Contact Hours: 3
This educational activity is credited for 3 contact hours at completion of the activity.
Course Purpose
The purpose of this course is to provide an overview of pharmacological interventions for weight loss, delving into their mechanisms of action and clinical indications, and discuss the various types of Federal Drug Association (FDA) approved and off-label medications, safety profiles, and nursing considerations.
Overview
In today’s healthcare environment, obesity presents a formidable challenge worldwide as its prevalence continues to rise unabated. Among the management strategies available, weight loss medications emerge as pivotal treatment, offering targeted therapeutic options for those unable to lose weight through lifestyle modifications alone. This course aims to provide an overview of pharmacological interventions for weight loss, delving into their mechanisms of action and clinical indications. This course also discusses the various types of Federal Drug Association (FDA) approved and off-label medications, safety profiles, and nursing considerations.
Course Objectives
Upon completion of this course, the learner will be able to:
- Define obesity according to the World Health Organization (WHO), as relates to Body Mass Index (BMI).
- Review the Food and Drug Administration (FDA) approved weight loss medications, their mechanisms of action, and side effects.
- Review off-label use medications that have been prescribed for weight loss.
- Discuss the benefits and contraindications of weight loss medications.
- Review weight loss medication considerations for the pediatric population.
- Understand that weight loss medications should be used as an adjunct to dietary changes and increased physical activity to achieve weight loss goals.
Policy Statement
This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.
Disclosures
Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.
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| Adipose Tissue | Commonly known as fat tissue, is a type of connective tissue that stores energy as fat. |
| Arrhythmias | A condition characterized by abnormal heart rhythm. |
| Bariatric Surgery | A surgery that helps reduce food consumption and help weight loss by removing a part of stomach thereby reducing its size. |
| Body Mass Index (BMI) | A measure of body fat based on weight and height. |
| Brainstem | The distal part of the brain that connects the cerebrum, cerebellum, and spinal cord. |
| Central Nervous System (CNS) | The part of the nervous system consisting of the brain and spinal cord. |
| Central Obesity | Also known as abdominal obesity and truncal obesity. Is the condition of an excessive concentration of visceral fat around the stomach and abdomen to such an extent that it is likely to cause health problems. |
| Coronary Artery Disease | A type of heart disease where the arteries of the heart cannot deliver enough oxygen-rich blood to the heart. |
| Cytokines | Signaling proteins that help control inflammation in the body. |
| Depression | A mood disorder that causes a persistent feeling of sadness and loss of interest. |
| Dopamine | A chemical messenger that helps regulate many functions in the body and brain. |
| Energy Homeostasis | A biological process that involves the coordinated homeostatic regulation of food intake (energy inflow) and energy expenditure (energy outflow). |
| Enteroendocrine Cells | Specialized cells of the gastrointestinal tract and pancreas with endocrine function. |
| Estrogen | A hormone that plays a role in both male and female reproductive systems. |
| Gamma-Aminobutyric Acid (GABA) | A natural amino acid that acts as a calming neurotransmitter in the brain. |
| Ghrelin | A hormone that signals the brain to feel hungry and increases appetite. |
| Glucagon-Like Peptide-1 (GLP-1) | A hormone that is produced and secreted by the brain and intestine upon food consumption. |
| Glucagon | A peptide hormone, produced by alpha cells of the pancreas. |
| Glycemic Control | Maintaining euglycemic blood glucose levels. |
| Heart Failure | A progressive heart disease that affects pumping action of the heart muscles. |
| Hypertension | High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). |
| Hypothalamus | A brain structure that controls your body’s balance and hormones. |
| Insulin Resistance | A complex condition in which the body does not respond as it should to insulin, a hormone the pancreas makes that is essential for regulating blood sugar levels. |
| Lipase Inhibitor | Substances used to reduce the activity of lipases found in the intestine. |
| Liraglutide | An anti-diabetic medication used to treat type 2 diabetes, and chronic obesity. |
| Low Self-Esteem | Lack of confidence, feeling incompetent or inadequate. |
| Menopause | The time when menstrual periods permanently stop, marking the end of reproduction. |
| Monoamine Oxidase Inhibitors (MAOI) | A type of antidepressant that blocks the breakdown of neurotransmitters in the brain. |
| Neurotransmitters | The chemical messengers that carry signals between nerve cells, muscles and glands. |
| Norepinephrine | Also called noradrenaline (NA) or noradrenalin, is an organic chemical in the catecholamine family that functions in the brain and body as a hormone, neurotransmitter and neuromodulator and is responsible for the “fight or flight” response. |
| Obesity | A condition characterized by abnormal or excessive fat accumulation. |
| Orlistat | A medicine that blocks some of the fat that is consumed, causing weight loss and preventing weight gain. |
| Osteoarthritis | The most common form of arthritis that affects any joint and causes pain, stiffness and loss of mobility. |
| Overweight | Having more body fat than normal for height and weight. |
