After nearly a year of hard work, and as the lead author of this chapter, I am honored and thrilled to announce the release of our Obesity Canada Clinical Practice Guidelines 2022 Update on Pharmacotherapy For Obesity Management! Though our last Guidelines chapter on weight management medication was published just two years ago, a lot has changed since then.
In this 2022 update, we emphasize that the focus of obesity management should be on the improvement in health parameters (metabolic, mechanical, mental, quality of life), and not solely on weight reduction. Treatment goals should include outcomes that the person being treated identifies as being important (this can include anything from having less pain, to walking further with your dog, to improving blood sugars, to improving quality of life).
There are now four medications approved for weight management in Canada. In addition to the existing options of liraglutide (Saxenda), naltrexone/bupropion (Contrave), and orlistat (Xenical), we now also have semaglutide (Wegovy) approved, though it’s not yet available on shelves in Canada.
In our search strategy for studies upon which to build our Guidelines recommendations, we searched not only for evidence of efficacy of medications for weight loss, but this time around, we searched on a much longer list of obesity-related health issues, looking for evidence on weight management medications to improve these health issues. This list included: prediabetes, type 2 diabetes, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NASH), dyslipidemia (high cholesterol), hypertension (high blood pressure), polycystic ovary syndrome, obstructive sleep apnea, osteoarthritis, gastroesophageal reflux disease (heartburn), depression, heart failure with preserved ejection fraction, heart failure with reduced ejection fraction, chronic kidney disease, and atherosclerotic (cardio)vascular disease. See Table 2 for a summary of where data exists on each of these health issues.
From this search on obesity-related health issues, in addition to our prior recommendations for weight loss medication in people with prediabetes and type 2 diabetes, we now have new recommendations for weight management medications that have shown benefit in people with overweight/obesity to improve obstructive sleep apnea and fatty liver disease (specifically NASH).
We have also included the recommendation for metformin for prevention of weight gain in people with severe mental illness who are treated with antipsychotic medications associated with weight gain, which coexists in the Mental Health chapter of the Guidelines.
We also specifically searched the literature for evidence on weight loss medications to improve cravings and control of eating, and quality of life, as these are important outcomes of treatment. Check out our new sections on these topics on page 13!
Importantly, we point out that obesity is defined by body mass index (BMI) in clinical trials, which does not itself adequately reflect the burden of adiposity (fat tissue)-related disease. Also, because BMI and waist circumferences that correlate with health issues vary by ethnicity, the prescribing doctor may elect to interpret our BMI-based recommendations with ethnic-specific BMI criteria in mind (see these criteria in Table 1 and Table 2 here).
We have created a new Decision Tool with an accompanying table, as a guide in how to choose which medication may be most appropriate for each patient.
On behalf of my co-authors Dr Priya Manjoo, Dr Sean Wharton, and myself, and on behalf of Obesity Canada, we are excited to share these Guidelines with health care providers, and with adults living with elevated weight, to guide the use of weight management medication in Canada.
Disclaimer: I (and co-authors) of the chapter volunteered my time and received no remuneration for writing this chapter. I receive honoraria as a continuing medical education speaker and consultant from the maker of semaglutide and liraglutide (Novo Nordisk) and naltrexone/bupropion (Contrave). I am/have been an investigator in clinical trials of liraglutide and semaglutide.
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