medications

GLP-1 medications slow gastric emptying, increase feelings of fullness, reduce appetite and food cravings. Many lose 10-15% of body weight or more.

If you are hoping for insurance coverage: Check to see if your insurance covers obesity care (many employers or plans will opt-out or exempt obesity care, thus will not pay). You may have coverage if you are diabetic, have sleep apnea, cardiovascular disease or steatohepatitis/ liver fibrosis (F2-3).

- Saxenda (liraglutide, Victoza) may be as low as $128/mo for the lowest dose on costplusdrug.com, $240 on GoodRX (as Victoza) if cash pay. Full dose could be around $300/mo +. This is a daily injection.

- Zepbound (tirzepatide, Mounjaro) starts at $349/mo ($499 for higher doses) through Lilly Direct when cash-pay. This is a weekly injection. No generics yet.

- Wegovy (semaglutide, Ozempic) now starts at $199 for the first 2 months, then $349-499/mo if cash-pay through Novo-Care Pharmacy, or $349/mo at Costco. This is a weekly injection. No generics yet. *THIS PRICE MAY BE DECREASING

Potential side effects include reflux, nausea, vomiting, constipation and diarrhea. Rare side effects include pancreatitis, gallbladder problems, kidney problems, bowel obstruction or worsening retinopathy. These are contraindicated in anyone with a history of pancreatitis, multiple endocrine neoplasia syndrome type 2 (MEN2), or a personal or family history of medullary thyroid cancer. These may not be a good fit if you have severe gallbladder disease, severe gastroparesis, history of bowel obstruction, anorexia or eating disorders, or diabetic retinopathy.

Wellbutrin (bupropion) is an antidepressant FDA-approved for treating major depressive disorder, seasonal affective disorder and smoking cessation (as Zyban). While not directly approved as a weight-loss drug, weight loss is thought to stem from its influence on dopamine and norepinephrine, which can suppress appetite, increase energy, and potentially alter metabolism and reduce cravings.

Weight loss is typically modest, such as 5-10 pounds over several months, and is most effective combined with a healthy diet and regular exercise. This is a component of the FDA-approved weight-loss medication Contrave (naltrexone/bupropion), where effects are synergistic with naltrexone to further reduce cravings, promote satiety and can lead to a loss of 5-10% of body weight. 

Potential side effects/risks include headaches, dizziness, nausea, increased anxiety, insomnia, fast heartbeat, elevated blood pressure, mood changes, mania, angle-closure glaucoma, hypersensitivity and can increase the risk of seizures particularly at higher doses or in those with a pre-existing seizure disorder. Wellbutrin is contraindicated in individuals with a seizure disorder or conditions that increase the risk of seizures (severe head injury, AV malformation, CNS tumor, CNS infection, severe stroke, abrupt discontinuation of alcohol or certain medications) and a history of bulimia or anorexia.

Naltrexone is a medication primarily known for treating alcohol and opioid dependence but plays a role in weight management as a component of the FDA-approved medication, Contrave (naltrexone/bupropion). Naltrexone is thought to work by blocking opioid receptors in the brain, helping to reduce food cravings and the rewarding aspects of eating. This action, especially when combined with bupropion (which affects dopamine and norepinephrine), can lead to decreased appetite, increased feelings of fullness and reduced calorie intake.

The combination of naltrexone and bupropion can lead to a loss of 5-10% of initial body weight over several months, especially when combined with diet and exercise. 

Potential side effects include nausea, vomiting, constipation, headache, fatigue and dizziness. Naltrexone blocks opiate receptors and is contraindicated in individuals on opiate therapy.

Topiramate is FDA-approved for treating seizures and preventing migraines. While not approved as a standalone weight-loss drug, it has led to weight loss as a side effect and is frequently prescribed off-label for this purpose. Its exact mechanism for weight loss isn't fully understood, but is believed to involve appetite suppression, increased feelings of fullness, changes in taste perception, and potentially alterations in metabolism, all contributing to reduced caloric intake.

When used for weight management, alone or in combination with phentermine (as FDA-approved Qsymia), topiramate can result in an average loss of 5-7% of body weight over several months. 