| Pancreatic Beta Cells | Located in the pancreas and found in groups called islets, beta cells create insulin, a hormone that regulates blood glucose levels. |
| Peripheral Artery Disease (PAD) | Caused by a buildup of fatty, cholesterol-containing deposits (plaques) on artery walls. |
| Phentermine | Used to speed weight loss in overweight people. |
| Pro-Opiomelanocortin Deficiency | A rare genetic disorder that causes severe obesity that begins at an early age |
| Serotonin | A chemical that carries messages between nerve cells and influences mood, sleep, digestion, nausea and more. |
| Serotonin Reuptake Inhibitors (SSRIs) | A class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorder, and other psychological conditions. |
| Sibutramine | An appetite suppressant which has been discontinued in many countries. |
| Sleep Apnea | A potentially serious sleep disorder in which breathing repeatedly stops and starts. |
| Steatorrhea | Oily stool is not always related to an underlying condition. |
| Teratogenicity | The study of abnormalities of physiological development in organisms during their life span. |
| Total Cholesterol | The overall amount of cholesterol in the blood. |
| Triglyceride | Fats in the body that can raise the risk of heart and vascular disease. |
| Type-2 Diabetes | A condition that occurs as a result of the inefficient way that the body regulates and uses sugar as a fuel. |
| Visceral Fat | Also known as intra-abdominal fat, is a type of fat that accumulates deep within the abdominal cavity and surrounds vital organs. |
In today’s healthcare environment, obesity presents a formidable challenge worldwide as its prevalence continues to rise unabated. In the US, the economic and social burden of this burgeoning health crisis is staggering, with recent estimations revealing a surge, with costs surpassing $1.4 trillion – a marked escalation from $976 billion reported just a decade earlier. These costs include a spectrum of expenditures, from direct healthcare costs and expenses linked to disability and premature mortality to indirect costs stemming from diminished productivity and increased absenteeism.5 Among the management strategies available, weight loss medications emerge as pivotal treatment, offering targeted therapeutic options for those unable to lose weight through lifestyle modifications alone. This course aims to provide an overview of pharmacological interventions for weight loss, delving into their mechanisms of action and clinical indications. This course also discusses the various types of Federal Drug Association (FDA) approved and off-label medications, safety profiles, and nursing considerations.
Obesity is a medical condition where excess body weight poses a risk to health. These conditions are commonly assessed using Body Mass Index (BMI), a measure derived from an individual’s weight and height. According to the World Health Organization (WHO), a BMI under 18.5 is underweight, a BMI between 18.5 and 24.9 is healthy, a BMI between 25 and 29.9 is classified as overweight, and a BMI between 30 and 39.9 is defined as obese. A BMI of 40 or higher is morbidly obese.26 However, it is not advisable to rely solely on BMI as it cannot distinguish between fat mass and muscle mass. This is because, per unit volume, muscle weighs more than fat. Consequently, those with higher muscle mass, such as athletes, may be classified as overweight or obese despite having a healthy body composition.16
The body mass index does not consider body fat distribution, particularly central obesity, characterized by excess abdominal fat, which carries significant health risks. Hence, individuals with a healthy BMI may not realize they can have obesity-related health issues. In specific demographics, like older adults or diverse ethnic backgrounds where body composition differs, BMI may not provide an accurate assessment of health.16 Despite these limitations, BMI remains a valuable screening tool in clinical practice due to its simplicity and accessibility. To improve the accuracy of the evaluation, healthcare providers should consider additional criteria, along with BMI. These include factoring in waist circumference, body fat percentage, and medical history. Completing a comprehensive evaluation helps identify at-risk individuals, even if their BMI appears normal. For instance, a person within the healthy BMI range who has an increased waist circumference, high body fat, and diabetes is recognized as being at heightened risk for obesity-related complications.9
Excess weight, whether overweight or obese, significantly increases the risk of several health complications. The most critical include cardiovascular disease, type 2 diabetes, respiratory issues, joint problems, mental health issues, and certain cancers.4 Excess weight, particularly abdominal obesity, results in elevated strain on the heart and blood vessels. It also contributes to inflammation and dysregulation of metabolic processes in the body, which in turn increases the risk of hypertension, coronary artery disease, arrhythmias, peripheral artery disease, and heart failure. Obesity is a major risk factor for developing type-2 diabetes. Extra visceral fat, the adipose tissue found around internal organs, releases inflammatory substances such as cytokines, which interfere with insulin action and impair glucose regulation. Over time, untreated diabetes can lead to other serious complications, including kidney failure and nerve damage. Extra fat around the neck and chest can exacerbate respiratory problems. Extra fat can cause a specific form of asthma, where the excess fat around the chest wall mechanically limits breathing and causes inflammation. This eventually reduces respiratory muscle strength and lung function. During sleep, it can restrict airflow, causing breathing pauses and disruptions in oxygen supply, leading to sleep apnea.
