Experts debate pharmacologic management of a patient with obesity

Experts debate pharmacologic management of a patient with obesity

This ‘Beyond the Guidelines’ feature is based on a discussion held at Internal Medicine 2024, the annual meeting of the American College of Physicians

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-01740   

URL goes live when the embargo lifts        

In a new Annals “Beyond the Guidelines” feature, two internal medicine physicians discuss treatment for a patient with obesity and prediabetes in the context of American Gastroenterological Association (AGA) evidence-based recommendations for the pharmacologic management of obesity in adults. Currently, 1 in 8 adults worldwide has obesity and minority populations are disproportionately affected. New pharmacologic options have shown effectiveness for weight loss in clinical trials, but adverse effects, adherence, and cost are strong considerations. As such, asking “How would you treat this patient with obesity?” is an important clinical question. 

They reviewed the case of an adult female patient with obesity. At her most recent doctor’s visit, the patient’s blood pressure was 115/82 mm Hg, weight was 171 pounds, BMI was 31.2 kg/m2, and her blood work showed prediabetes. The patient reported struggling with her weight since having children and sought advice for losing about 25 lbs.

The first discussant, Anne N. Thorndike, MD, MPH, is a member of the Division of General Internal Medicine at Massachusetts General Hospital and an Associate Professor of Medicine at Harvard Medical School, Boston, Massachusetts. She noted that lifestyle modification is the foundation for obesity management, that moderate- to high-intensity multicomponent behavioral interventions can produce 5% to 10% body weight loss, and that weight loss from lifestyle interventions improves numerous health outcomes. While the patient had expressed an interest in losing about 25% of her body weight, Dr. Thorndike pointed out that even 5% weight loss can result in positive health changes. Given the potential benefit and limited harms, she would advocate intensive lifestyle modification before moving on to pharmacologic therapy. 

The second discussant, Melanie R. Jay, MD, MS. is a member of the Division of General Internal Medicine and the Department of Population Health and an Associate Professor at the NYU Grossman School of Medicine. She is also a staff physician at the New York Harbor Veterans Affairs. Dr. Jay agrees that lifestyle modification is paramount in obesity management, but if the patient has coverage and access, Dr. Jay believes that the patient’s weight and metabolic risk factors warrant treatment with a GLP-1RA. If not, she would recommend phentermine-topiramate (barring contraindications) or metformin as the patient has prediabetes and it can decrease the risk for progression to type 2 diabetes. Both discussants noted that obesity is a chronic disease requiring a lifelong commitment to follow-up and treatment.

All “Beyond the Guidelines” features are based on selected clinical conferences at Beth Israel Deaconess Medical Center (BIDMC) and include multimedia components published in the Annals of Internal Medicine.

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. To speak with one of the discussants, please contact Kendra McKinnon at [email protected].