Potential Risks and Concerns When Considering Medication

When considering long-term weight-loss medication treatment for obesity, you should consider the following areas of concern and potential risks.

  • Potential for Abuse or Dependence
    Currently, all prescription medications to treat obesity except orlistat are controlled substances, meaning doctors need to follow certain restrictions when prescribing many weight-loss medications. Although abuse and dependence are not common with non-amphetamine appetite-suppressant medications, doctors should be cautious when they prescribe these medications for patients with a history of alcohol or other drug abuse.
  • Development of Tolerance
    Most studies of weight-loss medications show that a patient's weight tends to level off after 4 to 6 months while still on medication. While some patients and physicians may be concerned that this shows tolerance to the medications, the leveling off may mean that the medication has reached its limit of effectiveness. Based on the currently available studies, it is not clear if weight gain with continuing treatment is due to drug tolerance.
  • Reluctance to View Obesity as a Chronic Disease
    Obesity often is viewed as the result of a lack of willpower, weakness, or a lifestyle "choice"--the choice to overeat and underexercise. The belief that persons choose to be obese adds to the hesitation of health professionals and patients to accept the use of long-term appetite-suppressant medication treatment to manage obesity. Obesity, however, is more appropriately considered a chronic disease than a lifestyle choice. Other chronic diseases, such as diabetes and high blood pressure, are managed by long-term drug treatment, even though these diseases also improve with changes in lifestyle, such as diet and exercise. Although this issue may concern physicians and patients, social views on obesity should not prevent patients from seeking medical treatment to prevent health risks that can cause serious illness and death. Appetite-suppressant medications are not "magic bullets" or a one-shot fix. They cannot take the place of improving one's diet and becoming more physically active. The major role of medications appears to be to help a person stay on a diet and exercise plan to lose weight and keep it off.
  • Side Effects
    Because weight-loss medications are used to treat a condition that affects millions of people, many of whom are basically healthy, their potential for side effects is of great concern. Most side effects of these medications are mild and usually improve with continued treatment. Rarely, serious and even fatal outcomes have been reported. Two approved appetite-suppressant medications that affect serotonin release and reuptake have been withdrawn from the market (fenfluramine, dexfenfluramine). Medications that affect catecholamine levels (such as phentermine, diethylpropion, and mazindol) may cause symptoms of sleeplessness, nervousness, and euphoria (feeling of well-being).

    Sibutramine acts on both the serotonin and catecholamine systems, but unlike fenfluramine and dexfenfluramine, sibutramine does not cause release of serotonin from cells. The primary known side effects of concern with sibutramine are elevations in blood pressure and pulse, which are usually small but may be significant in some patients. People with poorly controlled high blood pressure, heart disease, irregular heart beat, or history of stroke should not take sibutramine, and all patients taking the medication should have their blood pressure monitored on a regular basis.

    Some side effects with orlistat include oily spotting, gas with discharge, urgent need to go to the bathroom, oily or fatty stools, an oily discharge, increased number of bowel movements, and inability to control bowel movements. These side effects are generally mild and temporary, but may be worsened by eating foods that are high in fat. Also, because orlistat reduces the absorption of some vitamins, patients should take a multivitamin at least 2 hours before or after taking orlistat.

    Primary pulmonary hypertension (PPH) is a rare but potentially fatal disorder that affects the blood vessels in the lungs and results in death within 4 years in 45 percent of its victims. It should be noted that the vast majority of cases of PPH have occurred in patients who were taking fenfluramine or dexfenfluramine, either alone or in combination. There have been only a few case reports of PPH in patients taking phentermine alone, although the possibility that phentermine alone may be associated with PPH cannot be ruled out. No cases of PPH have been reported with sibutramine, but because of the low incidence of this disease in the underlying population, it is not known whether or not sibutramine may cause this disease.

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