Additional weight places disproportionate stress on weight-bearing joints, such as the knees, hips, and lower back.4 This accelerates joint degeneration and contributes to conditions like osteoarthritis, a degenerative joint disease that causes pain, stiffness, and reduced mobility. Obesity and its link to certain types of cancer, such as breast, colon, and pancreatic cancer, is due in part to the excessive hormones and inflammatory substances produced by surplus adipose tissue. Research has shown that these heightened levels promote tumor growth and progression. Likewise, obesity-related metabolic abnormalities, such as insulin resistance and chronic low-grade inflammation, have been seen to create a favorable environment for the development of these cancers. Along with physical complications, weight issues and obesity can have significant psychological impacts, contributing to mental health disorders such as depression and low self-esteem. Societal stigma and discrimination related to body weight can exacerbate these issues, leading to social isolation, poor body image, and diminished quality of life.12 In addition, the hormonal and neurobiological fluctuations associated with obesity can influence mood regulation and cognitive function.
Epidemiology of Obesity
Obesity has become a serious health concern in the US and globally, affecting individuals across all age groups and socioeconomic strata. Recent data indicates that approximately 43% of adults, approximately 3 billion people aged 18 and above worldwide, are overweight, and 16% live with obesity.27 In the United States, the statistics underscore a particularly concerning reality, with an estimated 1 in 3 adults classified as overweight and a staggering 2 in 5 adults living with obesity.14 The prevalence of severe obesity is notably higher among women (11%) compared to men (6%), which highlights the interplay of biological factors such as adipose tissue storage and metabolism. Women typically have a higher proportion of body fat compared to men, which can predispose them to obesity-related health risks. Also, during menopause, women experience a decline in estrogen levels, which can lead to alterations in fat distribution and metabolism, leading to visceral fat accumulation.10
The impact extends beyond adulthood, affecting the younger population as well. Among children and adolescents aged 2 to 19, the prevalence of overweight is strikingly high, with 1 in 6 considered overweight and 1 in 5 classified as obese.14 This prevalence has escalated dramatically over the past few decades, with rates of obesity more than doubling since the 1980s. This rise is attributed to various factors, including changes in dietary patterns, increased intake of processed and sugary foods, sedentary lifestyles, urbanization, and socioeconomic factors.14 Disparities in overweight and obesity prevalence persist across demographic groups, with specific populations, including racial and ethnic minorities and individuals from low-income backgrounds being disproportionately affected. Studies consistently show disparities in obesity rates among racial and ethnic groups. The prevalence of obesity was highest among non-Hispanic Black individuals, with 38% classified as obese, followed by Hispanic adults at 32% and non-Hispanic white adults at 28%. In addition to genetic variations in adipose tissue, fat distributions, and metabolic rates, environmental factors such as access to healthcare, cultural influences on diet and physical activity, and availability of healthy food options contribute to disparities.15
Weight management medications employ diverse pharmacological strategies to influence the physiological systems implicated in appetite regulation, metabolism, and energy homeostasis.3 Depending on the class of drugs, these interventions target specific molecular pathways within the central nervous system (CNS), peripheral tissues, and gastrointestinal tract to achieve their therapeutic effects. Weight management medications that act on neurotransmitters usually target serotonin, dopamine, norepinephrine, or a combination of these to control appetite and food intake. For instance, those that inhibit the reuptake of serotonin in the brain, such as sibutramine, increase serotonin levels in the CNS.2 This leads to improved mood and reduced appetite, both shown to help weight loss. Alternatively, weight management medications primarily targeting dopamine receptors, like phentermine, influence reward pathways and food-seeking behaviors.3 By inhibiting the reuptake of dopamine, they reduce food cravings and pleasure eating, helping individuals regulate their food intake and adhere to dietary goals. Medications like phentermine also target norepinephrine, boosting noradrenergic neurotransmission. This in turn, suppresses appetite, promotes satiety, and increases energy expenditure, making it easier for individuals to adhere to reduced-calorie diets and remain in a calorie deficit.
