What Compounding Pharmacists Should Know About Medications and Lifestyle Guidelines for Weight Loss
Let’s face it: it’s hard to know exactly how to approach patients who are battling weight issues. As a result, practitioners seem to take one of two approaches—either they push too aggressively or they avoid the topic. With statistics saying that 33 percent of adults are overweight or obese, would it surprise you to learn that only 1 percent of them are prescribed weight-loss medications? Researchers haven’t determined whether doctors don’t recommend medications or if patients turn them down out of concern over adverse effects. Regardless of the reason, it’s a sure bet that compounding pharmacists can help by taking the initiative to educate patients about medications and lifestyle guidelines for weight loss. After discussing the risks and benefits of certain options and the significance of lifestyle changes, you can then encourage them to talk with their physician about a weight-loss program.
Diagnostic Criteria for Managing Obesity
Over the years, different groups have issued guidelines for obesity. The most recent practice guidelines were released in May 2016 by the American Association of Clinical Endocrinologists (AACE). They reinforced earlier recommendations to assess using BMI and waist circumference, then also created a comprehensive algorithm for staging obesity and guiding treatment decisions.1 The AACE suggests annual BMI screening and initiating a weight loss program for patients that meet the following requirements:
- BMI of 25 to 29.9 (overweight) plus one weight-related comorbidity.
- BMI at or above 30 (obese).
- BMI cut-offs of 23 to 24.9 for overweight and 25 or above for obesity should be used for some ethnicities.
The staging guidelines are as follows:
- Stage 0 – BMI of 25 or above with no complications. Treatment goal is to prevent additional weight gain and lose weight following lifestyle and behavior recommendations. Medication may be considered if lifestyle efforts aren’t successful.
- Stage 1 – BMI of 25 or above with one or more mild complication. Recommend lifestyle changes—consider medications if BMI is 27 or above.
- Stage 2 – BMI of 25 or above with at least one severe complication. More aggressive weight loss management—add medications if BMI is 27 or above. Consider bariatric surgery if the BMI is at or above 35.
Lifestyle and Behavioral Interventions
All the guidelines agree that weight loss depends on lifestyle changes. Patients need to know this up front. They need to understand that medications are just one component of a weight loss plan; the only way to lose weight—and keep it off—is by consistently restricting calories and following an exercise regimen. The recommendations state:
- Calorie restriction: Daily deficit of 500 to 750 calories. It’s best to calculate each patient’s daily maintenance calories, which is easy with online calculators, then deduct 500 calories.2 Very low-calorie diets may be considered but they require medical supervision.
- Exercise plan: Patients should aim for 150 minutes of aerobic activities every week and engage in resistance exercises two or three times weekly. Sedentary and obese patients should work with a physical therapist or professional trainer to develop an individualized and safe program.
Ongoing support gives patients the best chance for successful and permanent weight loss. This could mean consulting a registered dietitian to create a balanced diet or getting behavioral counseling to break habits that contribute to weight gain such as emotional eating. Some patients will benefit from Internet support groups or a commercial program. A systematic review published in the Annals of Internal Medicine found that Weight Watchers and Jenny Craig were the best for long-term weight loss.3
Compounding pharmacists can keep patients active by assessing for acute and chronic pain that may interfere with their exercise regimen. Suggest compounded topical treatments to relieve aches and pains. Topical NSAIDs are an option but for patients who prefer to limit medications, they can consider using a combination of capsaicin, methyl salicylate and menthol.
FDA-Approved Weight-Loss Medications
It’s worth repeating that all of the FDA-approved weight loss medications are intended to be used as part of a diet and exercise program. If weight loss of 5 percent hasn’t been achieved by 12 weeks, the medication should be discontinued and the treatment plan revisited. While it’s a good idea to assess progress and ask if patients are sticking with the diet at every refill, be sure to have a counseling session when they pick up the third or fourth refill that will take them to the 12-week point.4 If they haven’t lost weight, they may benefit from switching to one of the other FDA-approved medications:
- Liraglutide: A glucagon-like peptide-1 receptor agonist that stimulates the release of incretin, which improves insulin secretion and increases satiety by slowing gastric emptying. Bloating, cramping, nausea, diarrhea and low blood sugar are potential adverse effects, but slowly titrating the dose up over five weeks should help prevent GI upset. Phase III data showed that liraglutide resulted in a 5 percent weight loss in 63 percent of patients, while a third lost 10 percent.5
- Bupropion-naltrexone: The antidepressant and opioid antagonist work together to reduce food cravings. Over 56 weeks, patients achieved weight loss of 5 to 10 percent. Common adverse effects include nausea, headache, constipation, insomnia, vomiting, dizziness and dry mouth. This drug is also titrated up over four weeks.
- Phentermine-topiramate: Phentermine causes early satiety, while topiramate likely helps to reduce food cravings. It’s titrated up and should be discontinued gradually if patients don’t lose at least 5 percent of initial body weight after 12 weeks on maximum dose. Dry mouth and constipation are common, but other adverse effects are more serious, as this drug can cause birth defects, increased heart rate and lead to suicidal ideation.
- Lorcaserin: Promotes satiety and suppresses appetite by activating 5-HT2C receptors in the hypothalamus. Pregnant women should not take lorcaserin. It’s not contraindicated in heart patients, but blood pressure and heart rate must be monitored. Other adverse effects include headache, upper respiratory infections and GI symptoms.
- Orlistat: Reduces absorption of dietary fat. When combined with lifestyle changes, most patients can expect weight loss of 8 to 10 percent after one year. About 10 to 15 percent of patients will experience stomach cramps, gas, diarrhea, stool leakage or oily stools.
Pharmacist Outreach Can Promote Weight Loss
When pharmacists were surveyed, most said they weren’t comfortable counseling patients about weight loss strategies. However, it may help if you consider the situation from a patient’s perspective. Overweight patients are frustrated, discouraged, desperately seeking options and need suggestions. You can help by offering expert advice regarding medications and lifestyle guidelines for weight loss, and making sure they have realistic expectations. With an encouraging attitude and the desire to help them succeed, you can contribute to their weight loss success.
Pharmaceutica North America provides high-quality bulk APIs, emollient delivery bases and custom compounding kits to meet the varied needs of patients. Contact us today to learn about our products and to explore how we can support your pharmacy.
- “AACE/ACE Algorithm for the Medical Care of Patients With Obesity,” May 2016, http://journals.aace.com/doi/suppl/10.4158/EP161365.GL/suppl_file/10.4158_ep161365gl-algorithm.pdf ↩
- “Adult Energy Needs and BMI Calculator,” 2016, https://www.bcm.edu/cnrc-apps/caloriesneed.cfm ↩
- “Weight Loss: Two Commercial Plans are the Biggest Winners,” July 2015, http://www.pharmacist.com/weight-loss-two-commercial-plans-are-biggest-winners-0 ↩
- “How Pharmacists Can Help Patients Remain Adherent to Weight-Loss Medications,” November 2015, http://www.pharmacytimes.com/perspectives/weight-loss-interventions-for-obesity/how-pharmacists-can-help-patients-remain-adherent-to-weight-loss-medications ↩
- “Data on FDA-Approved Weight Management Medications Dominate Obesity Week,” May 2015, http://www.pharmacytoday.org/article/S1042-0991%2815%2930333-9/fulltext ↩