Weight Loss Medications
Weight loss medication education to review. If interested, call your insurance company to determine coverage and out-of-pocket expense. This information will be used by our team to guide treatment.
- Introduction
- Indications
- Insurance Coverage and Cost
- Pregnancy
- Medications Causing Weight Gain
- Scientific Resources
- Medication Options
Introduction
Treating the chronic disease of obesity with medications should be thought of similarly to how we treat other chronic diseases like high blood pressure. Medicines for high blood pressure are used for life to control blood pressure. Similarly, obesity medications, when effective without side effects, should be used for life to maintain weight.
Studies show that weight management medications work best with a behavioral lifestyle program. Modern weight loss medications have made great strides in safety profile and weight loss.
Indications
The FDA has approved the use of weight loss medications for any patient under the following conditions: obesity (defined as body mass index 30 kg/m2 ) or preobesity (or overweight) (defined by body mass index 27 kg/m2 ) with at least 1 obesity-related co-morbidity.
Weight loss medications are considered effective when patients are able to lose. greater than 3%-5% of total body weight after 12 weeks. If minimum weight loss has not been achieved after 12 weeks should consider modification of dose, discontinue the medication, or try an alternative medication.
Insurance Coverage and Cost
Insurance coverage and cost are some of the biggest challenges to patients taking these medications. Each patient’s insurance coverage differs based on the insurance company and a specific plan. Our team needs you to call your insurance company and ask about each medication to determine coverage and out-of-pocket expenses so we can help decide whether or not they are economically an option to prescribe. Once we know the options based on economic factors, we can determine which is a safe option for you based on your other medical conditions.
- Phentermine is a generic medication, meaning it is typically affordable regardless of your insurance.
- Contrave is a combination medication, which is comprised of two generic drugs. If Contrave is not covered, it is sometimes significantly less expensive to prescribe the two components separately.
- Qsymia is also a combination of two generic medications and can be prescribed as two separate components if the brand name is not covered by insurance.
- Saxenda, Wegovy, and Mounjaro are not offered as their generic equivalents yet. They can be very expensive without insurance coverage.
- There are often coupons available on the manufactures websites which can dramatically reduce cost.
Pregnancy
All weight loss medications should not be taken by a patient who is pregnant, breastfeeding, or trying to conceive. All female patients of childbearing age should strongly consider taking a home pregnancy test before starting these medications. Patients should use two forms of birth control while taking these medications. If there are any concerns about pregnancy, a pregnancy test should be taken, and if positive, alert your prescriber immediately. Patients interested in pregnancy should discuss with their OBGYN and prescribing physician well in advance of attempting to conceive. Some of these medications must be stopped 2-3 months in advance.
Use of MOUNJARO may reduce the efficacy of hormonal birth control due to delayed gastric emptying. This delay is largest after the first dose and diminishes over time. Patients need to add a barrier method such as condom use for 4 weeks after initiation and for 4 weeks after each dose escalation with MOUNJARO.
Medications That Cause Weight Gain
As a patient interested in medications for weight loss, you should first look at your existing drugs to see if they cause weight gain. Every new medication physicians put you on should be questioned for its potential to cause weight gain. If currently taking or prescribed a new medication that promotes weight gain, you should ask about the feasibility of a suitable alternative that doesn’t encourage weight gain.
Scientific Resources
Medication Options:
Phentermine
Phentermine is a stimulant and appetite-suppressant. It can only be used for a short period, typically three months. If used long-term, your body gets used to the drug and does not provide the same effect. After three months, you should take at least one month off. After that, we can re-start, depending on how well it was working. It can increase BP and heart rate, so it should not be used by anyone with uncontrolled hypertension or elevated heart rate, hyperthyroidism, any history of heart problems, or anyone with a family history of heart attack or stroke before the age of 55. We also avoid use in patients over 60. It’s essential to track your BP and heart rate after starting this medication to ensure they are not rising to unsafe levels. Approved for adults and adolescents older than 16 years old.