Certain weight loss medications control appetite and influence energy metabolism by moderating hormonal signaling pathways, such as those involving ghrelin and glucagon-like peptide-1 (GLP-1). Ghrelin is a hormone primarily produced by the stomach and acts as an orexigenic hormone to stimulate appetite and food intake.13 Medications that act on ghrelin receptors slow its actions, thereby reducing hunger and food cravings. Conversely, medications, such as semaglutide and liraglutide, mimic or enhance the activity of GLP-1 by targeting GLP-1 receptors.25 These receptors are primarily found in the gastrointestinal tract, pancreas, and central nervous system (CNS). Within the gastrointestinal tract, these medications bind to the GLP-1 receptors on enteroendocrine cells in the intestinal mucosa. This exerts several physiological effects. The binding of GLP-1 receptors to enteroendocrine cells enhances glucose-dependent insulin secretion from pancreatic beta cells, which helps lower blood sugar levels and suppresses the secretion of glucagon, a hormone that raises blood glucose. Both these improve glycemic control, which results in less glucose being stored as fat. Also, GLP-1 medications delay gastric emptying (the rate at which food leaves the stomach and enters the small intestine), thereby increasing feelings of fullness and reducing appetite. In the CNS, GLP-1 receptors are in areas of the brain involved in appetite regulation and energy homeostasis, such as the hypothalamus and brainstem. Activation of GLP-1 receptors in brain regions can lessen appetite and increase energy expenditure.25 Weight management medications that target enzymes involved in lipid metabolism reduce the absorption of dietary fats. For example, orlistat is a lipase inhibitor that reduces pancreatic lipase activity in the gastrointestinal tract, preventing the hydrolysis of dietary triglycerides into absorbable free fatty acids. As a result, dietary fat absorption is reduced, leading to a decrease in calorie intake and potentially promoting weight loss.
Indications for Weight Loss Medications
Healthcare providers should evaluate several factors, including BMI, co-morbidities, previous weight loss attempts, and psychological state, when prescribing weight loss medication.3 Generally, these medications are recommended to those who are classified as obese or morbidly obese, with a BMI of 30 or higher. Individuals with a BMI above 27 but below the threshold of obesity may be considered if they also present with obesity-related co-morbidities such as type 2 diabetes, hypertension, dyslipidemia, or obstructive sleep apnea. In some instances, weight loss medications may be suitable for those within the healthy BMI range if they present with significant weight-related health issues or are at a higher risk of developing such issues, such as a family history of obesity-related conditions, a history of gestational diabetes, or significant abdominal obesity.
Candidates for weight loss medications should have made previous attempts at lifestyle modifications.3 This includes having made significant efforts to change their dietary intake, increase their physical activity, and engage in behavior therapy. If candidates are unsuccessful in these attempts or unable to achieve sustainable weight loss, pharmacological intervention may be preferred over more invasive procedures such as bariatric surgery. As most weight loss medications target neurotransmitters, receptors, or both in the central nervous system (CNS), they may also affect mood, energy levels, or cognitive function. This modulation can impact an individual’s psychological well-being. Healthcare providers must assess the individual’s psychological state to ensure that they are mentally prepared to initiate and adhere to medication therapy and to monitor for any changes in mood or behavior during treatment.
In the last 20 years, the Food and Drug Administration (FDA) has approved six weight-loss drugs for long-term use. These include8:
- Bupropion-naltrexone (Contrave)
- Liraglutide (Saxenda)
- Orlistat (Xenical, Alli)
- Phentermine-topiramate (Qsymia)
- Semaglutide (Wegovy)
- Setmelanotide (Imcivree)
Lorcaserin was another medication that received FDA approval in 2012 and was used clinically for eight years. However, its approval was revoked in 2020 due to heightened concerns regarding its link to cancer.6
Bupropion-Naltrexone(Contrave)
Bupropion-naltrexone is a combination drug that was approved by the FDA in 2014.8 Naltrexone, an opioid receptor antagonist, is typically used in the treatment of alcohol and opioid addiction. Bupropion is known for its dual role as an antidepressant and an aid to stop smoking. Studies have shown that the combination of these two medications works synergistically to help individuals achieve a 5% weight loss compared to those on a placebo. At the one-year mark, participants experienced an excess weight loss of 11 lbs. compared to placebo. There are certain limitations and contraindications to consider before prescribing bupropion-naltrexone. Bupropion-naltrexone is associated with a relatively higher rate of treatment discontinuation due to adverse events compared to other weight loss medications. Common adverse effects of bupropion-naltrexone include nausea, vomiting, constipation, dry mouth, and dizziness. Bupropion-naltrexone may also raise blood pressure, which may require regular monitoring by healthcare providers, especially at the onset of treatment. It is contraindicated in individuals with uncontrolled hypertension due to its sympathomimetic effects. Furthermore, naltrexone cannot be used in patients taking opioid analgesics, and bupropion use is contraindicated for individuals that take medications that may lower a seizure threshold and monoamine oxidase inhibitors.
