Pharmacotherapy in Obesity Management

Pharmacotherapy in Obesity Management | Dr. Sue Pedersen

Estimated read time: 1:20

Summary

In this detailed session hosted by Obesity Canada, Dr. Sue Pedersen discusses the role of pharmacotherapy in the management of obesity. The session is part of a broader webinar series on obesity guidelines and is presented by the University of Alberta in partnership with Obesity Canada. Dr. Denise Campbell Sharer introduces the session, emphasizing the newly expanded Canadian Clinical Practice Guidelines, which focus on patient-centered care. Dr. Pedersen outlines pharmacotherapy as a critical pillar in obesity management alongside health behavior changes and bariatric surgery. The session explores various aspects of pharmacotherapy, including specific medications available in Canada, their effectiveness, and considerations for their use. Dr. Pedersen also discusses the potential for pharmacotherapy to maintain weight loss achieved through lifestyle changes and addresses common questions from the audience.

Highlights

Dr. Sue Pedersen, a leading voice in obesity management, shares insights on pharmacotherapy. 🗣
Weight management involves a balance of lifestyle changes, pharmacotherapy, and potentially surgery, all tailored to individual patient needs. ⚖️
Dr. Pedersen explains the significance of health improvement through weight loss and how pharmacotherapy fits into this framework. 🏥
The session highlights the significance of personalized approaches in using pharmacotherapy based on comorbidities, patient preferences, and medication interactions. 🤝
With emerging therapies on the horizon, the landscape of obesity treatment is evolving, offering new possibilities for improved outcomes. 🚀

Key Takeaways

Pharmacotherapy is a key pillar in obesity management, complementing health behavior changes and bariatric surgery. 💊
Several medications are available for obesity management in Canada, including Saxenda, Contrave, and Xenical. Each has unique benefits and considerations. 💼
Achieving and maintaining weight loss is crucial to improving health, with pharmacotherapy playing a significant role when lifestyle changes alone are insufficient. 💪
Health behavior changes alone may not sustain long-term weight loss, making pharmacotherapy a useful strategy for enhancing and sustaining outcomes. 🏃‍♂️
Addressing broader health implications, pharmacotherapy can aid in improving co-morbid conditions such as diabetes, hypertension, and sleep apnea. 🌡

Overview

In her insightful session, Dr. Sue Pedersen dives into the critical role of pharmacotherapy within the broader spectrum of obesity management. Hosted by the University of Alberta and Obesity Canada, this webinar aims to educate healthcare professionals on the applications and considerations of pharmacotherapy. Dr. Pedersen stresses that pharmacotherapy is a core component, working alongside lifestyle interventions and surgery to provide holistic patient care.

The session provides a comprehensive look at the current pharmacological options available in Canada, such as Saxenda, Contrave, and Xenical. Each medication comes with its own set of considerations, effectiveness levels, and side effect profiles, making it crucial for healthcare providers to tailor treatment plans to individual patients. The talk also emphasizes the importance of maintaining weight loss achieved through lifestyle modifications, with pharmacotherapy offering a backup when these efforts alone are insufficient.

Furthermore, Dr. Pedersen addresses the broader health benefits of effective obesity management. By achieving even modest weight loss, patients can see significant improvements in conditions like diabetes, hypertension, and sleep apnea. With the promise of new and more effective therapies on the horizon, the field of obesity pharmacotherapy is poised for exciting advancements, potentially offering patients better outcomes and improved quality of life.