Potential side effects include neurological symptoms like tingling, cognitive slowing ("brain fog"), dizziness, reduced sweating (risk of overheating) as well as gastrointestinal issues. More serious but less common side effects include kidney stones, mental health changes, vision loss, metabolic acidosis and skin reactions. 

Metformin is FDA-approved for managing type 2 diabetes by improving insulin sensitivity, reducing glucose production in the liver, and decreasing glucose absorption from the gut. While not specifically approved as a weight-loss drug, many individuals taking it for diabetes, insulin resistance or Polycystic Ovarian Syndrome (PCOS) experience modest weight loss as a side effect. Weight reduction is thought to be a result of several mechanisms, including a reduction in appetite, alterations in the gut microbiome, and potential effects on appetite-regulating hormones.

Weight loss is typically gradual, averaging 3%, or 5-10 pounds. Metformin is sometimes prescribed "off-label" for weight loss in non-diabetic individuals, particularly those with insulin resistance or obesity. It should be combined with consistent lifestyle changes, including a balanced diet and regular physical activity, for optimal results.

Potential side effects include gastrointestinal upset like nausea, diarrhea, bloating. fatigue, lower blood sugar, lower vitamin B12 levels. Metformin is contraindicated in those with severe renal impairment (GFR under 30).

Orlistat is FDA-approved for weight loss and weight maintenance, available by prescription (Xenical) and over-the-counter (Alli). It works as a lipase inhibitor, blocking approximately 30% of dietary fat absorption in the digestive tract, which is then eliminated from the body. When used with a reduced-calorie, low-fat diet and increased physical activity, Orlistat can lead to weight loss averaging 3% more body weight than diet alone and can be beneficial for weight maintenance.

Due to its impact on fat absorption, it is recommended to take a daily multivitamin containing fat-soluble vitamins (A, D, E, K) 2 hours apart from the medication.  It is important to consider potential drug interactions.

Common side effects can limit its use, such as oily stool, gas, bowel leakage and increased bowel movements, which are often mitigated by a low-fat diet. While generally safe, rare but serious side effects like liver injury have been reported. It is contraindicated in conditions like chronic malabsorption syndrome, cholestasis, eating disorders, and organ transplant recipients.

Phentermine (alone or in combination with Topiramate) and Diethylpropion are stimulant medications that are controlled substances (schedule IV medications). Their use requires close medical supervision due to potential cardiac risks. These two medications cannot be used together.

Either one of these can be an effective part of a weight management plan for some patients. They work by stimulating the brain to produce dopamine and norepinephrine, suppressing appetite and hunger signals. These may also lead to an increase in motivation and energy.

Potential side effects include nervousness, restlessness, impaired sleep, increased blood pressure, rapid heart rate, dry mouth, constipation, blurred vision or changes in libido. These are contraindicated in anyone with hyperthyroidism, glaucoma, cardiovascular disease, pulmonary hypertension, heart valve disease or a history or drug abuse or dependence.

It is completely valid to consider non-medication approaches. Understanding all your options is key to making the best choice for yourself. Ultimately, the path you choose should align with your personal preferences and health goals.

Regardless of whether you use a medication, important components to weight loss and maintenance success may include:

- nutrition and meal planning (78% of those who maintain their weight eat breakfast), 

- macronutrient or calorie tracking, 

- incorporating meal replacements if helpful, 

- working with a registered dietician (RD), 

- working with a fitness professional or physical therapist

- evaluating for medications that may promote weight gain,  

- managing and reducing stress, 

- addressing mental health conditions, and 

- improving sleep.  

Bariatric surgery refers to a range of surgical procedures performed on the stomach or intestines to help people living with obesity lose a significant amount of weight. Common procedures include gastric bypass and sleeve gastrectomy. 

These surgical procedures are highly effective for weight loss, and like other weight management approaches,  require a lifelong commitment to dietary changes, exercise, and follow-up care. Long term medication treatment may be needed to help with weight loss and management at some point after a bariatric surgery. 

The decision to pursue bariatric surgery should be made in consultation with your PCP and a bariatric surgery center. Your PCP can refer you if you are interested. We can discuss this as well at any time during our work together.