Liraglutide (Saxenda)
Liraglutide is a subcutaneous GLP-1 agonist used for managing both type 2 diabetes mellitus and weight in diabetic individuals with obesity.8 It was approved by the FDA in 2014 [TA1] after studies demonstrated participants achieving upwards of 5% weight loss compared to those on placebo.6 In overweight or obese diabetic patients, liraglutide also improved glycemic control. However, despite its efficacy, liraglutide is associated with a relatively high rate of treatment discontinuation. This is mainly due to its associated gastrointestinal side effects, such as nausea and vomiting, and the subcutaneous route of administration.8 Nevertheless, liraglutide presents a valuable option for those who can tolerate it.
Orlistat (Xenical, Alli)
Federal drug administration approved in 1999, orlistat is an oral pancreatic lipase and gastric lipase inhibitor that can limit fat absorption by as much as 30%.8 Research demonstrates that in combination with diet and exercise, orlistat can reduce BMI, body weight, waist circumference, and levels of total cholesterol and LDL cholesterol. In terms of efficacy, orlistat has been effective in lowering baseline weight by 5%. It also has cardiovascular benefits through its positive effects on endothelial function. However, orlistat is commonly associated with gastrointestinal adverse effects, such as steatorrhea, due to impaired fat absorption. This may lead to deficiencies in fat-soluble vitamins and nutrients. Other side effects include passing gas frequently and having loose stools. While rare, severe liver injuries have been reported with orlistat use, although researchers have not established a direct causal relationship between the drug and liver injuries. It is essential for individuals taking orlistat to follow a low-fat diet to minimize these side effects. Orlistat is contraindicated in pregnant and breastfeeding women, and its safety has not been established in children under the age of 12. Close monitoring is required in patients with thyroid disease, blood coagulation disorders, epilepsy, and human immunodeficiency virus (HIV), as orlistat can interact with certain medications.
Phentermine-Topiramate (Qsymia)
Phentermine-topiramate is a combination medication consisting of phentermine, a sympathomimetic, and topiramate, an anticonvulsant.8 Phentermine functions by suppressing appetite by increasing norepinephrine activity in the CNS. Topiramate decreases appetite and enhances satiety by acting as a gamma-aminobutyric acid (GABA) receptor agonist. The FDA approved this combination in 2012 after studies showed a 5% or greater reduction in baseline weight.6,7 Common adverse effects of phentermine-topiramate include blurry vision, headaches, insomnia, and neuropsychiatric symptoms such as irritability, anxiety, and depression.8 Phentermine-topiramate is contraindicated in pregnant women because of teratogenicity, and should be used cautiously in individuals with acute angle-closure glaucoma and those of reproductive age because of potential birth defects. Phentermine-topiramate may cause side effects such as increased heart rate, elevated blood pressure, constipation, and nervousness. Due to its similarity to stimulant drugs like amphetamines, phentermine has the potential for misuse. However, compared to other anti-obesity medications such as orlistat and naltrexone-bupropion, it has been shown to be more effective with fewer side effects.
Semaglutide (Wegovy)
Semaglutide is a long-acting GLP-1 receptor agonist for the management of type 2 diabetes and, in 2021, was approved by the FDA for weight loss.6 In clinical trials, including the Semaglutide Treatment Effect for People with Obesity (STEP) program, it was administered subcutaneously and showed participants achieve up to 16% weight loss compared to 5% with placebo.8 Treatment also led to improvements in waist circumference, systolic blood pressure, and physical functioning scores. However, not all patients tolerate semaglutide well. Gastrointestinal side effects, including nausea, vomiting, diarrhea, and abdominal pain, were reported. Compared to liraglutide, semaglutide has been found to be more effective for weight loss, with participants experiencing a mean weight change of 15% versus 6% with liraglutide. This potential superiority and similar risk profile to other weight management medications make it a favorable option for individuals willing to undergo subcutaneous therapy.