Chapters

00:00 - 10:00: Welcome and Introduction The chapter 'Welcome and Introduction' serves as an opening to the content, setting the stage for what is to come. It usually includes a greeting and a brief overview of the topics covered, highlighting key themes and important points. This chapter aims to engage the audience and provide context for the subsequent material.
10:00 - 33:00: Overview of the Guidelines and Pharmacotherapy The chapter introduces the guidelines and pharmacotherapy related to adult obesity. The transcript begins with a welcome message, setting the tone for an informative discussion on this subject.
33:00 - 59:00: Details on Approved Medications in Canada This chapter is part of a webinar series hosted by the Office of Lifelong Learning at the University of Alberta in association with Obesity Canada. It is introduced by Denise Campbell, the Associate Dean for the Office of Lifelong Learning and a family physician at the University of Alberta. Denise Campbell also served on the executive of the Canadian Clinical Practice Guidelines.
59:00 - 87:00: Clinical Considerations in Pharmacotherapy The chapter on Clinical Considerations in Pharmacotherapy is a part of a comprehensive set of clinical practice guidelines focusing on obesity. These guidelines are the first of their kind to be truly patient-centered, reflecting the efforts of leading researchers, health practitioners, and patient advisors in Canada. These guidelines encompass 19 chapters, each exploring different dimensions of obesity diagnosis and management. The chapter in question dives into pharmacotherapy for obesity and highlights the expansive work and dialogue sparked among professionals regarding weight bias and other related issues. This represents the culmination of more than three years of dedicated work and collaboration.
87:00 - 121:00: Recommendations and Algorithm for Treatment The chapter titled 'Recommendations and Algorithm for Treatment' discusses the importance of bariatric surgery as part of the treatment process. An invitation for a live event related to bariatric surgery is mentioned, along with the availability of recordings for those registered in the series. The chapter encourages participation in the Timed Right group to engage in active dialogue between sessions. It begins with an acknowledgment of the traditional territories across Canada, emphasizing respect for the First Nations, Métis, and Inuit communities who have historically inhabited these lands.
121:00 - 156:00: Expert Panel Discussion The chapter titled 'Expert Panel Discussion' covers the initial housekeeping steps for a webinar. Participants are advised to use the chat feature for technical difficulties or questions regarding l3 or Boost Obesity Canada programs, while the Q&A feature should be used for questions directed to the panelists. Both features are accessible on the black bar at the bottom of the screen.
156:00 - 187:00: Questions on Pharmacotherapy and Further Discussion In this chapter, the panelists address various questions that arise following an oral presentation. They mention that some questions may be answered through text in the Q&A window. Participants can submit their queries using the Q&A button. Due to the expected high volume of questions, the audience is encouraged to review and upvote existing questions to indicate their priority. However, there is no assurance that all questions will be answered. Additionally, a recording of the webinar will be made available.

