No 47 - The Big Business of Obesity: A Summary of weight loss medications
tldr
This piece summarises the prescription only medication, illegal drugs and over the counter supplements that can cause weight loss. It is purely a theoretical list to demonstrate the size of the issue and certainly not a recommendation for anything listed.
Obesity is a big problem in the West and especially in the UK. Weight-loss is therefore a big issue and big business!
I’ve been fascinated by the physiology, pathophysiology and pharmacology of obesity and weight-loss since I started medical school. One of my very first choices at medical school was to select the special study module on obesity in my first year and I continued an interest in the area ever since. I was even lucky enough to work with the specialist weight management team and bariatric surgery team at Birmingham Heartlands Hospital. During that time we were able to publish a couple of papers on the trends in Bariatric surgery at the time:
1. M Alam, S Bhanderi, J H Matthews, D McNulty, D Pagano, P Small, R Singhal, R Welbourn, Mortality related to primary bariatric surgery in England, BJS Open, Volume 1, Issue 4, August 2017, Pages 122–127, https://doi.org/10.1002/bjs5.20
2. Bhanderi S, Alam M, Matthews JH, et alInfluence of social deprivation on provision of bariatric surgery: 10-year comparative ecological study between two UK specialist centresBMJ Open 2017;7:e015453. doi: 10.1136/bmjopen-2016-015453
4. STARSurg Collaborative, Multicentre prospective cohort study of body mass index and postoperative complications following gastrointestinal surgery, British Journal of Surgery, Volume 103, Issue 9, August 2016, Pages 1157–1172, https://doi.org/10.1002/bjs.10203
Now, I am working as a GP trainee in the West Midlands in the UK and now, more than ever, I am realising just how large an issue obesity is for our population. At least once or twice a day, I am having to inform people that they are obese or that they have gone from being “pre-diabetic” to full on “type 2 diabetic”.
Even more frequently, I am having to advise patients that their weight is having an impact on their health and that weight loss would probably be a good idea for improving their: gout; diabetes; hypertension; asthma; COPD; obstructive sleep apnoea; knee pain; hip pain; back pain; GORD (reflux); IBS; acne; swollen legs; varicose veins; sweating; difficulty walking; difficulty sleeping and skin infections.
The 2019 Health Survey for England estimated 28% of adults in England were obese and a further 36% were overweight (that is 64% of the population). The Government estimates that obesity costs the NHS £6.1 billion and £27 billion to wider society.
This really made me think about the situation because it feels like I am saying the same things over and over again. And I am really not sure that its making a difference. Either because what I am saying isn’t being followed or because what I am recommending is not very effective. Or an even scarier thought, is that maybe obesity is now out of control and we have no good way to rein it in.
https://www.nhs.uk/conditions/obesity/treatment/ - The official government advice can be found here.
As in any medical consultation, the healthcare professional will try to approach the issue through a “holistic-Bio-Psycho-Social model”. The treatment can then be escalated using the normal treatment ladder - conservative, medical, psychological and surgical treatments.
I’ve stated the Government guidance so many times now that I think I could say it in my sleep. So, I thought it would be interesting to quickly review what “the Net” says might help weight loss.
Before you read any further, please note that none of this is medical advice or a recommendation of any particular product. This is purely a bit of a list of stuff that is relevant to weight loss and I found interesting and thought I should read more about. Its a list of products that a patient might search and then come in to discuss with you, or ask your advise on whether they should buy it/take it. This is for awarenss only!
So, after a very quick Google, and review of some papers, some guidelines and some supplement websites, I have produced the following list to get started.
