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Qsymia
Qsymia is a medication approved by the FDA for weight loss 6-9 months ago. The pill in a combination of two other medications- each has been available for years. The first is phentermine and has long been used for weight loss. It is thought to be a stimulant medication and is currently a controlled medicine; however, in the formulation used, relatively low dosages of the medication is prescribed. Therefore, most persons will not have a stimulant feeling. They will, however, benefit from the appetite suppressing effects of the drug. The second medication is topiramate, a medication that calms the central nervous system and reduces food cravings. The side effects of topiramate include sedation, nausea and tingling . For this reason, the medication has to be begun at low doses and increased in small steps.
I cannot say enough about how useful this medication combination is. The combination of the two medications produces a result far greater than that which can be obtained by either alone. I have treated about 40-50 persons so far and have found that about 70% of my patient seem to obtain a weight loss of 10-15% (of their starting weight) within the first three months. Some patients reach 30-35% weight loss.
The FDA's concern is whether the risk of heart attack is increased with long term use. However, studies of phentermine show no increase in blood pressure and minimal increase in pulse. Perhaps, the weight loss obtained more than made up for any stimulation provided by the medication. Certainly, we need to be concerned about heart issues, but there is no clear cut increase in heart disease in available studies. Of course, I would not treat a person at high risk of heart attack and have sent a few of my patients for stress tests before beginning treatment. We need to be careful. That still leaves plenty of other patients including those whose risks of heart attack is years away and can be lowered by significant weight loss.
The concern over topiramate is birth defects in pregnant woman. Of course this is a concern; however, topiramate has been used in young women for years for other reasons such as seizures and migraine headaches. Birth defects should not be more of an issue for the overweight population. We also have to worry about kidney stones in patients using this medication.
These medication will not be tolerated by everyone. 5% cannot tolerate phentermine. (If you can't tolerate decongestants, you will not be able to tolerate phentermine) About 10% of persons cannot tolerate the topiramate. Other medications can be substituted for these and are also effective. see Weight Loss Medications
The cost is about $150 for Qsymia without insurance or a brand name copay with insurance. Many commercial insurance companies have been paying for the generic medication, some of the medicare part D companies do not. Luckily, phentermine costs only about $30-35/month. Topiramate costs range from $15. to over $200 depending on the pharmavy you go to (in Rite Aid, 50 mg two times daily costs $232)
The drugs only suppress appetite; they need to be used with a structured diet. Most popular diets are fine and I recommend any. Weight Watchers, South Beach, Jenny Craig or any other, will all be beneficial. Excercise is also neccessary for optimal results.
Treatment with these medications may become chronic. Some patients may learn new eating habits and maintain their weight without medication. Unfortunately, most others require help indefinately. I compare obesity to hypertension or diabetes(especially since these problems improve with weight loss). We often use combinations of medications to treat these other problems. We don't stop medication once a target pressure, cholesterol level or diabetes result has been achieved. Rather, we continue medication as long as the benefits outweigh the risks and monitor for side effects. That is my job.
The office is open 5 days/week See link below for more detailed office information. Insurance may cover treatment if your BMI is greater than 28. Patients are seen on a monthly basis.
CONTRAVE
In 2010, the FDA approved the first new weight loss medication in several years. Contrave is a combination of two medications already discussed in this website: naltrexone and buproprion (Wellbutrin). This is a useful combination of medication that I have been using for some time.
The mechanism of action is twofold. First, there is a direct reduction of appetite. The increased activity of Nor-epinephrine cause by the buproprion does this as well as the blockade of the CART neuron opioid receptors. (see How the Brain Control Appetite) In addition, the activity of B-endorphin is blocked in the Nucleus Accumbens, reducing the drive to overeat.
Expected side effects include irritability and sleep disturbances from the buproprion. The naltrexone may cause nausea and has a risk of causing mild depression. Anyone on opioid pain medication will be unable to use this.
I have found this combination of moderate help leading to a 5-10% weight loss in about 1/3 of the people to whom it is prescribed. It will be more effective when used in combination.
Belviq
An exciting new medication has come to the market in June of 2013. Belviq is similar to prior weight loss medications in that it effects serotonin physiology. Serotonin has key roles to play in brain "pacemaker" activity, emotional regulation, and homeostasis. Part of these functions includes regulating feelings of satiety, hunger and therefore weight. It is interesting that there are a myriad of different receptors throughout the body that react to serotonin-sometimes in opposite directions. However, it is the opposing directions of action that allows serotonin to stabilize brain function.
In considering the specifics of Belviq function, it stimulates the Serotonin 2C receptor (often referred to as the 5-HT2c receptor).. Even though this receptor stimulates the target nerve, many of the target nerves themselves are inhibitory. So we are increasing the inhibition of certain brain functions that lead to irritability and hunger; reducing such functions will lead to decreased food intake and hopefully weight loss.
The weight loss seen in studies was probably between 5-10 % which is significant but admittedly more modest than that seen with Qsymia. However, it is important to remember that Qsymia is a combination of two different medications; the combination of which produces a weight loss of 10-15%. Each of the components has a different mechanism of action than Belviq. Also, Belviq is likely as strong or stronger than either component of Qsymia alone. Although it remains to be proven, I suspect that combining Belviq with either medicine component of Qsymia (both are available generically) may lead to even more profound weight loss.
Now it is appropriate to be cautious with a new Serotonin drug given the history of heart valve problems caused by Redux (dexfenfluramine) and fen/phen. Those drugs led to profound release of seratonin. The released serotonin stimulated serotonin 2B (not 2C) receptors in the heart valves leading to overgrowth of tissues in the heart valve (and pulmonary tissues as well?). Many other drugs (ecstasy, migraine medications)which cause significant release of Serotonin also have led to similar heart problems. Belviq stimulates the 2C receptor directly and does not lead to serotonin release. Therefore the heart tissues are not stimulated. The release of the drug was delayed for years while this issue was studied and no heart valve problems have been identified.
My first approach to patients, based solely on price, will still be the generic equivalent of qsymia. However, Belviq represents a viable option for patients who do not get a sufficient benefit or cannot tolerate the first line treatment.
General Approach to weight loss
As I write this introduction in November of 2010, I do not consider myself an expert in nutrition. I do not really know if low carb is or is not better than low fat. I have no special theories about food matching What I do know is that many people cannot stick to a diet and I do consider myself an expert in impulse control disorders.
I prescribe several combinations of medications that I have found help people lose weight. (see Medications Used for weight control) These may include traditional diet medications such as appetite suppressants and fat blockers. They are combined with one or several medications which have been found to suppress cravings and the reinforcing aspects of eating that lead us to eat more than we should. I may use diabetic medication which has been found to be helpful. I am certainly open to any other suggestions that my patients might have. It is the combination of several different medicines at once that makes my approach more unusual. It results in greater weight loss as it simultaneously exploits several mechanisms by which the body attempts to maintain weight. It allows me to use lower doses of certain medicines to minimize side effects of any one medication.
Of course, dietary and lifestyle changes are essential. I am not focused on any one diet. Low carbohydrate diets seem to be better for more people but each person has to find what works for them. Portion control is fine and exchange diets at the 1200, 1500, 1800 and 2000 calorie levels are available. Support groups always work and I recommend any and all programs such as over-eaters anonymous, Weight Watchers, Jenny Craig or any other less known diets.
Exercise is also important and I will discuss regimens that I consider optimal. Many of the medical regimens that I use will be maintained for a year or longer. If one is successful with weight loss, you do not want to stop what is working. Of course, we should attempt to wean people off medications but we should resume medications if weight gain should occur