Pharmacotherapy in Obesity Management | Dr. Sue Pedersen Transcription

00:00 - 00:30
00:30 - 01:00 welcome to the adult obesity guidelines
01:00 - 01:30 webinar series hosted by the office of lifelong learning at the university of alberta and obesity canada my name is denise campbell sharer i am the associate dean for the office of lifelong learning as well as a family physician here at the university of alberta it was my great pleasure to serve on the executive of the canadian clinical practice guidelines
01:30 - 02:00 the new clinical practice guidelines are expansive 19 chapters on a wide range of topics related to obesity diagnosis and management weight bias and more all written by canada's top researchers health practitioners and patient advisors they're the first truly patient-centered clinical practice guidelines on obesity and the results of more than three years of hard work we're really thrilled and overwhelmed by the interest in stimulating discussion for this series given the scope of the pharmacotherapy session we've decided to provide a
02:00 - 02:30 separate session on bariatric surgery we'll send the invitation for the live event to everyone registered for this series with recordings sent after the event as usual i encourage everyone to join the timed right group to participate in the active dialogue going on between sessions just before we begin i'd like to go over a few items we acknowledge that we are on the traditional territories across canada the many first nations metis and inuit footsteps have marked these lands for centuries
02:30 - 03:00 webinar housekeeping if you have questions pertaining to technical difficulties l3 or boost obesity canada programs and services please use the chat feature of the webinar the chat box is located in the middle of the black bar on the bottom of your screen if you have a question for our panelists please use the q a feature of the webinar also located on the black bar at the bottom of your screen
03:00 - 03:30 our panelists will answer several questions following the oral presentation some questions will be responded to through text in the q a window you can at any point use the q a button at the bottom of your screen to submit questions we anticipate many questions please review what's already been asked and upvote those questions you'd really like to see answered we cannot guarantee the panelists will be able to respond to all of your questions a recording of the webinar will be
03:30 - 04:00 available next week it will be sent via email to all of those that registered this link is for your personal use and is not to be forwarded or shared this activity has not been formally reviewed by the cfpc or royal college however it is eligible for non-certified credit main pro plus participants may also earn additional certified credits by completing a linking learning to practice exercise
04:00 - 04:30 please contribute your experience with obesity management to inform our advocacy and programming so while you're waiting or after the event or after you see your next patient please take five minutes to contribute your perspective we're working to try to build a national overview of the current state of affairs going on with obesity management so it is my very great pleasure to present dr sue peterson who will be sharing with us about pharmacotherapy and obesity management
04:30 - 05:00 dr sue peterson is a specialist in endocrinology and metabolism and a deployment of the american board of obesity medicine she has a busy practice at the cno diabetes and endocrinology clinic in calgary alberta dr peterson is involved extensively in clinical research for obesity and diabetes furthermore she's the lead author on the pharmacotherapy chapter on the 2020 canadian obesity guidelines and a member of the expert committee for the 2018 diabetes canada guidelines dr peterson has become a leading voice
05:00 - 05:30 on how to treat obesity and educate health care professionals globally she has a public information website about weight management and diabetes at www.drsu.ca so sue i'm going to turn it over to you to present your guideline chapter wonderful thank you so much denise and thank you very much to everyone who is joining us for this symposium and seminar these are my disclosures
05:30 - 06:00 lisa is really a pleasure and honor to be able to present the pharmacotherapy chapter of the canadian obcd guidelines in the next 35 minutes or so we'll have the formal part of the presentation and then we'll open up and have lots of time for a good discussion in the previous sessions over the last four weeks there have been lots and lots of questions about pharmacotherapy so we want to make sure that we've got good amount of time to address those questions the guidelines
06:00 - 06:30 have been a labor of love i think all of us as authors can agree over the last three years or so and it's really wonderful to have the chance now to share the learnings from our literature review and to present our suggested approach to obesity management in canada and today with our focus on pharmacotherapy so the things that we'll go through in the next half hour or so first i'll just describe the rationale for pharmacotherapy
06:30 - 07:00 the methodology behind the literature review for our chapter we'll talk about the pharmacotherapy options that are available for obesity management in canada we'll talk about the considerations that we want to make in the use of pharmacotherapy what helps us to choose which medication might be best for our patient and what in what framework or context should we be thinking about pharmacotherapy i'll go through some of the evidence that we collected from our literature review that have informed our key
07:00 - 07:30 recommendations which we'll go through one by one we have also generated an algorithm a pragmatic approach as far as how we should choose which pharmacotherapy might be best for our patient and then we'll round out with the key messages from our chapter in terms of the rationale for pharmacotherapy we know that a modest and sustained weight loss is associated with improvements in comorbidities associated with obesity so
