Pharmacologic treatment of obesity in adults: Standards of care in overweight and obesity

Abstract

Obesity medications may be part of a comprehensive care plan for adults with obesity. The Obesity Association, a division of the American Diabetes Association (ADA), developed comprehensive, evidence-based guidelines on the pharmacologic treatment of obesity in adults. When used in conjunction with lifestyle modifications, obesity medications have demonstrated efficacy in inducing and sustaining weight reduction while concurrently improving clinical outcomes of obesity and obesity-related diseases and complications. Healthcare professionals should engage people with obesity in a person-centered, shared decision-making approach when selecting an obesity medication to optimize health outcomes while emphasizing individual needs and preferences. The ADA's Obesity Association encourages healthcare professionals to adopt these guidelines for treatment of obesity in adults.

Keywords: Drug Therapy; Obesity; Pharmacology; Practice Guideline.

Figure 1. Obesity medications among adults without obesity-related diseases or complications. Among adults without obesity-related diseases or complications, obesity medications are indicated in adults with obesity. *The level of evidence ratings are identified in parentheses. Obesity medications are listed in relative order of benefit within each box where medications with greatest magnitude of benefit are listed first, although most obesity medications have not been compared in direct head-to-head trials. Categorization reflects expected average placebo-subtracted weight loss in meta-analyses to represent the weight-reducing effect of the obesity medication beyond that achieved with lifestyle change alone (51,52). Individual responses may vary. Given that obesity medications should be used in combination with lifestyle changes, the total anticipated weight reduction effect would be the combined effect of the obesity medication plus lifestyle (e.g., >13% loss for high weight-reducing effect obesity medication plus lifestyle). In meta-analyses, lifestyle counseling achieved 2.6% weight reduction (2); however, intensive behavioral therapy typically results in greater magnitude of weight reduction relative to lower intensity lifestyle counseling. Therefore, the combination of obesity medication with intensive behavioral therapy may result in greater total anticipated weight reduction effect. Of note, the maximum dose of semaglutide and liraglutide approved to treat obesity differs from the doses of these medications approved to treat type 2 diabetes. †To date, phentermine has only been studied in short-term RCTs (≤6 months duration). ‡Barriers to long-term use may include adverse medication effects, insurance coverage, out-of-pocket costs, etc.

Figure 2. Obesity medications among adults with obesity-related diseases and complications. Among adults with obesity-related diseases or complications, obesity medications are indicated in adults with overweight or obesity. *Obesity medications are identified as “demonstrated benefit” if there is A-level evidence of benefit in the specified outcome for each obesity-related disease or complication. Obesity medications with B- or C-level evidence for these outcomes are identified as having “potential benefit.” Obesity medications are listed in relative order of benefit where medications with greatest benefit are listed first; to date, no head-to-head trials have compared these outcomes in obesity medications. The level of evidence ratings are identified in parentheses. †Barriers to long-term use may include adverse medication effects, insurance coverage, out-of-pocket costs, etc. AHI, apnea hypopnea index; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HTN, hypertension; MACE, major adverse cardiovascular events; MASH, metabolic dysfunction–associated steatohepatitis; OA, osteoarthritis; OSA, obstructive sleep apnea; PreDM, prediabetes; T2D, type 2 diabetes.