From the specialties

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

Norwegian
    Jøran Hjelmesæth, Randi Størdal Lund, Jørn Vegard Sagen, Tone Gretland Valderhaug
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    Jøran Hjelmesæth
    Orcid

    joran.hjelmeseth@siv.no

    Morbid Obesity Centre

    Vestfold Hospital Trust

    University of Oslo

    Norwegian Nutrition Council

    Jøran Hjelmesæth, specialist in internal medicine and nephrology. He is the head of the Morbid Obesity Centre, adjunct professor and head of the Norwegian Nutrition Council.

    The author has completed the ICMJE form and declares the following conflicts of interest: He has received lecture or expert panel fees from Novo Nordisk (manufacturer of liraglutide and semaglutide), Navamedic (manufacturer of bupropion/naltrexone), Boehringer Ingelheim and the Norwegian Diabetes Association.

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    Randi Størdal Lund

    Morbid Obesity Centre

    Vestfold Hospital Trust

    Randi Størdal Lund, senior consultant, conducts clinical research into quality of life and lifestyle treatment for obesity.

    The author has completed the ICMJE form and declares the following conflicts of interest: She has received fees from Novo Nordisk for writing information material.

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    Jørn Vegard Sagen

    Department of Medical Biochemistry and Pharmacology

    Haukeland University Hospital

    Department of Clinical Science

    University of Bergen

    Jørn Vegard Sagen MD PhD, head of department and professor. He is the president of the Norwegian Association for the Study of Obesity and is vice president for Northern Europe on the Executive Committee, European Association for the Study of Obesity.

    The author has completed the ICMJE form and declares the following conflicts of interest: He has received lecture fees from Novo Nordisk, the Norwegian Medical Association, the Norwegian Diabetes Association and NOKLUS, has taken part in a Novo Nordisk advisory board and is a member of the Re-start reference group and the Lifeness Advisory Board.

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    Tone Gretland Valderhaug

    Department of Endocrinology

    Akershus University Hospital

    Tone Gretland Valderhaug PhD, specialist in internal medicine and endocrinology, senior consultant and medical lead for the morbid obesity outpatient clinic. She conducts clinical research into type 2 diabetes and obesity.

    The author has completed the ICMJE form and declares the following conflicts of interest: She has received lecture fees from Novo Nordisk, AstraZeneca, Eli Lilly, Sanofi Aventis, the Norwegian Medical Association and the Norwegian Diabetes Association, and has taken part in advisory boards for Eli Lilly, Novo Nordisk and AstraZeneca.

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    Article

    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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    Published: 4 April 2022
    Tidsskr Nor Legeforen 4 April 2022 Vol. 142.
    doi:
    10.4045/tidsskr.22.0115

    Received 9.2.2022, first revision submitted 2.3.2022, accepted 3.3.2022.
    Copyright: ©️️ Tidsskriftet 2025
    PlumX
    Published: 4 April 2022
    Tidsskr Nor Legeforen 2022 Vol. 142.
    doi: 10.4045/tidsskr.22.0115

    Received 9.2.2022, first revision submitted 2.3.2022, accepted 3.3.2022.
    Copyright:
    ©️️ Tidsskriftet 2025
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