With the explosion of weight loss medications in recent years, we are seeing a progressive broadening of the age ranges of people being prescribed these treatments. For older or elderly people using weight loss medication, are there any special considerations?
Muscle mass declines as we age, to the point where some people have insufficient muscle mass, called sarcopenia (read more here). When people lose weight with weight loss medication, the weight lost is about 2/3 fat, and 1/3 muscle. If older people lose too much muscle, this could lead to weakness, falls, or loss of independent functioning.
Bone density also decreases with weight loss (more on this here), and age is a risk factor for osteoporosis.
As some weight loss medications can cause gastrointestinal side effects that could lead to dehydration, this may put older people at higher risk of dizziness, falls, or kidney injury.
Older folks tend to be taking more medications, so there’s a higher risk of medication interactions. As health conditions associated with obesity (eg hypertension or diabetes) often improve with weight loss, other medications may need to be reduced or stopped as weight loss occurs.
Thenthere’s the question of the ‘obesity paradox’ – meaning, do older people have better survival with a little more weight on board? If an older person gets sick with eg COVID or the flu, and loses say 15 or 20 lbs (7-10kg), the person who is thin and doesn’t have that weight to lose could be at higher risk of poor outcomes.
In clinical trials of weight loss medications, we have less data in older people; a couple of recent publications (here and here) have summarized the current evidence on this topic.
As noted in this systematic review, only about 10% of people included in the clinical trials used for FDA submission were over 65. In fact, some of the older trials excluded people age 65+. The medication with the most data in people over 65 is semaglutide 2.4mg (Wegovy, also known as Ozempic for diabetes) from the SELECT trial of over 17,000 participants, which demonstrated a 20% reduction in risk of cardiovascular events in people with obesity and preexisting cardiovascular disease over 40 months. Participants had an average age of 62 at the start of the study.
In general , weight loss seems to be similar with weight loss medications for older vs younger adults. Rates of discontinuation of medication seem to be higher in people over 65, which may speak to some of the sensitivities mentioned above.
So how can we reduce risks associated with obesity medication in older people?
A careful assessment of other medications is important from the outset. Flagging medications that may need reducing with weight loss is important. Monitoring blood pressure, blood sugars (for people with diabetes), and thyroid hormone levels (for people who take thyroid hormone) are important.
Coaching on physical activity and ensuring adequate protein intake to retain muscle mass is super important, from the start of use of weight loss medication. These steps are good not only for muscle mass but bone health as well. (throw adequate calcium and vitamin D in here as well for bones).
Older people may be less tolerant to side effects of medication, so closer clinical follow up is important. Watch for side effects. Consider increasing the dose of medication more slowly. We don’t need to reach the maximum dose of medication – titrated as needed and tolerated to reach goals of treatment (improvement in health, well being, quality of life, and/or weight).
BOTTOM LINE: Though data are limited in older people, there is no upper age limit for use of weight loss medication. It’s important to assess and adjust other medications as needed, ensure adequate nutrition, and support physical activity. Seeing your doctor more frequently, consideration of increasing medication more slowly, and (as always) titrating medication as needed and tolerated to reach treatment goals are fundamental.
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