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Clinical Pharmacist - Family Medicine
Center for Family Medicine
Cleveland Clinic Akron General
Megan Adelman, PharmD, BCPS, BCGP, CDCES, has no relevant conflicts of interest to report.
Department of Pharmacy Practice
College of Pharmacy-Glendale
Elizabeth Pogge, PharmD, MPH, BCPS-AQ Cardiology, BCGP, FASCP, FAzPA, has no relevant conflicts of interest to report.
The incidence of obesity in the United States is increasing, and pharmacists can have an important role alongside other healthcare professionals (HCPs) in counseling patients about obesity management. We should consider obesity-related counseling for all patients with a BMI ≥25 kg/m2 regardless of whether we are considering pharmacologic therapy, because reducing obesity can have a big impact on chronic disease states. Even a 3% to 5% weight loss can reduce the risk of obesity-related cardiometabolic disease. Hence, counseling our patients with obesity on the benefits of weight loss can be a helpful approach for treating other disease states.
In our practices, we like to use a 3-pronged approach consisting of (1) dietary and activity counseling, (2) behavioral therapy, and (3) pharmacotherapy.
Dietary and Activity Counseling
The foundational approach to treating obesity is to develop a plan for dietary therapy. The plan should be individualized and tailored to your patients’ needs and wants. Work with them to determine what they like to eat and how they like to eat, and then help individualize that plan, because the plan will not work if they are unable to follow it. A good rule of thumb is to aim to reduce calories by approximately 500 kilocalories per day, which helps with the goal of losing approximately 1 pound per week. Some patients like a specific meal plan, such as the Mediterranean diet or a DASH diet (both of which are especially helpful for persons with cardiovascular disease). Making specific, minor changes can have significant long-term effects on weight loss goals.
Along with dietary modifications, it is important to integrate physical activity. Ideally, plans should include aerobic activity progressing up to 150 minutes per week on 3-5 separate days, plus resistance exercise 2-3 times a week. The latter is especially helpful to build muscle and increase the amount of calories that patients burn throughout the day.
The second important foundation for helping patients manage obesity is behavioral therapy. Our top recommendation for behavioral therapy is self-monitoring of food intake. This could involve food logs, which helps patients become more aware of the foods that they are putting in their body. The concept of mindful eating has become very popular, which is the idea of being aware of how you eat and paying attention so that you only consume enough to be satisfied.
Similarly, self-monitoring of weight can be helpful. However, overweighing yourself can be detrimental, so we recommend weighing in approximately once per week as a good place to start. We also recommend helping patients set appropriate goals by following the SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) criteria. For example, rather than setting the goal “I want to quit snacking,” a SMART goal would be “I'm not going to eat or drink anything except for water after 6 PM for the next 4 weeks.”
As pharmacists, we can help with behavioral therapy by educating patients on stress management, stimulus control, and triggers as well as help with the development of SMART goals. We can help patients become more aware of barriers to weight loss and identify the best ways to reach their weight goals.
The third foundational approach to treating obesity is to consider pharmacotherapy for eligible patients. Any individual with a BMI ≥27 kg/m2 in the presence of comorbid disease states or a BMI of ≥30 kg/m2 should be considered for adjunct pharmacotherapy in addition to the lifestyle intervention listed above.
When considering pharmacotherapy, pharmacists should ensure that patients understand that medications supplement dietary, physical activity, and behavioral interventions, and that some patients may not respond effectively. An effective response is considered a 5% reduction of body weight in about 3 months; weight loss should be slow and steady.
Among the available pharmacotherapy options, we prefer the long-term medications. That excludes drugs such as sympathomimetics, which are generally not recommended long term. Instead, we recommend medications such as phentermine/topiramate extended release, naltrexone/bupropion, the glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) liraglutide and semaglutide, or orlistat, which is available as an over-the-counter or a prescription-based product. All of these might be pharmacotherapy considerations for our patients, and it is important that therapy is individualized by considering potential side effects, dosing, and administration.
Dosing Considerations for GLP-1 RAs
Originally indicated for persons with type 2 diabetes, the GLP-1 RAs liraglutide and semaglutide are now approved by the FDA specifically for weight management at higher doses. Pharmacists are in an ideal position to help patients who are prescribed GLP-1 RAs, as they require stepwise dosing, which can be somewhat confusing. We are probably most familiar with the diabetes dosing of these agents. For liraglutide, a stepwise approach begins with 0.6 mg, escalating to 1.2 mg, and 1.8 mg daily. For weight loss therapy, there is an additional 2.4 mg and 3 mg daily dosing option. For semaglutide, the diabetes dosing starts with 0.25 mg, then 0.5 mg, and 1 mg weekly. For weight loss, there is an additional 1.7 mg and 2.4 mg weekly. Of note, a higher dose of 2.0 mg semaglutide may soon be available for diabetes; keep an eye out for that approval. As noted, dosing is a little bit different for each GLP-1 RA as well as for each indication. Moreover, the titration schedule differs between the agents. With liraglutide, we step up every 1-2 weeks, whereas semaglutide can be increased every 4 weeks.
These stepwise dosing approaches are important to help with some of the common side effects of GLP-1 RAs, specifically gastrointestinal intolerance, including bloating, vomiting, and nausea. Recall that these drugs work in part by slowing gastric emptying, so in addition to reducing the absorption of sugar for persons with diabetes, this helps with weight loss by helping patients to feel fuller for longer. Slow-dosing titration can help patients get the optimal benefit while mitigating these side effects.
Although GLP-1 RAs can have great benefit for weight loss when used alongside lifestyle intervention, the cost can be somewhat limiting. It is important to discuss this with patients. There are manufacturer coupons available to help with the cost, but pharmacists and other HCPs need to have a conversation with patients to determine what is feasible for them. For patients with diabetes who would also benefit from weight loss, it is a no brainer to use these agents. For other patients, you may need to help assess the cost–benefit ratio of GLP-1 RAs.
In addition to the GLP-1 agents, there are some emerging options on the horizon for pharmacologic treatment of obesity. Tirzepatide is an injectable, dual–GLP-1/glucose-dependent insulinotropic polypeptide agonist that is currently under FDA review for diabetes management. Studies to date have focused on individuals with diabetes, but the secondary outcomes for weight loss have been fantastic. So we suspect that this may eventually be an option for weight management.
Have you used dietary, behavioral, and/or pharmacologic interventions for obesity treatment? Answer the polling question and join the discussion by posting a comment.