| Generic Name | Phentermine (FDA approved in 1959) |
| Trade Name (Manufacturer) | Adipex-P, Suprenza (multiple) |
| How it works | appetite suppression suspected to be due to increased norepinephrine |
| Available Doses | 15, 30, 37.5 mg |
| Frequency | Once a day (before breakfast or 1-2 hours after) |
| Cost for 30 day (GoodRx.com) | $15 |
| Weight Loss (above placebo) | 17 lbs |
| Cautions | See Contraindications |
| Contraindications (Do NOT Take if…) | -Pregnancy -Heart disease/stroke -Uncontrolled high blood pressure -Pulmonary hypertension -Overactive thyroid -Glaucoma -Drug or alcohol abuse |
| Drug Interactions | –MAO inhibitors (phenelzine, tranylcypromine, selegeline, isocarboxazid) in past 14 days |
| Possible Side Effects | Increased heart rate and blood pressure, nervousness, insomnia, tremors, dry mouth, constipation |
| Notes | -Schedule IV controlled substance -Approved for only up to 12 weeks -Do not stop abruptly—decrease dose gradually before stopping |
Topiramate
Topiramate is a medication historically used for seizures and headaches. Was approved by the FDA to manage obesity in 2012 for long term use. It required you to slowly increase the dose when starting and stopping. Do not stop suddenly because can increase risk of a seizure even if you don’t have a history of seizures. It can lower effectiveness of birth control thus two forms of birth control should be used. Should not be used during pregnancy because can cause birth defects.
| Generic Name | Topiramate |
| Trade Name (Manufacturer) | Topamax |
| How it works | unknown effects neurotransmitter and cell signaling modulation |
| Available Doses | 15, 25 mg (start at low dose and can titrate up to 200 mg) |
| Frequency | Once a day |
| Cost for 30 day (GoodRx.com) | $38 |
| Weight Loss (above placebo) | 11 lbs |
| Cautions | -Kidney Stones -Metabolic Acidosis -Low Potassium |
| Contraindications (Do NOT Take if…) | -Pregnancy -Glaucoma -Overactive thyroid |
| Drug Interactions | -Lowers blood potassium with thiazide; -Increased blood ammonia with valproate -Topiramate level decreased by phenytoin or carbamazepine -Increases alcohol, other sedatives’ effect |
| Possible Side Effects | Increased heart rate, tingling, dizziness, altered taste, insomnia, constipation, dry mouth, memory problems or difficulty concentrating. Worsening of mood disorders including anxiety, depression, and suicidal ideation is possible. Patients should be warned of vision changes, such as blurred vision or sudden loss of sight. |
| Notes | -When stopping should taper dose over 3-5 days -Periodically monitor electrolytes and creatinine levels. -Glucose should be monitored in patients on diabetic medications because can get low blood sugar -Can reduce effectiveness of birth control -Can cause birth defects so recommend monthly home pregnancy test |
Qsymia
Qsymia is a combination of low-dose phentermine and topiramate. Phentermine is described above, and topiramate increases its effectiveness. Approved by FDA in 2012 for long term use for obesity
| Generic Name | Phentermine/Topiramate |
| Trade Name (Manufacturer) | Qsymia (Vivus, 2012) |
| How it works | see phentermine; see topiramate |
| Available Doses | 7.5/45 mg, 15/92 mg (3.75/23 mg, 11.25/69 mg pills for titration) |
| Frequency | Once a day |
| Cost for 30 day (GoodRx.com) | $210 at max dose |
| Weight Loss (above placebo) | 15 lbs (7.5/45 mg) 19-23.5 lbs (15/92 mg) |
| Cautions | -May cause birth defects (orofacial clefts); see Risk Evaluation and Mitigation Strategy (REMS) at http://www.qsymiarems.com/ -Pregnancy test prior and monthly |
| Contraindications (Do NOT Take if…) | -Pregnancy -Overactive thyroid -Glaucoma –MAO inhibitors past 14 days |
| Drug Interactions | -Lowers blood potassium with thiazide; -Increased blood ammonia with valproate -Topiramate level decreased by phenytoin or carbamazepine -Increases alcohol, other sedatives’ effect |
| Possible Side Effects | Nervousness, insomnia, dry mouth, constipation, numbness/tingling, abnormal taste, decreased attention/concentration/ memory, dizziness |
| Notes | -Schedule IV controlled substance -Take 3.75/23 mg x 14d, then 7.5/46 mg; if <3% weight loss at 12 wks, then increase to 11.25/69 mg for 14d, then 15/92 mg -7.5/46 mg max if mod. kidney/liver disease -Decrease gradually before stopping, if less than 5% weight loss at 12 weeks -Seizures can occur if stopped abruptly! -Approved for long term use -Periodically monitor electrolytes and creatinine levels. -Glucose should be monitored in patients on diabetic medications because can get low blood sugar |
Contrave
Contrave is a combination of bupropion (antidepressant) and naltrexone (an opioid receptor antagonist). Bupropion helps control appetite, and naltrexone increases this effect. No one with a history of seizures should use bupropion, and naltrexone should not be used by anyone on opioid pain medications or MAOIs. In addition, you cannot drink alcohol while taking Contrave or naltrexone. Bupropion and naltrexone are generic medications and can be prescribed separately if your insurance does not cover Contrave. The appetite-suppression effect of bupropion-naltrexone tends to decrease after 1 year of therapy.