Setmelanotide (Imcivree)
Setmelanotide is a melanocortin-4 receptor (MC4R) agonist that binds to and activates MC4 receptors in the hypothalamus, specifically those involved in appetite regulation.23 This mechanism of action leads to appetite suppression and increased resting energy expenditure in humans with obesity. Unlike earlier generation MC4R agonists, setmelanotide has demonstrated a favorable safety profile, with no concerning elevations in heart rate or blood pressure observed. Consequently, it has garnered FDA approval in 2020 for individuals aged 6 and older who have obesity due to rare inherited conditions such as pro-opiomelanocortin deficiency, proprotein subtilisin-kexin type 1 deficiency, and leptin receptor deficiency. These conditions disrupt MC4R pathway signaling, resulting in severe early-onset obesity, hyperphagia, and increased metabolic co-morbidities. However, to be eligible for setmelanotide treatment, individuals must undergo genetic testing to confirm the presence of one of these rare conditions. While setmelanotide does not address the underlying genetic abnormalities, it helps individuals with these conditions lose weight. Setmelanotide is administered as a daily subcutaneous injection. Common side effects include local skin reactions at the injection site, patches of darker skin, nausea, diarrhea, abdominal pain, and unwanted sexual reactions. More serious adverse effects, such as depression and suicidal thoughts, have also been reported, necessitating close monitoring and prompt medical attention if experienced.
Certain medications, which are FDA-approved for other conditions, are prescribed off-label for weight management because weight loss has been seen as a secondary effect of their primary action based on emerging evidence, clinical experience, or medical judgment.7 They are not approved by the FDA because of limited clinical evidence. Examples of medications commonly used off-label for weight loss include antidepressants, antiepileptics, and diabetic medications. Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs) or bupropion, may lead to weight loss as a side effect in some individuals. While their efficacy for long-term weight management is limited, they have been seen to be more tolerable than their FDA-approved counterparts. Antiepileptic medications, such as mono-therapy topiramate and zonisamide, are prescribed for their appetite-suppressing effects and effectiveness in treating binge eating. While this may help some individuals lose weight, there is not enough evidence to support their effectiveness and safety in the context of sustained obesity treatment. Similarly, certain diabetes medications, including metformin and specific formulations of semaglutide, such as Ozempic, may help patients lose weight, but this is based on clinical observation rather than robust evidence from controlled trials. Although off-label drug use is neither illegal nor unethical, certain authorities may impose limitations on the prescribing practices of healthcare providers.7 For instance, in the state of Ohio, regulations prohibit the prescription of controlled substances for weight loss in a manner that deviates from the FDA-approved labeling. These restrictions aim to ensure patient safety and uphold standards of care by aligning prescribing practices with established regulatory guidelines. The decision to prescribe medications off-label requires careful consideration of patient-specific factors, including medical history, treatment goals, and alternative therapeutic options. Healthcare providers must weigh the potential benefits of off-label use against the risks of adverse effects or inefficacy, ensuring that patient care remains paramount.
Benefits
Weight loss medications have been shown to facilitate significant and sustained reductions in body weight when used as part of a comprehensive weight management program.1 Depending on the dosage, individuals can achieve clinically meaningful weight loss, typically defined as losing 5% – 7% of their initial body weight within three months. For someone who weighs 250 pounds, this translates to a potential loss of 12.5 pounds of fat. This extra weight loss alone can noticeably enhance respiratory function, reduce obstructive sleep apnea, stabilize blood sugar, reduce blood pressure, and improve lipid profiles.
Weight loss medications also provide additional benefits, depending on the mechanism of action.1 For example, GLP-1 receptor agonists, such as liraglutide and semaglutide, have been shown to also reduce insulin resistance, while medications, such as orlistat, can lead to decreases in LDL cholesterol levels.25 Studies have shown that weight loss medications, particularly those that target GLP-1 receptors, may have cardioprotective effects beyond their effects on weight loss alone. These medications may reduce inflammation, improve endothelial function, and decrease arteriosclerosis, thereby lowering the risk of heart attacks and strokes in those with obesity and metabolic syndrome. Weight loss medications can help individuals achieve long-term weight maintenance. By assisting individuals in achieving initial weight loss and providing support for behavior change, these medications can help establish sustainable lifestyle habits that promote weight maintenance over time.
In addition to the improvements in health parameters, weight loss medications can boost physical functioning.1 The loss of the extra weight reduces strain on joints, alleviating discomfort and improving mobility. Psychologically, seeing physical changes can boost self-esteem and body image. As individuals experience better mobility and body image, they may feel more comfortable engaging in physical activities and social interactions, which further improves overall quality of life. Achieving weight loss goals can also instill a sense of accomplishment and empowerment, further boosting self-esteem and motivation to maintain healthy lifestyle habits. Overall, the positive psychological effects of weight loss can contribute to a greater overall sense of well-being, fulfillment, and enjoyment in daily life.
