Expert interview: New ENDO guidelines.

Abstract

I understand that the Endocrine Society has new clinical guidelines on medicating patients with obesity. What exactly do these guidelines cover? Daniel Bessesen, MD: About a year ago, the American Heart Association, in conjunction with the Obesity Society and the American College of Cardiology, published updated guidelines on obesity care. Unfortunately, that document left out information or guidance on medications, in particular, the use of medications to help patients lose weight, and also the role that medications we prescribe for other health conditions play in producing weight gain in some patients. The Endocrine Society's clinical guidelines really focus on these aspects of medication use in patients who are obese. How were these guidelines developed? Bessesen: The Endocrine Society has a guideline committee that selects areas where there might be a need for a new direction for care providers. They decided that the area of medication use in obesity was an important area, so they convened a task force to draft the new guidelines. Caroline Apovian, MD, was the chair of that task force, and it had members from a variety of backgrounds. They conducted an extensive review of the evidence available on the topic in the literature and used the ‘Grade System,' which is an international system for deciding about the level of evidence available, to come up with their recommendations around the use of medications in patients who are obese. How can these guidelines be accessed?Bessesen: The guidelines were published in The Journal of Clinical Endocrinology and Metabolism in February 2015 and are available on the Endocrine Society website. Can you tell us something about the content?Bessesen: The original guidelines from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) gave some guidance about the use of weight loss medications, but these new guidelines provide critical updates, and the focus is really on 3 areas. First is the medications that doctors use for other health care problems and the guidelines provide guidance about which of those medicines are most likely to cause weight gain. Second, they provide guidance about alternative medications for those problems that might cause less weight gain with a special focus on the use of medications in the treatment of diabetes that are least likely to promote weight gain. And finally, they provide guidance about the use of weight loss medications specifically and in clinical conditions where obesity is a problem. What is new in these guidelines, and what will they tell us?Bessesen: For many years there were not many options when a patient came to the office and told us that they were concerned about their weight and asked if there is a medication that might be helpful. We now have a total of 5 FDA-approved medications, with another one currently under review at the FDA, so it may well be that by the middle of next year we will have 6 medications available to help people who are obese. The guidelines suggest that it is appropriate to have a conversation with patients about a weight-loss medication if their body mass index (BMI) is greater than 30 kg/m2, or if their BMI is greater than 27 kg/m2, and they have a weight-related health problem such as diabetes, lipid problems, or sleep apnea. The guidelines really give specific advice about the use of these medications, in particular, giving a trial of medications and seeing if the patient actually loses weight. If a patient does not lose 5% of his or her weight after several months on the medications, then it would seem inappropriate to continue the medications. But, if at 3 months the patient loses 5% of their baseline weight, the medication should probably be continued indefinitely. The guidelines give some suggestions about which medications might be most appropriate for which patient, in particular if a person has a problem with blood pressure or coronary heart disease, then the medications that could raise blood pressure or pulse should be avoided in favor of those that have less risk of this effect. The guidelines strongly emphasize that diet, exercise, and behavior modification are a foundation for all obesity care, and that pharmacotherapy should be used only in conjunction with a good diet and exercise program. I think the other suggestion, or point of view, that the guidelines offer is, in the past, physicians have tended to treat the complications of obesity, such as diabetes, high blood pressure, hypertension, and left the problem of weight off to the side, providing some diet and exercise guidance, or perhaps not even mentioning it at all. I think the guidelines suggest a shift in paradigm. We know that weight and obesity are integral and central to the development of these metabolic problems, and so the guidelines really suggest that clinicians focus on weight as a central factor in the treatment of these other metabolic problems, and treat the weight first or at least in conjunction with the treatment of these other metabolic disorders. What was your role in developing these new clinical guidelines?Bessesen: I am a clinician and researcher, and I have been involved with the Endocrine Society for a long time. I think our committee gave a variety of perspectives on the care of the patient who is obese, and so my role was to participate in the group to try to provide a sense of what the working clinician sees in the office when faced with a patient who struggles with weight gain. One of the things I think the guidelines address are a reluctance on the part of many clinicians to prescribe or to even discuss weight-loss medications with their patients. Even though we have 5 FDA-approved medications, the reality is, very few patients who are obese ever get a prescription for a weight-loss medicine. There was a recent study in the journal Obesity (1) that looked at Veterans hospitals and how many patients who are obese and would qualify for consideration of a weight loss medication actually ever got a prescription for one. Out of 2 million eligible veterans, only 0.2% ever received a prescription for a weight-loss medicine. In fact, national data collected from the United States shows that the number of prescriptions written for weight loss medications has gradually fallen over the last 15 years (2). This has occurred despite the evidence from research studies that weight loss medications can help people lose weight, and even epidemiologic data that suggest that weight loss medications, short of surgery, are one of the most effective ways for people to lose weight (3). Part of my role on the committee was to be a voice of the working clinician who feels that it is important to provide general clinicians with some guidelines about a reasonable approach to discussing weight-loss medicines with their patients. Weight-loss medicines are really not a panacea, they do not fix the problem of obesity on their own. But on the other hand, how many health problems do we wait for the patient to ask us for a medication, and then tell the patient if they have diabetes, "No, no, you cannot use a medication for your diabetes because you are not sticking to your diet well enough yet?" In the area of weight-loss medicines, there has been a bit of a reluctance for clinicians to prescribe. Some of this comes from a history of adverse effects of weight-loss medicines, so I think the reluctance is understandable. On the other hand, obesity is incredibly common, and many of our patients want information about their options. More than anything, my role on the committee was to try to be a voice for providing clinicians with some information on which they could provide a useful conversation with their patients about weight-loss medicines. Overall, the Endocrine Society has done a great service to practitioners by providing these clinical guidelines. How active is the society in managing obesity?Bessesen: Obesity is a huge public health problem, and I think all clinicians, whether they be surgeons, gastroenterologists, nurse practitioners, or family doctors see the health toll that obesity is putting on their patients. A lot of organizations are trying to address the problem of obesity within their specific areas of expertise. Endocrinologists are uniquely positioned to provide information or guidance in this area. The Endocrine Society has a long history of being a source of reputable scientific information that can be trusted. In addition, endocrinologists take care of some of the most common complications of obesity, including diabetes and hyperlipidemia. The Endocrine Society has made a decision within the last year to take a bigger role in the area of obesity. Over the coming years, this may involve activities both in training to try to develop a good curriculum of what clinicians should know about the care of the patient who is obese, to information for patients with diabetes who have obesity, and even perhaps efforts at the government level to help improve the insurance coverage for the care of people with obesity. Is there anything else about the guidelines that we should know to keep primary care physicians up-to-date?Bessesen: I did not touch on the other big area, which is the use of medications in patients who have other health problems. Clinicians will find some useful information in these guidelines about the care of patients with high blood pressure, arthritis, women who need birth control medications, patients who have depression or other psychiatric diseases, and which medications might be the most weight-friendly in these other health care conditions. A lot of primary care physicians see patients who get put on a psychiatric medication and then gain a lot of weight, and may have health complications from that weight gain. This new guideline provides authoritative evidence on the selection of medications that are the least likely to produce unwanted weight gain in those conditions. In summary, there are a lot of guideline documents out there, and sometimes clinicians might think that some of them do not give them clear guidance or may even provide conflicting guidance. I think clinicians should find these new guidelines from the Endocrine Society useful in that they address situations that are seen every day in their practice. The purpose of the ENDO guidelines is not to insist on prescribing weight-loss medicines, but rather to provide information on which general clinicians can base their conversations with their patients around medications and their effects on weight.