07:30 - 08:00 remember that treating obesity is about improving health and we do know that that's about how much weight loss it takes in order to see substantial changes in weight but i would also point out that as little as one kilo of weight loss in a patient with pre-diabetes actually reduces the risk of developing type 2 diabetes by about 16 percent per kilo health behavior change which is what we traditionally think of as nutritional changes physical activity
08:00 - 08:30 generally only achieves about a 3.3 to 5 weight loss which can still be important as we talked about even a little bit of weight loss can benefit health but the reality is that this is most often not sustainable over the long term so the vast majority of people who do have some success with health behavior change end up regaining their weight and are not able to keep that success long term pharmacotherapy therefore should be considered to
08:30 - 09:00 decrease weight and improve metabolic parameters and improve health when behavioral intervention alone has been ineffective insufficient or without sustained benefit so i just want to put this in the context of the framework for the guidelines and this is part of the patient journey in obesity management which of course is a surrounded by the five a's of obesity that's the framework that we suggest going through this is the third a which
09:00 - 09:30 is advising advising our patient on how they can achieve their health goals with weight management so we see on the top left we have medical nutrition therapy which there's a separate chapter on that in the guidelines on the right we have physical activity there's another chapter there as well and these are the foci of the health behavior changes then we have the three pillars of obesity management that support medical nutrition therapy and physical
09:30 - 10:00 activity so we see on the bottom left we have psychological intervention which you heard about that chapter from michael vallis last week we have pharmacological therapy which we'll talk about today and we have bariatric surgery so with that framework now let's talk more about pharmacology pharmacologic therapy the methodology for our chapter was that we generated research questions to inform on pharmacotherapy studies published since the last guidelines which was 2006.
10:00 - 10:30 so you can imagine that there was a huge number of articles that came our way over the last 14 years to generate our recommendations and messages we opened our search to any prescription medication in canada so we wanted we know that there is a prescribing that happens sometimes for things like thyroid hormone or testosterone and so we said okay let's open keep our search open to include studies if there are any on those types
10:30 - 11:00 of treatments so that way we can inform and provide recommendations about whether or not these are appropriate treatments we looked at randomized control trials of at least six months duration and this was of course a systematic literature review so let's now talk about pharmacotherapy and what we have available in canada so first of all the indications for pharmacotherapy for chronic weight management is appropriate for individuals with a bmi
11:00 - 11:30 of 30 or greater or a bmi of 27 or greater with comorbidities associated with the excess adiposity so this can be for example type 2 diabetes hypertension dyslipidemia but isn't limited to those things so pre-diabetes could be included here polycystic ovary syndrome sleep apnea non-alcoholic fatty liver disease these could all be considered to be comorbidities associated with the excess
11:30 - 12:00 adiposity there are three medications included and indicated for chronic obesity management in canada and remember this is always in addition to the health behavior changes in addition to medical nutrition therapy and in addition to physical activity these three medications are the regulation three milligrams which is the trade name saxenda naltrexone bupropion in a combination tablet trade named contrai and orlistat
12:00 - 12:30 trade name xenocal so now let's talk about the things that we should consider when we are wanting to use pharmacotherapy to help our patient with chronic weight management so there's a number of things that we need to think about what's the mechanism of action how does this medication work what are the potential side effects what are tolerability issues or concerns that side effects that could happen that we need to talk with our patient about that we need to think through with them
12:30 - 13:00 what are safety aspects are there any patient comorbidities for which those particular comorbidities would also be benefited by a particular medication choice what are their other existing medications that our patient is taking are there any drug interactions that we need to think about what is the mode of administration is it oral is it subcutaneous injection how often is it needing to be given and of course the reality is cost considerations we need to take into consideration as
13:00 - 13:30 well as medical coverage and so forth that our patient may or may not have i'm going to spend a little time now to go through several elements from one of the tables that we have in our chapter so all of this is right in the chapter so we just literally cut and pasted some of the elements from this table and we'll go through each of the three medications i'm going to kind of jump back and forth a little bit so just bear with me here
13:30 - 14:00 so or list out first of all which you see on the left this is the first medication that was available of these three for obesity management in canada approved in 1999 this is an oral medication and the way that it works is that it blocks fat absorption in the intestine so if you eat a diet that's about 30 percent fat it will block about 30 percent of that fat from being absorbed an important point here is that orlastat does nothing for appetite so every other medication available for
14:00 - 14:30 obesity management helps to reduce appetite orlastat does nothing for appetite it only blocks fat absorption it's taken with meals at a dose of 120 milligrams three times a day liraglutide which you'll see in the middle column at three milligrams was approved in canada about five years ago this is a subcutaneous injection given once a day at a dose of three milligrams and you actually increase that
