Should you start prescribing lorcaserin or orlistat to your overweight or obese patients?
This question needs to be asked. As a specialty, we must do more to help our patients achieve and maintain a healthy weight.
Orlistat
Orlistat is a reversible inhibitor of gastric and pancreatic lipases, thereby inhibiting fat absorption. This leads to weight loss but also causes an increase in fecal fat excretion, which may cause side effects such as borborygmi, abdominal cramps, flatus, oily spotting per rectum, loose stool, and fecal incontinence. Orlistat is taken 3 times daily with meals. Only 1% of the orlistat dose is absorbed into the circulation, minimizing the drug’s effect on other organs and reducing the probability of a medication interaction.
Orlistat may reduce the absorption of vitamins A, D, E, and K. Patients taking the drug should take a daily vitamin pill at bedtime to maximize absorption of the vitamins. According to a 2004 study in which orlistat was combined with behavioral intervention over 12 months, the average weight loss was approximately 10% of patients’ baseline weight.7 (The control group in this study received a placebo tablet plus behavioral intervention and experienced a 5% weight loss.) When orlistat treatment continues as long as 36 months, the reduced weight is typically maintained. Orlistat treatment also has been shown to reduce blood pressure in hypertensive patients and improve their lipid profiles.8,9
You should be aware that some health plans place weight-loss medications on a restricted formulary list that requires preapproval. From my experience, if you prescribe a weight-loss drug you may occasionally be asked to complete a case synopsis on a structured form that is sent to the health insurer or pharmacy management team for review and
preapproval.
Bariatric surgery
Consider bariatric surgery for women with:
- BMI of 40 kg/m2 or more
- BMI of 35 kg/m2 or more with comorbidities and no success with diet, exercise, and weight-loss medications.
Many bariatric surgery programs require that candidates undergo a 6-month interval of diet, exercise, lifestyle change, and psychological assessment prior to scheduling surgery. Bariatric surgery is the medical intervention most likely to result in major weight loss.10
Related article: Consider bariatric surgery first for severely obese women Robert L. Barbieri, MD (April 2008)
Call for input
As obstetricians and gynecologists, our duty is to continually strive to improve the health of all women. Overweight and obesity are highly prevalent major health problems—for society as a whole as well as for many of the individual patients we treat in our practices. Can we, and should we, provide more options to our patients who are trying to lose weight by offering to prescribe lorcaserin or orlistat?
This is a question for all of us. I would like to know your viewpoint on this issue.
Weigh in on the discussion!
Email your letter to Dr. Barbieri at rbarbieri@frontlinemedcom.com
or contact us by:
email: obg@frontlinemedcom.com
fax: 973-206-9251
letter: OBG Management
7 Century Drive, Suite 302
Parsippany, NJ 07054
INSTANT POLL
• Do you think primary care providers routinely present the treatment options of diet/exercise, weight-loss medicines, and bariatric surgery to obese patients?
• Should ObGyns offer to prescribe lorcaserin or orlistat to their obese patients?
Tell us—at rbarbieri@frontlinemedcom.com. Please include your name and city and state.
