Weight-loss drugs – for whom, how, how long?

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    Drug treatment of obesity is undergoing a scientific revolution, and it can be hard to keep up. Two relatively new drugs that suppress hunger and increase feelings of satiety can now be prescribed by all Norwegian doctors.

    Colleagues ask us daily for guidance on the use of new anti-obesity drugs, and so we would like to share a few practical tips in the Journal of the Norwegian Medical Association.

    Who may benefit?

    Who may benefit?

    The drugs can be prescribed as an adjunct to lifestyle treatment in adult patients with obesity (BMI ≥ 30 kg/m2) or overweight (BMI 27.0–29.9 kg/m2) with at least one weight-related complication or risk factor. Bupropion/naltrexone (Mysimba) and liraglutide 3.0 mg (Saxenda) result in a 4 % and 5 % greater mean 1-year weight reduction, respectively, compared with lifestyle treatment alone (1). Liraglutide 3.0 mg can also be prescribed to adolescents ≥ 12 years with obesity and body weight > 60 kg.

    Bupropion/naltrexone sustained-release tablets

    Bupropion/naltrexone sustained-release tablets

    Bupropion is a weak inhibitor of dopamine and noradrenaline reuptake, and is also used in the treatment of depression. People being treated with bupropion or monoamine oxidase inhibitors should not use bupropion/naltrexone sustained-release tablets. Other contraindications are uncontrolled hypertension, history of seizures, bipolar disorder, as well as bulimia or anorexia.

    Naltrexone is a µ-opioid antagonist, and patients who are dependent on opioids or opioid agonists (e.g. methadone) or in withdrawal from opioids are unsuitable for treatment with naltrexone. A lack of cardiovascular safety data means that bupropion/naltrexone sustained-release tablets should be used with caution in patients with cardiovascular disease.

    Liraglutide

    Liraglutide

    Liraglutide 3.0 mg is a glucagon-like peptide-1 analogue (GLP-1 analogue) and is administered as daily subcutaneous injections. A drug with the same active substance but lower dosage (Victoza) is used for type 2 diabetes.

    Who can prescribe and how?

    Who can prescribe and how?

    All Norwegian doctors can prescribe both these drugs. The starting dose is low for both drug groups, with weekly incremental increases up to a maintenance dose. Treatment with the product should be discontinued if weight reduction is less than 5 % after 4 months of treatment. Submaximal drug doses can produce a good therapeutic effect, particularly if adverse reactions prevent dose increase.

    How long?

    How long?

    Obesity is a chronic disease that requires lifelong follow-up and treatment. Therefore, lifelong treatment with weight-loss drugs may be necessary.

    Product choice and reimbursement rules?

    Product choice and reimbursement rules?

    The drug is chosen in agreement with the patient based on indications, contraindications and price (2). The drugs are expensive, and many patients cannot afford to buy them themselves. However, all doctors can apply to the Norwegian Health Economics Administration (Helfo) for individual reimbursement under the Norwegian reimbursable prescription scheme for people with a BMI ≥ 40 kg/m2 or ≥ 35 kg/m2 and at least one weight-related complication (3). For cost reasons, bupropion/naltrexone sustained-release tablets must be tried initially unless there are medical contraindications. BMI at the start of treatment is the basis for the application, and the entitlement to reimbursement is not lost if BMI falls to < 35–40 kg/m2 during ongoing treatment. In the event of intolerable adverse reactions or lack of efficacy, reimbursement can be sought for liraglutide. Remember to prescribe needles for the use of liraglutide (medical consumables § 5, point 14).

    New, effective drugs are coming

    New, effective drugs are coming

    Several anti-obesity drugs are being investigated in phase 3 trials, and provisional results give cause for optimism. Another GLP-1 analogue (weekly semaglutide 2.4 mg (Wegovy)) has marketing authorisation in Norway. Randomised controlled clinical trials have shown that this drug has more than double the weight-loss effect (> 12 % vs. 4–5 %) of the two other drugs described in this article (4, 5). A drug with the same active substance but lower dosage (Ozempic) is used in type 2 diabetes.

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