14:30 - 15:00 dose gradually over the course of at least a month in order to mitigate any or ideally limit or avoid any potential gi side effects and we'll talk about that in the next slide we won't go there yet so this again is a subcutaneous injection and it works by reducing appetite in the brain that's the primary mechanism of how of its efficacy we then have naltrexone bupropion or contrave in the far right this is a oral formulation taken
15:00 - 15:30 twice a day you also titrate this medication up over the course of about a month again to limit any side effects which we'll talk about in a subsequent slide and the if you take the full dose after you've titrated up that dose then becomes 16 milligrams of naltrexone 180 milligrams of bupropion twice daily this medication also works by reducing appetite in the brain and it also has evidence that it reduces
15:30 - 16:00 cravings so it affects that um the wanting and liking of food as well if we go down to the third line in this slide this is the percentage placebo subtracted weight loss so we can see that orlistat is not overly effective in reducing weight you get about three percent placebo subtracted weight loss though it can work for some people again it doesn't reduce appetite so when a patient loses weight there is nothing there is no mechanism in place with orlistat that helps to manage that appetite
16:00 - 16:30 increase that happens when a person loses weight loraglutide and naltrexon bupropion both have about five percent placebo subtracted weight loss and just to point out these are not head-to-head comparisons these are all individual trials compared to placebo one of health canada's approval recommendations for pharmacotherapy is wanting to know that a certain proportion of patients will achieve clinically significant weight loss which
16:30 - 17:00 is traditionally defined as five percent so we've also included what proportion of patients achieve five percent or even 10 weight loss and the message here is that there are many patients who can achieve clinically significant weight loss with these medications and we see a range of weight loss results from person to person so there is no one medication fits all in obesity medicine just like there isn't in any other type of medicine different things will work for different people
17:00 - 17:30 and i really want to draw an emphasis now to the bottom of this slide which is the effect on maintenance of previous lifestyle-induced weight loss so both orlastat and laraglotide have evidence that they can help patients to keep weight off that that they have lost previously with lifestyle changes and this is actually a foundation for one of our probably one of our most important recommendations because it's quite new that we are recommending consideration
17:30 - 18:00 of pharmacotherapy not just for weight loss but also to help patients keep weight off that they have lost previously and this is very clinically relevant because of course a lot of patients will come to us and say hey i have done it again i joined weight watchers i lost five percent weight but i'm really worried that i'm going to regain the weight because that is what has always happened to me can we do something to help to keep that weight off and this is where we have the evidence for both
18:00 - 18:30 the regulation and or lestat that they can help to keep weight off that has previously been lost with lifestyle change so remember that obesity management is about improving health so i want to now go through some of the improvements in the cardio metabolic parameters that we see with obesity pharmacotherapy so we had specific directed literature review questions about pre-diabetes and diabetes so we see that there is evidence for both orlistat
18:30 - 19:00 and the regulative to prevent development of type 2 diabetes so that's really really important because we know that if we can help to nip the pre-diabetes in the bud and even revert it back to normal glucose tolerance that is very powerful for improving that patient's health over time if we can prevent development of type 2 diabetes if we go down to the bottom and we look at the effect of these medications in people who have type 2 diabetes all three medications
19:00 - 19:30 have been studied and we do see a reduction in a1c with all of them the a1c reduction we see with orlistat and naltrexone bupropion are probably mostly related to the weight loss that we see with liraglutide of course we know that that is also a diabetes medication at the 1.8 milligram dose called victoza so it's perhaps not surprising to us that we see a greater benefit with the regulation to reduce a1c um in with the anti the anti-diabetes
19:30 - 20:00 glucose lowering effects as well as the weight loss effects and again just a reminder these are not head-to-head comparison trials we also see that there's an improvement in cardiovascular parameters so we see an improvement in blood pressure with oil stat and the regulation with naltrexone bupropion with the weight loss we actually do see a reduction in blood pressure but initially there's a little bump up in the blood pressure because bupropion has adrenergic properties
20:00 - 20:30 so that's why the placebo subtractive weight loss blood pressure change is actually a positive not a negative but with weight loss we actually do see an improvement in blood pressure but it is important that blood pressure is well controlled prior to starting naltrexone bupropion we also had specific literature review questions in generation of this chapter with regards to fatty liver disease polycystic ovary syndrome
20:30 - 21:00 osteoarthritis and obstructive sleep apnea so we have put a specific information in our table as well and as you can see the theme is that there's not a lot of study on these health conditions at this point in time we do see that la regular tide three milligrams has shown improvement in nash non-alcoholic steatohepatitis which is this is a very important and very common complication of obesity so it's really nice to see some data emerging in this area polycystic ovary syndrome none of them
21:00 - 21:30 have been studied with view to looking at improvement in menstrual cyclicity doloregluted three milligrams has shown weight loss in this group of patients osteoarthritis not yet studied sleep apnea has been studied only with the regulation showing a reduction in the apnea hypopnea index now in terms of cost so the these are medications that unfortunately are only covered by about 20
