Obesity has become a significant health concern, particularly among young individuals. While lifestyle modifications remain the cornerstone of obesity management, some cases may require additional interventions. This blog post delves into the use of anti-obesity medications in the pediatric population, shedding light on their effectiveness, safety, and considerations.
Case Study:
Let's begin by examining the case of a 16-year-old female with obesity and a BMI of 34, who also had prediabetes with an A1c of 6.1%. Despite multiple attempts at weight loss, including a structured youth-based program, she faced challenges and experienced frustration due to the lack of significant progress. Seeking further solutions, she approached a clinic after being denied insurance coverage for bariatric surgery. With a family history of obesity and mild anxiety, she was prescribed 1000mg of metformin twice daily. Although her labs and physical exam were normal, she sought alternative options as lifestyle changes alone did not yield the desired outcomes.
Exploring Pharmacotherapy:
In such cases, the Endocrine Society recommends considering pharmacotherapy only after attempting lifestyle management. Moreover, it suggests that these medications should be prescribed by specialists who are trained in obesity medication. Several FDA-approved medications have shown promise in treating obesity in individuals under 18 years old. Some of these medications include Orlistat, Phentermine, Liraglutide, Phentermine/Topiramate, and Semaglutide. Off-label use of medications include metformin and Topiramate.
Orlistat:
Approved by the FDA in 2003 for ages 12-18, Orlistat acts as a pancreatic and gastric lipase inhibitor, reducing fat absorption. It is typically taken as a capsule of 60-120mg up to three times per day before meals. Side effects may include fatty stools, fecal urgency, oily spotting, and flatulence. Studies have shown that Orlistat can effectively reduce BMI in pediatric patients.
Phentermine:
Phentermine, approved in 1959, is a norepinephrine reuptake inhibitor. It is recommended for short-term use in ages 16-18, and the typical dosage is 15mg every morning. Side effects may include headache, increased blood pressure, elevated pulse, anxiety, and insomnia. Studies have shown that Phentermine successfully reduces BMI in pediatric patients.
Liraglutide:
As a GLP1 receptor agonist, Liraglutide increases satiety through a central mechanism. FDA-approved for pediatric patients aged 12-18, Liraglutide is taken as a once-daily injection. Side effects may include nausea, vomiting, diarrhea, and headache. Patients are advised not to overeat to limit these effects. Clinical trials have demonstrated that Liraglutide can significantly reduce BMI in pediatric patients, with continuous treatment being essential for long-term success.
Metformin and Topiramate:
Metformin, FDA-approved for diabetes, is commonly used off-label for obesity. It is typically prescribed at doses of up to 1000mg per day and may cause side effects such as diarrhea, nausea, abdominal pain, and vitamin B12 deficiency. Topiramate, a GABA receptor modulator, is prescribed in doses of 25mg to 75mg in the evening and may be associated with side effects like depression.
Phentermine/Topiramate:
Recently, the FDA approved the use of Phentermine/Topiramate for adolescents with obesity. In a trial study, this combination medication demonstrated a 10.4% change in BMI. Notably, 47% of participants achieved the target BMI reduction, with nearly 5% experiencing significant weight loss. Furthermore, 42% achieved a BMI reduction greater than 10%, and 28% reached a reduction greater than 15%.
Semaglutide:
In adult trials, Semaglutide, administered weekly at a dose of 2.4mg, showed an average baseline BMI change/reduction of 12.4%. The results of the Step Teens trial involving adolescents are not explicitly mentioned in the provided information.
Case Study Conclusion:
In the case study of our 16-year-old patient with prediabetes, metformin was continued, and a discussion regarding the addition of a GLP-1 agonist took place. Considering the patient's preference for oral medications over injections, topiramate was initiated due to baseline anxiety, resulting in successful initial weight loss. However, weight loss plateaued, and the patient experienced side effects with phentermine, leading to a switch to liraglutide, which yielded significant success. When semaglutide became available, the patient transitioned, resulting in a BMI reduction to 26, normalized A1c of 5%, and a weight loss of 24%. The patient was subsequently titrated off topiramate while continuing semaglutide and metformin alone.
Conclusion:
Obesity is a chronic and treatable disease that may require the use of various tools, including anti-obesity medications. While lifestyle modifications remain essential, these medications can be beneficial in selected cases. However, it is crucial to consult with healthcare professionals specialized in obesity management and adhere to FDA guidelines and age-specific recommendations when considering the use of such medications in the pediatric population.
Comments