Are Weight Loss Medications and WLS a Good Combo?
August 19, 2020Weight Loss Medications and WLS
The growing epidemic of obesity in the United States has grown to over 40% of our adult population. For patients with moderate to severe obesity (body mass index greater than 35), bariatric or weight loss surgery remains the most effective means to lose weight. Despite the considerable weight loss after bariatric surgery, up to one-third of patients may experience inadequate weight loss or weight regain. Are weight loss medications and WLS compatible and effective for inadequate weight loss or weight regain?
In the bariatric population, weight loss medications have been universally underused. But is it safe to combine these two weight loss modalities? The answer is “yes!”
When many first think about weight loss medications, their mind immediately goes to Fen-Phen, a combination of fenfluramine and phentermine that was used for weight loss in the 1990’s. This drug combo was linked to heart and lung disease, eventually leading to its very public withdrawal from the market in 1997. Today’s weight loss medications have been proven to be a much safer alternative.
Rule Out Problems Before Using Weight Loss Medications
Patients and their healthcare providers must first rule out a problem with the weight loss surgery, itself, before considering weight loss medications. Is the pouch connection too wide? Is the sleeve dilated? Has the band slipped? A conversation with the doctor and possibly imaging studies and/or endoscopy will be needed to rule out these problems.
If the bariatric surgeon does not prescribe weight loss medications, patients will want to visit their surgeon first before consulting with the healthcare provider prescribing the medications. In our office, we have a Bariatric Nurse Practitioner who visits with our patients who are further out from their surgery and will be able to also prescribe the weight loss medications, if appropriate.
Bariatric patients who are considering revisional surgery (changing from a sleeve to a bypass, for example) should discuss the option of weight loss medication. Revisional surgeries are high risk, especially when compared to the risks associated with weight loss medications.
Who’s a Good Candidate for Weight Loss Medications?
Who’s a good candidate for weight loss medications? Bariatric patients with a BMI (body mass index) greater than 30 or between 27 and 30 with a medical problem like diabetes, obstructive sleep apnea, or hypertension(1). Remember that weight loss surgery is a tool. Lifestyle modifications play a much bigger role in long-term success. Before considering weight loss medications, patients must optimize their diet and physical activity. Sleep and stress also play important roles in weight loss.
Many patients will use weight loss medications to “jump-start” their weight loss efforts.
But the truth about weight loss medications? If the medication is discontinued and no significant underlying changes have been made to a patient’s diet and exercise, the weight inevitably comes back!
These medications are typically continued indefinitely and not just until the desired weight is achieved. Patient and their doctors need to consider this when discussing if and when to start these medications.
There are a lot of medications on the market for weight loss. Many of them already serve another role, treating diseases like depression and diabetes, but have been found to also stimulate weight loss. The list below highlights some of the more popular medications but is not inclusive and further discussion regarding the risks and benefits should be had with a provider.