21:30 - 22:00 of private medical plans and there's no public coverage at this time and this is something that we in the obesity community are really working hard and to advocate for better coverage and better access to pharmacotherapy and we hope that the guidelines is a helpful thing for employers and public health agencies and so forth to inform in order to hopefully get more access in terms of cost if a patient is paying for it out of pocket the cost is about a
22:00 - 22:30 hundred and ninety dollars a month for orlastad about 450 dollars a month for the regulation three milligrams and about three hundred dollars a month from naltrexone bupropion in the interest of time i'm not going to go through all of this table in detail but again it's right in the guidelines in terms of common side effects for orlastat because it blocks fat absorption it can cause loose stools and flatus because of the state and the fat excretion that comes out in the stool in terms of luraglutide it
22:30 - 23:00 transiently slows down the stomach so because of that it can cause nausea constipation diarrhea heartburn occasionally vomiting this can be mitigated by increasing the dose more slowly so it tends to be temporary usually only for the first couple of months if it happens it happens in about 15 percent of people and again if you can slow down the dose escalation if the patient is having those side effects that can often be very helpful to mitigate that
23:00 - 23:30 naltrexone bupropion has side effects which are already known from the individual components of these of these two medications so country of itself has been available in canada since 2018 but each of these medications has been around for over 20 years and so nausea constipation headache dry mouth dizziness diarrhea are the most common side effects again you can try to increase the dose more slowly if the patient is experiencing any concerns to mitigate that
23:30 - 24:00 in terms of contraindications pregnancy and breastfeeding are contraindications to all pharmacotherapy and in the interests of time i'm not going to go through each of those in detail but if anyone has questions we can certainly take those at the end in terms of medication interactions that's a an important one particularly with naltrexone bupropion because it does have interactions with several other many other medications so it's really important that you run through the other medications and search
24:00 - 24:30 them up and make sure that there's no significant drug interactions as you would with starting any pharmacotherapy for any medical condition okay so the literature review that we just went through was what informed our recommendations so let's go through those our first recommendation is that pharmacotherapy for weight loss can be used for individuals with a bmi over 30 or 30 or more or a bmi of 27 or more
24:30 - 25:00 with adiposity related complications in conjunction with medical nutrition therapy physical activity and the psychological interventions which is the that pillar that you saw on the left side of that pillar picture that i showed you earlier pharmacotherapy may be used to maintain weight loss that has been achieved by health behavior changes and to prevent weight regain so that's that really important recommendation we want to move away from we want to be
25:00 - 25:30 thinking about the patient's context of where they came from in their weight journey prior to coming to us when we're prescribing pharmacotherapy if they've lost weight already then further weight loss may not be the goal but rather maintaining that weight may be the goal for that patient so we want to individualize those goals in the context of the patient's weight journey prior to initiating pharmacotherapy for people living with type 2 diabetes and a bmi of 27 or greater
25:30 - 26:00 pharmacotherapy can be used in conjunction with health behavior changes for weight loss and improvement in glycemic control with evidence for all three pharmacotherapies for that recommendation for people with pre-diabetes and overweight or obesity we recommend pharmacotherapy in conjunction with health behavior change with bmi of 27 or greater to delay or prevent type 2 diabetes with the evidence there
26:00 - 26:30 at this time being for the regulation and orlistant we do not suggest the use of prescription or over-the-counter medications other than those approved for weight management so coming back to our what i discussed about our literature review process that we opened this literature review to all prescription medications and none of the others had sufficient data to support their use for weight management so thyroid hormone and synthrom
26:30 - 27:00 testosterone and other prescription medications do not have sufficient evidence so they should not be used and in addition over-the-counter supplements and so forth are actually reviewed in great detail in the commercial products chapter of the guidelines so i would also refer you to that for further discussion there and finally for people living with overweight or obesity who require pharmacotherapy for other health conditions we suggest choosing medications that are not associated with weight gain
27:00 - 27:30 so you'll see that recommendation and that theme echoed many times in many chapters in the guidelines so anti-depression medications anti-seizure medication diabetes medications antipsychotic medication there's many medications that within those classes that can cause weight gain but alternatives that actually can be weight neutral or weight negative so any patient struggling with weight we always want to be going to their list of medications to say is there anything here we can optimize anything that's working against
27:30 - 28:00 them in their health journey that we can improve upon so i'd now like to take you through our algorithm that we generated to help primary care in making a choice about okay i have this patient who's struggling with weight i want to help them i want to use a medication how do i decide which one to consider and this is really a pragmatic approach that we have developed so we'll go through this there's two
28:00 - 28:30 slides here and i'm going to jump a little bit back and forth between them uh so bear with me on that but again this is right out of the guidelines chapter so you can look at the whole picture if you want to call the chapter and look at it at the same time so starting at the top so we have a patient who has a bmi of 30 or more or bmi of 27 with obesity related comorbidity or comorbidities so first thing we want to do is look at their medication list is there anything here that is having an
