New Guidelines: Treat Obesity First
Monday, March 02, 2015 02:22 PM

Treat weight problems first, then deal with comorbidities like dyslipidemia, hypertension, and impaired glucose tolerance, a new guideline urges.

It's an entirely new approach to the treatment of disease, said the lead author of a new guideline for treating obesity with medications.  "The old paradigm was to treat each comorbidity with medications ... then manage obesity, which caused most of the original problems in the first place," Apovian said during a press briefing. "The new paradigm is to manage the obesity first, with lifestyle change and medications, then manage the remainder of the comorbidities that have not responded."

The guideline focuses on medical management of obesity, a component left out of earlier guidelines released by the American Heart Association, the American College of Cardiology, and the Obesity Society, since they were written before many of the new weight-loss drugs were approved.

Four new obesity drugs have been approved in the last few years, and many of these medications work by amplifying the effects of behavioral changes.  They have the greatest effect when they're reinforced with face-to-face visits -- the literature says at least 16 visits per year, a figure that federal insurers reimburse for.  "Adding the medications to a diet and lifestyle program leads to a greater enhancement of their effects," she said. "And we recommend that if you're going to treat weight management patients that you see them frequently."

The new guidelines are the first to mention specific obesity drugs and give some guidance on how to prescribe them.  Patients should be put on the drugs for a 3-month trial period, starting at the lowest dose and titrating up, the guidelines state. If they don't lose at least 5% of their body weight in that time, they should be switched to another drug.

"You have to give your best guess as to which drug the patient should go on based on their lifestyle characteristics that make them amenable to that particular drug,” the author said. "Unless you have a very clear idea of what drug you think the patient will do best on, it's going to be trial and error."

The question remains whether insurance will cover these medications.  "Many insurances do not want to pay for obesity drugs, and they're expensive. They can cost between $4,000 and $6,000 per year."

With more clinicians focused on the treatment of obesity as a disease -- which is what the American Medical Association called it in 2013 -- experts say that could change.