Clinical Considerations Regarding the Use of Obesity Pharmacotherapy in Adolescents with Obesity

Abstract

A growing number of youth suffer from obesity and in particular severe obesity for which intensive lifestyle intervention does not adequately reduce excess adiposity. A treatment gap exists wherein effective treatment options for an adolescent with severe obesity include intensive lifestyle modification or metabolic and bariatric surgery while the application of obesity pharmacotherapy remains largely underutilized. These youth often present with numerous obesity-related comorbid diseases, including hypertension, dyslipidemia, prediabetes/type 2 diabetes, obstructive sleep apnea, nonalcoholic fatty liver disease, musculoskeletal problems, and psychosocial issues such as depression, anxiety, and social stigmatization. Current pediatric obesity treatment algorithms for pediatric primary care providers focus primarily on intensive lifestyle intervention with escalation of treatment intensity through four stages of intervention. Although a recent surge in the number of Food and Drug Administration-approved medications for obesity treatment has emerged in adults, pharmacotherapy options for youth remain limited. Recognizing treatment and knowledge gaps related to pharmacological agents and the urgent need for more effective treatment strategies in this population, discussed here are the efficacy, safety, and clinical application of obesity pharmacotherapy in youth with obesity based on current literature. Legal ramifications, informed consent regulations, and appropriate off-label use of these medications in pediatrics are included, focusing on prescribing practices and prescriber limits.

Figure 1.. Proposed Clinical Approach to Obesity Treatment for Adolescents with Obesity.

Progress through algorithm as clinically required for a patient with risk factors/ready to make change. Start with family-based therapy (can encompass basic education to more intensive therapy based on resources, time constraints, and psychosocial support) followed by microenvironment-targeted therapy with the help of ancillary services such as a dietitian, exercise specialist, nutritionist, and therapist if initial therapy is unsuccessful. Modifiable micro-environmental factors (20), such as nutrient signaling, muscle activity, sleep, stress, circadian rhythm, and iatrogenic causes (weight promoting medications which are frequently prescribed (60)), influence neuro-hormonal pathways affecting food intake and satiety. Prior to more aggressive intervention, these factors should be assessed and altered if perturbing the physiology leading to excess body fat accumulation. This may include physician and ancillary team evaluation providing more intense structure to weight management and medical evaluation with assessment of health targets and cardiovascular risk factors (usually prompting a corresponding AAP Stage 2–3 referral for intervention (24)). If microenvironment-targeted therapy fails, the option to add on adjunctive obesity pharmacotherapy falls under the domain of corresponding AAP Stage 3–4 intervention, either preceded or followed by MBS (corresponding to AAP Stage 4 intervention). Because obesity is a life-long disease, patients often may experience weight regain post-bariatric surgery and continue to need aftercare more closely especially in the adolescent population. As a result, they should continue to resume aftercare and may require lifestyle and/or combination pharmacological intervention later on in life.