A comprehensive list of “drugs/medicines/substances/supplements” that people might take to lose weight as according to Dr Google:
(POM = Prescription Only Medication)
1. Orlistat (POM)
2. Mysimba (POM)
3. Liraglutide (GLP1a) (POM)
4. Semaglutide (GLP1a) (POM)
5. Bupropion-naltrexone (POM)
6. Phentermine-topiramate (Qsymia) (POM)
7. Levothyroxine (POM)
8. Metformin (POM)
9. SGLT2 (empagliflozin etc) (POM)
10. Acarbose (POM)
11. Anabolic steroids (POM)–
12. Amphetamines (illegal)
13. Cocaine (illegal)
14. MDMA (illegal)
15. Supplements:
16. Nicotine (patches or smoking)
17. Caffeine
18. Berberine
19. Chitosan
20. Glucomannan / Soluble fibre
21. Conjugated linoleic acid (CLA)
22. Chromium Picolinate
23. Green Tea Extract
24. Green Coffee Extract
25. Guar Gum
26. Hoodia
27. 7-keto-DHEA
28. Ephedra
29. Bitter Orange - synephrine
30. Yohimbine
31. Garcinia cambogia extract
32. Hydroxycut
33. Meratrim - Sphaeranthus indicus and Garcinia mangostana
34. Raspberry ketones
35. Forskolin
Currently in the UK, these medications are licensed to be used for weight loss:
· Saxenda®, Victoza (Liraglutide),
· Ozempic® (Semaglutide),
· Orlistat®
· Mysimba®
Four weight-loss drugs have been approved by the U.S. Food and Drug Administration for long-term use:
· Bupropion-naltrexone (Contrave) – currently not recommended in the UK
· Liraglutide (Saxenda)
· Orlistat (Xenical)
· Phentermine-topiramate (Qsymia) https://www.drugs.com/qsymia.html - not in the BNF
Diabetes medication with the added benefit of weight loss:
1. Metformin
2. Glucagon-lie peptide 1 (GLP1) = incretin hormone secreted by enteroendocrine L cells.
3. SGLT-2 inhibitors
4. Pramlintide –https://go.drugbank.com/drugs/DB01278 - interestingly isn’t in the BNF yet.
5. Acarbose (a-Glucosidase inhibitors)
Diabetes medication which do not reduce weight:
1. Insulin
2. Sulfonylurea
3. DPP4 inhibitors
4. Pioglitazone (Thiazolidinediones)
5. Repaglinide (Meglitinide)
6. Colesevelam
Here is a quick summary of their indications and actions for some of the licence and private weight loss meds:
· Samaglutide (GLP-1 agonist) – suppresses appetite
· https://www.nice.org.uk/news/article/nice-recommends-new-drug-for-people-living-with-obesity
· BMI >35 with a weight related comorbidity and from a specialist weight loss clinic only.
· The list price of semaglutide 2.4 mg and 1.7 mg is commercial in confidence and cannot be reported here. The list price of semaglutide 0.25 mg, 0.5 mg and 1.0 mg is £73.25 per pack (4 pre-filled pens; excluding VAT).
· https://bnf.nice.org.uk/drugs/semaglutide/#indications-and-dose
· https://bnf.nice.org.uk/drugs/naltrexone-with-bupropion/#prescribing-and-dispensing-information – BMI >30 or BMI >27 with comorbidities.
· £73.00 per pack of 112 tablets. It should be increased slowly over 4 weeks, and continued for 16 weeks. If significant weight loss of 5% of total body weight is not achieved then stop after 16 weeks.
· https://www.nice.org.uk/guidance/ta494/chapter/2-The-technology
https://bnf.nice.org.uk/search/?q=weight%20loss – Searching the BNF for weight loss, produces 150 web pages which mention “weight” or “loss” – many of these include “weight gain” and lots refer to “memory loss”.
The following is a comprehensive list of drugs that might “cause weight loss” that can be used in the UK. Most of these have weight loss listed as an uncommon side effect (SE). Most of the drugs on this list you would really not want to take and even if you did, they probably wouldn’t help you lose weight. I just thought it would be interesting to make a comprehensive list:
· https://bnf.nice.org.uk/drugs/orlistat/#indications-and-dose Orlistat, a lipase inhibitor, reduces the absorption of dietary fat.
· https://bnf.nice.org.uk/drugs/naltrexone-with-bupropion/#prescribing-and-dispensing-information
· https://bnf.nice.org.uk/drugs/liraglutide/ - GLP1 agonist – licenced for weight loss.
· https://bnf.nice.org.uk/drugs/semaglutide/#indications-and-dose – GLP1 agonist – licenced for weight loss.