Contraindications
Weight loss medications can be effective tools for managing weight, but they come with potential risks and contraindications that must be carefully considered.3 One significant concern is the long-term impact weight loss medications can have on cardiovascular health. Individuals with a history of heart disease, high blood pressure, or stroke may have increased risks when taking certain formulations. In addition, some medications may affect mood, even exacerbating psychiatric disorders such as depression or anxiety. Interactions with other medications must also be considered, especially in cases where there is a chance of adverse effects or reduced efficacy. For example, combining lipase-inhibiting weight loss medications like orlistat with supplements containing fat-soluble vitamins may interfere with nutrient absorption and lead to deficiencies. Similarly, concurrent use of antidepressants or other psychiatric medications with weight loss drugs like bupropion-naltrexone may aggravate mood disorders or increase the likelihood of adverse psychiatric effects. Gastrointestinal side effects such as nausea, diarrhea, or abdominal discomfort are common with weight loss medications.3 Therefore, individuals with gastrointestinal conditions should use weight loss medications cautiously. Other contraindications include pre-existing liver or kidney conditions as well as allergies or sensitivities to ingredients in formulations. Pregnant and breastfeeding women should avoid taking weight loss medications in general, as the effects of these drugs have not been sufficiently studied in these circumstances. There is a possibility that weight loss medications may cross the placental barrier during pregnancy or pass into breast milk during lactation, thereby raising concerns about exposing the fetus or infant to potential harm. Weight loss medications may also lead to hormonal disruptions or interfere with milk production, further underscoring the importance of caution. Stimulant-based weight loss medications such as phentermine and diethylpropion carry the risk of substance misuse or addiction as they increase the levels of “feel-good” neurotransmitters. This makes them particularly unsuitable for individuals with a history of substance use disorders. Given these risks, healthcare providers must thoroughly assess a candidate’s medical history, individual needs, and circumstances to determine the most suitable treatment option. Ongoing monitoring and follow-up are equally essential to maintain the safe and effective use of weight loss medications.
When considering the safety of weight loss medication use in children, age is a critical factor. Pediatric obesity management guidelines emphasize a cautious approach, typically reserving pharmacological interventions for adolescents who have severe obesity, noteworthy co-morbidities, and have failed to achieve meaningful weight loss through lifestyle modifications alone. The American Academy of Pediatrics (AAP) and other relevant organizations, such as the FDA, provide recommendations tailored to specific age groups.21 For younger children, generally under the age of 12, weight loss medications are rarely, if ever, recommended due to limited safety data and potential risks to growth and development.21 Only in cases of specific genetic abnormalities are medications such as setmelanotide prescribed. Instead, the focus is on comprehensive lifestyle interventions involving dietary changes, increased physical activity, and behavioral therapy under the supervision of pediatricians, dietitians, and psychologists. In adolescents aged 12 and older, FDA-approved pharmacotherapy may be considered in certain cases, but only after careful evaluation of risks and benefits. Medication use should be part of a broader treatment plan that includes ongoing monitoring, education, and support for lifestyle changes. Close monitoring is crucial to manage potential side effects and ensure adherence to treatment. Weight loss medications approved for adults are generally not approved for use in children and adolescents. Any off-label use should be approached with extreme caution, and treatment decisions should be made on a case-by-case basis, considering factors such as age, severity of obesity, presence of co-morbidities, and potential risks. Ongoing research is still underway to better understand the long-term safety and efficacy of weight loss medications in pediatric populations.
Weight loss medications are not standalone treatments. Rather, they are adjunctive therapies to be used within a comprehensive weight management plan that includes dietary counseling and physical activity recommendations.1 Patients should receive individualized dietary counseling from registered dietitians or nutritionists to develop healthy eating habits, create balanced meal plans, and learn portion control. Emphasis should be placed on increasing the consumption of whole foods, fruits, vegetables, lean proteins, and whole grains while limiting processed foods, added sugars, and unhealthy fats. In terms of physical activity, patients should be encouraged to engage in a combination of aerobic exercises, such as walking, jogging, swimming, or cycling, and strength training exercises to build muscle mass and improve metabolism. The recommended duration, frequency, and intensity of exercise may vary based on individual fitness levels and health status.
Behavioral interventions should be included as obesity and weight management are complex issues, which often involve stress, emotional eating, body image concerns, and disordered eating behaviors.17 A candidate’s mental stability plays a significant role in their ability to adhere to the dietary and lifestyle changes necessary for successful weight loss with medication. Addressing psychological factors is equally crucial for long-term weight management and preventing weight regain. Those who struggle with emotional eating or use food as a coping mechanism for stress, anxiety, or depression may find they are still unable to lose sufficient weight and may be at risk of relapse. Healthcare providers must closely monitor patients to regularly assess efficacy, manage side effects, and ensure patient safety throughout the treatment process.
