It is very difficult to use medications effectively, but if you learn how to use them well, they can be very helpful. To use them to their best potential, you must carefully select appropriate people that might benefit, the prescriber needs to understand the medication’s proper role, and the person taking the medication needs to understand what the medication can and cannot do.
The best candidate for the use of medications is someone who has been screened for all the easily reversible causes of excessive weight gain and who is already following sound weight control principles without success. Weight loss medications usually are not all that potent. They will not make up for poor food choices (at least not the medications currently available). But when someone is already making good choices and sticking to a healthy regimen, the proper medications can increase their weight loss significantly.
Every once in a while I come across someone who violates this rule I just presented. Sometimes weight loss medications help someone jump start their weight loss and it helps them to develop confidence and enthusiasm to stick with a good weight loss plan. Once they have established good habits, they can stop the meds. Almost always, though, for a medication to be truly useful it must be part of a long term plan.
The medications I use are ones that can be used safely long term – even many years if needed. This is because when you stop medications, the metabolic effects are lost and the individual often begins to regain the pounds they shed. I look at effective weight loss meds like I look at medications for high blood pressure and high cholesterol. Most people need to stay on them permanently to control these problems so they can avoid the damage that hypertension and atherosclerosis can cause. An effective weight control medication can often be used in lieu of the meds for blood pressure, arthritis, diabetes and other conditions that excessive weight can bring about or aggravate.
The medication I use most often, and the one that I find most likely to help is phentermine. This is a prescription drug in the US and it is currently a schedule IV controlled drug. This is the least restrictive control, but in my opinion, there is no reason for it to be controlled at all. I have never seen anyone hooked on it nor do I ever see it abused. If you read the PDR about it, it says that it works to control appetite. This is not actually how it works; the decreased appetite and increased energy that result from its use are more like temporary side effects rather than their mode of action. If you read the original metabolic research reports from when it was being developed, you will find it inhibits fat storage in the fat cells of the body, and stimulates these same felt cells to release fat faster so it can be burned for energy. It has these beneficial metabolic effects as long as you keep taking the medication; these effects do not wear off with time like the decrease in appetite often does.
Another very effective medication, but one that is much harder to use effectively, is orlistat. This drug is available in the US as Xenical by prescription in a 120 mg size. It has recently become available over the counter in a 60 mg size, called Alli. This drug works by blocking fat absorption in the intestines quite effectively. This is also why it is so hard to use. When you get fat not being absorbed it can cause loose bowel movements and several other bowel problems. I think the 120 mg size is way too large to start with. I tell my patients to start with Alli as only one a day prior to their main meal. If this is well tolerated, more can be added after a week or so. Increases must be very gradual. If someone runs into trouble, I have them stop this medication until they are back to normal and then resume the dosage that was previously tolerated. Like phentermine, orlistat can be used as long as needed without any risk from long term use. Also, if you get benefit from both of these drugs, they can be easily used together.
I occasionally use a few other medications that are not widely known as weight loss medications. Most physicians would not be aware of them, so I will not discuss them here. If someone wants this information, let me know in the comments and I’ll add it on.
We have come a long way in this series, but I have yet to discuss weight loss surgery. This is not because surgical interventions are not effective. I do think, though, that the other options we have covered should be thoroughly explored first. Surgery would be a last resort. This will be the topic of my next article.