| Generic Name | Naltrexone/Bupropion (FDA approved in 2014) |
| Trade Name (Manufacturer) | Contrave (Orexigen; Takeda, 2014) |
| How it works | Increases POMC neuron activity to regulate food intake Works in hypothalamus (appetite center) and mesolimbic dopamine circuit (reward system) |
| Available Doses | 8 mg/90 mg |
| Frequency | Two pills two times a day (see notes for titration) |
| Cost for 30 day (GoodRx.com) | $300 |
| Weight Loss (above placebo) | 5-9 lbs |
| Cautions | Bupropion may cause increased suicidal thoughts in children or young adults with depression Naltrexone may cause opioid (narcotic) overdose OR withdrawal symptoms in people taking these medications |
| Contraindications (Do NOT Take if…) | -Pregnancy -History of seizures -Uncontrolled blood pressure -History of anorexia or bulimia -Taking opioid (narcotic) pain medications -Excessive alcohol intake or sudden stopping of alcohol/benzo/barbiturate |
| Drug Interactions | MAO inhibitors past 14 days (antidepressant medication) -Opioid (narcotic) pain medications -CYP2B6 inhibitors (clopidogrel) -Can cause false positive amphetamine drug test |
| Possible Side Effects | -Nausea, constipation, headache, vomiting, dizziness, trouble sleeping, dry mouth, diarrhea -Liver damage -Mania/manic episodes -Glaucoma |
| Notes | -Titrate dose each week: 1 pill AM; 1 pill twice a day, 2 pills AM/1 pill PM; 2 pills twice a day (max dose) -Monitor for changes in mood and suicidal thoughts |
Orlistat
Orlistat (prescription and nonprescription) is used with an individualized low-calorie, low-fat diet and exercise program. When taken with a meal, it blocks fat absorption by 30%, thus decreasing overall total caloric intake. Patients need take with a multivitamin containing extra fat soluble vitamins including vitamin A, vitamin D, vitamin E, and vitamin K. Can be used to simulate gastrointestinal effects of duodenal switch for patients considering this procedure. Approved for adults and adolescents older than 12 years old.
| Generic Name | Orlistat |
| Trade Name (Manufacturer) | Xenical (Genentech, 1999) Alli (GlaxoSmithKline; Over the Counter) |
| How it works | Blocks absorption of 1/3 of fat in a meal |
| Available Doses | 120 mg 60 mg (Alli) |
| Frequency | Three times a day (with meals) |
| Cost for 30 day (GoodRx.com) | $700 $50 (Alli) |
| Weight Loss (above placebo) | 5.5-7 lbs |
| Cautions | May increase risk for oxalate kidney stones or liver failure |
| Contraindications (Do NOT Take if…) | -Gallstones -Chronic malabsorption |
| Drug Interactions | May increase effect of warfarin (Coumadin) -Decreases cyclosporine blood level -May decrease thyroid supplement levels |
| Possible Side Effects | -Flatulence, oily stools, BM urgency -Symptoms are worse if meals are high fat -Vitamin deficiencies |
| Notes | -Take within 1 hour of meal containing fat -Omit dose if meal is skipped or contains no fat -Take daily multivitamin (with A,D, E and K) at least 2 hours prior |
Saxenda
Saxenda (liraglutide) is a daily injectable medication or shot. Using a small needle (most patients do not report pain), you would give yourself daily pen injections. It is a GLP-1 agonist. It started as a diabetes medication because it helps control blood glucose, as well as appetite. So, it’s a good option for patients who struggle with insulin resistance, as well as weight. It is the same medication as Victoza which is what its called when strictly used fro diabetes. Unfortunately, it is sometimes hard to get insurance coverage for Saxenda. Still, there are other GLP-1 agonists available that also produce some but not as much weight loss that has better coverage (like Ozempic and Victoza). GLP-1 agonists are contraindicated in patients with a history of pancreatitis or a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2. The most common side effect is nausea. The dose is slowly increased to reduce nausea. Nausea typically dissipates after a few days on the medication at each new dose. Can cause low blood sugar if taken while on insulin or class of drugs called sulfonylureas. Approved for adults and adolescents older than 16 years old.
