Drugs for Weight Loss
|Phentermine/topiramate ER (Qsymia®)|
|Naltrexone SR/bupropion SR (Contrave®)|
|Liraglutide 3.0 (Saxenda®)|
|Orlistat (Xenical®, alli®)|
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Cite this: Why I Prescribe Weight Loss Drugs - Medscape - Mar 29, 2016.