Pharmacological treatment should be considered only after dietary, exercise and behavioural approaches have been started and evaluated (1).
- pharmacological treatment should be considered for patients who have not reached their target weight loss or have reached a plateau on dietary, activity and behavioural changes alone
- the decision to start drug treatment, and the choice of drug, should be made after discussing with the patient the potential benefits and limitations, including the mode of action, adverse effects and monitoring requirements, and their potential impact on the patient's motivation. When drug treatment is prescribed, arrangements should be made for appropriate healthcare professionals to offer information, support and counselling on additional diet, physical activity and behavioural strategies. Information on patient support programmes should also be provided
- prescribing should be in accordance with the drug's summary of product characteristics.
The pharmacological interventions stated by NICE in obesity management are (1,3,4):
- orlistat
- liraglutide
- semaglutide
Notes:
- sibutramine withdrawal - an interim analysis of the SCOUT (Sibutramine Cardiovascular Outcome Trial) study found that the drug increased morbidity from cardiovascular disease (2)
- rimonabant
- on October 23rd 2008 the European Medicines Agency (EMEA) recommended the suspension of the marketing authorisation for rimonabant (Acomplia). The EMEA's Committee for Medicinal Products for Human Use (CHMP) has concluded that the benefits of rimonabant no longer outweigh its risks and the marketing authorisation should be suspended across the EU
- liraglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist
- Liraglutide (Saxenda) received a European marketing authorisation in March 2015 and was launched in the UK in January 2017
- licensed as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial BMI of:
- 30 kg/m2 or more (obese), or from 27 kg/m2 to less than 30 kg/m2 (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (prediabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea
- treatment should be discontinued after 12 weeks on the 3.0 mg daily dose (recommended maintenance dose) if patients have not lost at least 5% of their initial body weight.
NICE has now recommended semaglutide as an option for weight management - weight loss and weight maintenance. This is alongside a reduced-calorie diet and increased physical activity in adults. The criteria for use are: (4)
- Must be used in a specialist weight management service.
- Must have BMI of >35 kg/m2.
- Must have BMI 30-30.4 kg/m2 and a condition that can be improved with weight management, such as diabetes.
- Lower BMI thresholds (lower by 2.5 kg/m2) for those in at-risk groups such as people from South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family backgrounds. These groups have a higher risk of diabetes and heart disease at lower thresholds of obesity.
Dexfenfluramine is no longer used because of the significant risk of fatal pulmonary hypertension.
References:
- Obesity: identification, assessment and management. Clinical guideline CG189. Published: 27 November 2014 Last updated: 26 July 2023.
- European Medicines Agency (2010). Sibutramine.
- Liraglutide for managing overweight and obesity. Technology appraisal guidance TA664. Published December 2020
- Semaglutide for managing overweight and obesity (https://www.nice.org.uk/guidance/ta875); NICE Technology appraisal guidance, March 2023