People who need to lose a significant amount of weight — and there are a lot of them — finally have more medical options. After a string of disappointments, the Food and Drug Administration has lately approved four drugs that can aid in weight loss when used alongside diet and exercise. The drugs can’t melt away the fat while you sit on the sofa for a Netflix marathon, but they can help kick-start the lifestyle habits crucial to dropping pounds.
It may seem pretty shocking that the pharmaceutical arsenal has been so small, given that almost 35 percent of American adults are obese and another 34 percent are overweight. Until fairly recently, there was just one approved option for long-term use: orlistat, sold over the counter as Alli and by prescription as Xenical, which prevents some of the fat in food from being absorbed by the digestive system. A few other drugs, like the stimulant phentermine, can be used for three months or less. And there’s a graveyard of drugs that had to be pulled due to concerns that they caused heart problems.
So obesity specialists were ecstatic when the FDA gave the OK, in rapid succession, to Belviq and Qsymia in 2012. Then came Contrave last September. Those three drugs, in pill form, were followed by the injectable Saxenda, approved last December. “Having four more options is a wonderful start,” says Martin Binks, secretary/treasurer of The Obesity Society and an associate professor of nutritional sciences at Texas Tech University in Lubbock. All are intended for use in the obese — people with a BMI of 30 (say, 203 pounds at 5’9″) or more — or in a subset of overweight people who also have a problem such as or high blood pressure.
The drugs all target parts of the brain involved with appetite and satiety, and interfere with hunger signals, explains Eric Ravussin, a physiologist at the Pennington Biomedical Research Center in Baton Rouge, Louisiana. So they can reduce the chances that you’ll overeat. Belviq is a new drug, while Qsymia is a combination of two older drugs, phentermine and the anti-seizure medication topiramate. Contrave is a combination of naltrexone, used to combat drug and alcohol addiction, and bupropion, prescribed as Wellbutrin for depression and as Zyban for smoking cessation. Saxenda is a higher dose of the diabetes drug Victoza.
“It was almost like a switch was turned off,” says Bonnie Pagliuca, 55, who lives in Saugus, Massachusetts, and is a veteran of multiple diets and gastric bypass surgery. Nothing worked, she says, until she was prescribed Belviq. Before, she couldn’t walk by a sleeve of Oreos without emptying it, she says. “Now, when I see the same cookies, I don’t have that draw.” Tamping down her sensations of hunger helped her lose a few pounds, a huge motivator to get serious about eating healthfully, walking in the morning and joining a gym to strength-train with a personal trainer. Doctors stress that the medications won’t cause weight loss without better dietary choices and regular exercise.
Pagliuca is unusual in that she’s lost 80 pounds. “We tell people to expect a 5 percent to 10 percent weight loss,” says Louis Aronne, director of the Comprehensive Weight Control Center at New York-Presbyterian Hospital/Weill-Cornell Medical Center. (He and the other weight-loss experts mentioned have had a financial relationship with one or more of the drugs’ manufacturers, such as serving as a consultant or as a trial investigator.)
While going from 200 pounds to 180 may not sound like a lot, that sort of weight loss can be enough to reduce the risk of developing diabetes by more than 58 percent, Aronne says. Ravussin notes that even modest weight loss can produce a disproportionately large reduction of dangerous fat engulfing important organs like the liver. “Most people want weight loss for the mirror and the scale, but it’s really important to consider your metabolic health,” he says.
Generally, people seem to respond well to a given drug or not at all. “The piece we don’t understand is which drugs will work for which patients,” says Caroline Apovian, director of the nutrition and weight management center at Boston Medical Center and Pagliuca’s physician.
Like all drugs, these four can cause side effects, some rare but serious. Contrave can prompt suicidal thoughts, seizures and elevated blood pressure, for example. Saxenda can cause pancreatitis, and animal studies suggested a link to thyroid cancer. So it’s important to talk over the potential for harm with your doctor. Even the more common milder problems — such as dry mouth, constipation and headache — can make people feel crummy. The potential for side effects is significant, because these drugs are meant to be taken for the long haul, even after a patient’s BMI dips below the 27 cutoff. Evidence shows people only maintain the weight loss as long as they take the drugs, so patients potentially face decades of use.
As of now, that can mean a lot of money. The sticker price is between $150 and $200 a month for the three oral medications, though manufacturers offer coupons, discounts and mail-order programs that can reduce that. At full price, Saxenda runs more than $1,000, though it, too, has a discount program. And insurance coverage is spotty. According to pharmacy benefit manager Express Scripts, about a third of plan sponsors cover the medications with no restrictions, another third cover them with some conditions (that the patient is enrolled in a formal diet and exercise program, say) and a third don’t cover them at all.
If you are mulling medication, keep in mind that it should be just one strand of a weight-loss program. Says Bartolome Burguera, an endocrinologist and director of the obesity programs at the Cleveland Clinic: “We don’t have a miracle drug where you can stay in bed all day and lose weight.”
Excerpted from U.S. News’ “Best Hospitals 2016,” the definitive consumer guidebook to U.S. hospitals. Order your copy now.
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