· https://bnf.nice.org.uk/drugs/exenatide/#cautions - GLP1 agonist, 1.5kg/week weightloss
· https://bnf.nice.org.uk/drugs/metformin-hydrochloride/ - appetite suppression SE
· https://bnf.nice.org.uk/drugs/levothyroxine-sodium/ - Weight loss SE
· https://bnf.nice.org.uk/drugs/acarbose/ - doesn’t mention weight loss as a SE
· https://bnf.nice.org.uk/drugs/empagliflozin/#drug-action - doesn’t mention weight loss as a SE
· https://bnf.nice.org.uk/drugs/ergocalciferol/#side-effects – All Vitamin D analogues can cause decreased appetite and weight loss SE
· https://bnf.nice.org.uk/drugs/apremilast/#cautions Apremilast inhibits the activity of phosphodiesterase type-4 (PDE4) which results in suppression of pro-inflammatory mediator synthesis and promotes anti-inflammatory mediators. – appetite suppression and weight loss SE
· https://bnf.nice.org.uk/drugs/hydralazine-hydrochloride/#side-effects – weight loss SE
· https://bnf.nice.org.uk/drugs/sodium-oxybate/#side-effects – weight loss SE
· https://bnf.nice.org.uk/drugs/zonisamide/#cautions – anti-epileptic, decreases appetite SE
· https://bnf.nice.org.uk/drugs/pitolisant/#side-effects Pitolisant is a histamine H3-receptor antagonist which enhances the activity of brain histaminergic neurons. weight loss SE
· https://bnf.nice.org.uk/drugs/pramipexole/#side-effects – Parkinson’s disease drug, weight loss SE
· https://bnf.nice.org.uk/drugs/ranolazine/#side-effects – BP drug, appetite suppression and weight loss SE
· https://bnf.nice.org.uk/drugs/imatinib/#side-effects Imatinib is a tyrosine kinase inhibitor for CML, appetite suppression and weight loss SE
o https://bnf.nice.org.uk/drugs/dasatinib/#side-effects – CML
o https://bnf.nice.org.uk/drugs/tivozanib/#side-effects – Renal cell carcinoma
o https://bnf.nice.org.uk/drugs/cabozantinib/#side-effects – Thyroid and Renal cancer
· https://bnf.nice.org.uk/drugs/letrozole/#side-effects – Breast cancer drug, weight loss SE
· https://bnf.nice.org.uk/drugs/oxaliplatin/#side-effects – Colorectal cancer drug, appetite suppression and weight loss SE
· https://bnf.nice.org.uk/drugs/belatacept/#side-effects – transplant rejection prevention, SE weight loss
Lastly, I thought I would look up the actual regulation and licenses, but classicly for a government website (the MHRA), it is actually really difficult to use! So, its actually hard to see a summary of what drugs are licenced for what. You have to individually search for drugs and then search for their licence.
https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency
https://www.gov.uk/government/publications/marketing-authorisations-granted-in-2022
https://www.gov.uk/guidance/regulating-medical-devices-in-the-uk
MHRA for Liraglitide
https://products.mhra.gov.uk/product/?product=VICTOZA%206MG%2FML%20SOLUTION%20FOR%20INJECTION%20IN%20PRE-FILLED%20PEN – doesn’t even mention weight loss
Lastly, I thought it would be a good idea to mention that the government agencies are cracking down on the online selling of “weight loss pills”. This is a highly regulated market in the UK and you should really not buy any of these medications online without speaking to a specialist clinician first, and ideally, not at all.
https://www.gov.uk/government/publications/advertising-investigations-february-2022/websites-offering-weight-loss-treatment-services-february-2022 - Companies told to stop advertising medicines as “weight loss pills”.
“Unlicensed medicines should not be mentioned, to comply with regulation 279 of the Regulations which prohibits advertising of medicines for which no marketing authorisation or registration is in force. Treatments that involve the use of unlicensed medicines may not be described as ‘clinically proven’ or similar.” https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/956859/Appendix_6.pdf
https://www.gov.uk/government/publications/blue-guide-advertising-and-promoting-medicines
https://www.asa.org.uk/news/prescription-only-weight-loss-products-an-enforcement-notice.html - POM (Prescription Only Medication) should not be advertised as “weight loss” treatments, and especially not to people via social media who are not obese.
https://www.londonslimmingclinic.co.uk/ - However, these “pens” can still be bought for £45.90. I suspect there will be more of a clamp down coming in the near future!
Some evidence that Anabolic steroids cause fat loss:
b. Kelly DM, Jones TH. Testosterone and obesity. Obes Rev. 2015 Jul;16(7):581-606. doi: 10.1111/obr.12282. Epub 2015 May 15. PMID: 25982085.
c. AlShareef S, Gokarakonda SB, Marwaha R. Anabolic Steroid Use Disorder. 2022 Jun 23. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30844201.
Again, this was just for interest. Before doing this bit of a lit review, I hadn’t realise they help reduce fat. I thought they just built muscle. Again, please dont take these unless you have a medical reason to do so.
Summary
A quick Google search produces a very long list of drugs and supplements that might cause weight loss. However, the guidance is still pretty limited and revolves mostly around reduced calories, more exercise and a few medications.