| Generic Name | Liraglutide (FDA approved for obesity 2014) |
| Trade Name (Manufacturer) | Saxenda (Novo Nordisk) (Victoza for diabetes) |
| How it works | glucagon like peptide-1 (GLP-1) receptor agonist |
| Available Doses | 3.0 mg (1.2 or 1.8 mg for diabetes) |
| Frequency | Once a day, subcutaneous injection |
| Cost for 30 day (GoodRx.com) | $1400 |
| Weight Loss (above placebo) | 12-13 lbs |
| Cautions | May cause gallbladder attack or pancreatitis May increase risk of thyroid cancer |
| Contraindications (Do NOT Take if…) | History of (or family history of) medullary thyroid carcinoma or multiple endocrine neoplasia (MEN) type 2 |
| Drug Interactions | Increased risk for low blood sugar if taking diabetes medication |
| Possible Side Effects | -Nausea, vomiting, diarrhea, constipation, low blood sugar if taking diabetes medication |
| Notes | -Discontinue if less than 4% weight loss at 16 weeks |
Wegovy
Wegovy (Semaglutide) – this is a GLP-1 agonist similar to Saxenda. Rather than a daily injection, it is a weekly injection. It is one of newest weight loss medication on the market. It is also the medication reported in research studies to have a high amount of weight loss. About 50% of patients taking the Wegovy lost up to 15% of their weight. GLP-1 agonists are contraindicated in patients with a history of pancreatitis or a personal, family history of medullary thyroid cancer, or multiple endocrine neoplasia type 2. The most common side effect is nausea. Nausea typically dissipates after a few days on the medication. At a low incidence can cause low blood sugar, acute kidney injury, gallbladder disease, appendicitis, retinopathy, and worsening depression. Dosing starts low and titrates up to minimize the side effects (nausea).
| Generic Name | Semaglutide (FDA approved for obesity June 2021) |
| Trade Name (Manufacturer) | Wegovy (Novo Nordisk) (Ozempic for diabetes) |
| How it works | glucagon like peptide-1 (GLP-1) receptor agonist |
| Available Doses | 2.4 mg (1.0 mg for diabetes) |
| Frequency | Once weekly, subcutaneous injection |
| Cost for 30 day (GoodRx.com) | $1400 |
| Weight Loss (above placebo) | 32 lbs |
| Cautions | May cause gallbladder attack or pancreatitis May increase risk of thyroid cancer May increase risk of diabetic retinopathy |
| Contraindications (Do NOT Take if…) | History of (or family history of) medullary thyroid carcinoma or multiple endocrine neoplasia (MEN) type 2 |
| Drug Interactions | Increased risk for low blood sugar if taking diabetes medication |
| Possible Side Effects | -Nausea, vomiting, diarrhea, constipation, low blood sugar if taking diabetes medication |
| Notes | -Discontinue if less than 4% weight loss at 16 weeks |
Zepbound
Zepbound is the same molecule as Mounjaro, a diabetes medication that results in weight loss. Zepbound was recently approved for obesity treatment and demonstrated excellent weight loss, about 20% of total body weight. It’s a combination of a GLP-1 agonist and GIP agonist.
| Generic Name | TIRZEPATIDE |
| Trade Name (Manufacturer) | Zepbound (Lilly) |
| How it works | glucagon like peptide-1 (GLP-1) receptor and GIP receptor agonist |
| Available Doses | 15 mg (titrate to max dose) |
| Frequency | Once weekly, subcutaneous injection |
| Cost for 30 day (GoodRx.com) | ??? |
| Weight Loss (above placebo) | 52 lbs |
| Cautions | May cause gallbladder attack or pancreatitis |
| Contraindications (Do NOT Take if…) | History of (or family history of) medullary thyroid carcinoma or multiple endocrine neoplasia (MEN) type 2 |
| Drug Interactions | Increased risk for low blood sugar if taking diabetes medication |
| Possible Side Effects | -Nausea, vomiting, diarrhea, constipation, low blood sugar if taking diabetes medication |
| Notes | – Only FDA Approved for type 2 Diabetes not obesity treatment at this time. – Use of Zepbound may reduce the efficacy of hormonal birth control due to delayed gastric emptying. This delay is largest after the first dose and diminishes over time. Patients need to add a barrier method such as condom use for 4 weeks after initiation and for 4 weeks after each dose escalation with Zepbound. |