Brief Overview of Common Weight Loss Medications
Topiramate |
Topiramate has been used in combination with phentermine in patients struggling with obesity but have not undergone bariatric surgery. More recent studies have shown significant weight loss following bariatric surgery with the use of topiramate alone. Topiramate is often the first line medication and can be slowly titrated up to increase its effectiveness. This medication is FDA approved for epilepsy and migraine prophylaxis. This drug is believed to enhance networks in the brain that have a calming effect and inhibit networks that are overstimulating which seem to reduce food craving. It is a Category X for pregnancy because of a potential teratogenic effect for cleft lip and palate when used during 1st trimester of pregnancy. Common side effects are drowsiness, dizziness, diarrhea, nervousness. |
Phentermine |
This medication will increase the release of a hormone called norepinephrine in the brain, resulting in reduced appetite and food consumption. In addition, it acts to active the sympathetic nervous system which increases resting energy expenditure, meaning you can burn more calories at rest. Common side effects are dry mouth, trouble sleeping, pounding heartbeat, feeling shaky. |
Phentermine and Topiramate combination (Qsymia) |
Phentermine is often used in combination with topiramate, called Qsymia. These agents are used in combination to address the two main mechanisms that impact eating behavior. Together these medications can decrease appetite and increase the feeling of fullness, or satiety. |
Bupropion and Naltrexone combination (Contrave) |
These agents are used in combination to work on two important area of the brain that control hunger and reward. The effect of the combination is to help reduce hunger and cravings. Some common side effects are nausea, vomiting, headache, and constipation. |
Bupropion (Wellbutrin, Zyban) |
| Bupropion is used to treat attention deficit disorder, depression and even help with smoking cessation. This medication has shown a low side effect profile while still achieving over 10% excess body weight loss is obese patients |
Metformin |
While usually a first line treatment for diabetes, Metformin has also shown promise as a weight loss medication. This medication works by decreasing production of glucose (sugar) by liver and possibly increasing the body’s sensitivity to the hormone, insulin, which has been associated with weight loss. Common side effects are diarrhea, nausea, and stomach upset. |
Liraglutide (Saxenda, Victoza) |
This injectable medication is used to treat diabetes, but gained FDA approval several years ago. In lower doses, it is called Victoza, and is used specifically for diabetes. Saxenda is a higher dosage that has been shown to promote weight loss. It works by mimicking the hormone called Glucagon-like peptide (or GLP-1). This hormone tells the body that you are full. It also slows emptying of the stomach and reduces hunger. While common side effects exist, like nausea, vomiting, headache, constipation and diarrhea, this medication has a black box warning for anyone with a family history of thyroid cancer. |
Lorcaserin (Belviq) |
Recently pulled from the market over its increased risk of pancreatic, colorectal and lung cancer. Weight loss medications and bariatric surgery can be a successful combination to help patients achieve their weight loss goals. Ultimately, lifestyle modifications are at the heart of anyone’s weight loss. Diet-alone accounts for 80% of one’s weight gain and must be optimized if a patient is ever to reach their goal weight. |
References
- Stanford FC. Controversial issues: A practical guide to the use of weight loss medications after bariatric surgery for weight regain or inadequate weight loss. Surg Obes Relat Dis [Internet]. 2019 Jan 1 [cited 2020 Feb 16];15(1):128–32. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1550728918303435
- Stanford FC, Alfaris N, Gomez G, Ricks ET, Shukla AP, Corey KE, et al. The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: A multi-center study. Surg Obes Relat Dis. 2017 Mar 1;13(3):491–500.
- New Weight Loss Drug Saxenda: FAQ [Internet]. [cited 2020 Feb 16]. Available from: https://www.webmd.com/diet/obesity/news/20141224/weight-loss-drug-saxenda#2
- FDA calls for withdrawal of weight loss drug Belviq after trials find cancer link - CNN [Internet]. [cited 2020 Feb 16]. Available from: https://www.cnn.com/2020/02/13/health/belviq-weight-loss-drug-cancer-fda/index.html
- Nor Hanipah Z, Nasr EC, Bucak E, Schauer PR, Aminian A, Brethauer SA, et al. Efficacy of adjuvant weight loss medication after bariatric surgery. Surg Obes Relat Dis. 2018 Jan 1;14(1):93–8.
- Yerevanian A, Soukas AA. Metformin: Mechanisms in Human Obesity and Weight Loss. Curr Obes Rep. 2019 Jun;8(2):156–64.
- Gadde KM, Parker CB, Maner LG, Wagner HR, Logue EJ, Drezner MK, et al. Bupropion for weight loss: An investigation of efficacy and tolerability in overweight and obese women. Obes Res [Internet]. 2001 Sep;9(9):544–51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11557835
 | ABOUT THE AUTHOR Caitlin Halbert, D.O., MS, FASMBS is a board-certified general surgeon with a focus in Bariatric & Foregut surgery. She practices at Bariatric Surgery Services of ChristianaCare & is the Assistant Program Director for the General Surgery Residency Program. Dr. Halbert specializes in bariatric surgery, including laparoscopic sleeve gastrectomy & roux-en-y gastric bypass. Her practice includes treatment of achalasia, gastrointestinal reflux disease, & hiatal and diaphragmatic hernias. |