Discontinuation of Weight Loss Medications
Weight loss medications may be discontinued for various reasons but must also be carefully managed to ensure patient safety and optimal health outcomes.1 If a patient successfully achieves their weight loss goals and maintains a healthy weight, discontinuing the medication may be considered. However, it is essential to smoothly transition to alternative strategies to prevent weight regain. If weight loss medication fails to produce the desired weight loss or if the patient experiences minimal benefits despite adherence to treatment, discontinuation may be warranted. In such cases, treatment plans will need to be reassessed, and other alternative medications or interventions may be necessary. The development of intolerable or concerning side effects may necessitate stopping the medication, especially if management strategies are not minimizing patient comfort. For some patients, emerging safety concerns or new contraindications may prompt the termination of a weight loss medication. Healthcare providers should stay updated on the latest evidence regarding the safety profile of medications and make informed decisions based on individual patient characteristics and risk factors.
The administration and management of weight loss medications necessitate a nuanced approach that integrates clinical expertise with patient-centered care principles.22 Nurses play a pivotal role in the continuum of care, from initial assessment to ongoing monitoring and patient education. As frontline healthcare providers, nurses are tasked with navigating complex considerations related to medication administration, patient safety, and therapeutic efficacy. Central to these considerations is the comprehensive assessment of patient health status, including medical history and co-morbidities, to aid in determining eligibility. Nurses should collaborate closely with interdisciplinary teams to ascertain the appropriateness of pharmacological plans, considering individual patient needs, preferences, and treatment goals. This joint approach ensures that treatments are tailored to each patient’s unique circumstances, optimizing outcomes while minimizing risks.
In the clinical setting, nurses should undertake vigilant monitoring of patients receiving weight loss medications, conducting regular assessments of vital signs, weight changes, and adverse reactions.24 Close observation enables early identification of potential complications, facilitating timely interventions and mitigating adverse outcomes. Nurses should also engage in ongoing communication with patients, as patient education is a crucial component of weight management treatment. Nurses should provide detailed information about the mechanism of action, potential side effects, and expected outcomes of weight loss medications, thereby fostering patient understanding and adherence. In the case of off-label use, it is essential that patients fully understand the rationale, potential risks, and alternative treatment options, as these medications are being prescribed for indications not explicitly approved by regulatory agencies. This comprehensive understanding enables patients to actively participate in their treatment decisions, promoting safety in interventions. Nurses also offer guidance on lifestyle modifications, dietary changes, and exercise regimens that complement pharmacological therapy, reinforcing holistic approaches to weight management.
Addressing the psychosocial dimensions of weight management is integral to nursing care, as it encompasses the emotional, social, and psychological aspects of the patient’s journey.11 Nurses should employ empathetic communication and motivational interviewing techniques to explore patient attitudes, beliefs, and barriers related to weight loss. This involves creating a supportive and non-judgmental environment where patients feel comfortable expressing their concerns, challenges, and goals. Some key psychosocial dimensions that nurses should consider include:
- Body image – Patients may have negative perceptions of their bodies, which can impact their self-esteem and motivation to engage in weight management activities.
- Emotional triggers and stressors – Can lead to overeating or unhealthy eating habits.
- Social networks – Includes family, friends, and community. Nurses should assess the level of social support available to patients and encourage the involvement of non-judgmental individuals in their treatment plan.
- Cultural norms, societal attitudes toward weight, and environmental factors – Can influence perceptions of weight and body image. Nurses should be sensitive to these factors and tailor their approach to meet the individual needs of each patient.
By addressing these psychosocial dimensions, nurses can provide holistic care that supports patients not only in achieving weight loss goals but also in improving their overall well-being and quality of life.
Weight management medications represent a crucial component in the multifaceted approach to combat the escalating global crisis of overweight and obesity. They can help individuals achieve clinically meaningful weight loss, improve metabolic parameters, enhance physical functioning, and boost psychological well-being. However, the use of these medications requires careful consideration of potential risks and contraindications, especially concerning cardiovascular health, psychiatric effects, and interactions with other medications. Pediatric use of weight loss medications necessitates particular caution, with a focus on evidence-based guidelines and individualized treatment plans. Nurses play a crucial role in the administration, monitoring, and education surrounding weight loss medications, ensuring safe and effective treatment while addressing the psychosocial dimensions of weight management. For sustained long-term weight management, a comprehensive and interdisciplinary approach that includes pharmacological interventions, lifestyle modifications, and psychosocial support is imperative. Only through collaborative efforts and evidence-based practices can we hope to stem the tide of this growing public health crisis and improve the health and well-being of individuals worldwide.
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