28:30 - 29:00 adverse effect on their weight is there anything we can change here then we want to be thinking about the patient's comorbidities so if we go to the left is this a patient who has diabetes pre-diabetes hypertension obstructive sleep apnea polycystic ovary syndrome if so on the top left here this is now continuing down the down in our algorithm in if a patient has any of those conditions based on the evidence that we've presented today
29:00 - 29:30 we may consider the regulation as a first choice because there's evidence for improving these health-related comorbidities naltrexone bupropion could be a second choice and orlistat and again has less efficacy it also does nothing for appetite so we generally consider that a third choice medication if we now go to the right here in our flow chart what if this is a patient who really struggles with cravings what if they are having some you know they've got some blue mood and some depression issues that they're
29:30 - 30:00 struggling with what if they're a person who smokes and they're trying to quit going down to the next then in those situations we can consider naltrexone or bupre naltrexon bupropion as a first choice medication because we know that it reduces cravings we also know that euproprian individually as a medication is a medication that treats depression can also be helpful for smoking cessation so though that might be a way to marry the goals of helping that patient with their mood issue and their weight or helping
30:00 - 30:30 them to stop smoking and help them with their weight and therefore we have then listed naltrexone bupropion as a first choice to consider followed by the regulation and then order stat lower efficacy is third once we've chosen a pharmacotherapy we then want to assess after at least three months on therapeutic dose if that patient has not had sufficient success for weight management then we can either think about
30:30 - 31:00 stopping the medication if we think it hasn't helped at all or if it's helped some but not enough then we could consider keeping that medication on board and adding a second line agent and i would just like to point out that there currently are no studies of combination pharmacotherapy that we can refer to here as far as using them together but we recognize this is an evolving area it's an evolving field and we foresee that if we look a few years down the road that we will
31:00 - 31:30 see more studies of combination pharmacotherapy emerging and if we look 10 or 15 years from now i think we'll see what we have now in the diabetes world where we have many different classes of medications and we use combinations depending on what works best for our patient if we then respect the algorithm here after three months on therapeutic dose if we find that this medication is successful for weight management then we want to continue that medication long term so remember that obesity medication does
31:30 - 32:00 not cure obesity it helps to control obesity just like a blood pressure medication doesn't cure hypertension it controls it a diabetes medication doesn't cure diabetes it controls it obesity pharmacotherapy helps to control weight helps to manage weight and is intended as a long-term treatment so again pharmacotherapy is intended to be part of a long-term treatment
32:00 - 32:30 so i just want to pause a minute here and in the algorithm we talked about deciding whether a medication was sufficiently successful for that patient's weight management so we want to think about how have we helped in this patient's weight journey have we helped in improvement of health parameters most importantly really important is that we want to think about the patient's previous weight trajectory as we alluded to as well with our weight maintenance indication and recommendation
32:30 - 33:00 for pharmacotherapy so if you have a patient who's been saying you know i've been gaining 10 pounds a year for the last five years my weight keeps going up up and we start pharmacotherapy we re-evaluate and they come back and say you know what my weight is actually stable for the first time in so many years i haven't gained more weight i would consider that a success of pharmacotherapy and i would not stop the medication so the traditional guidance is that a patient needs to lose at least five percent weight after three
33:00 - 33:30 months on a full dose but we want to push the envelope on that and realize that that does not take into account the patient's previous weight trajectory and the person who has also who has lost weight with lifestyle change and now is able to avoid weight regain with pharmacotherapy that too is a success of pharmacotherapy if you have a patient that comes in and says you know yeah i've had some success but you know maybe you look at the weight has gone down by a couple of percent um also think about what factors could
33:30 - 34:00 be impeding the patient's weight loss efforts has another medication that been started perhaps that is actually contributing to weight regain is that patient struggling with mental health issues or emotional eating and we actually need to address that in order to have success and if we don't find any other etiologies and for the lack of success and we're having no success then again we we can try stopping the medication
34:00 - 34:30 trying something else or if we feel like it has had some success but perhaps not enough then we could consider keeping that medication on board and then consider adding a second agent so finally our key messages there are three medications indicated for chronic obesity management in canada in addition to health behavior change that's the regulation three milligrams naltrexone bupropion in a combination tablet and orlistan all three medications have been shown to be
34:30 - 35:00 effective in producing weight loss greater than placebo for a duration of at least one year in the clinical trials medications that are not approved as pharmacotherapy for obesity management should not be used for this purpose finally the individual response to obesity management pharmacotherapy is heterogeneous the response to medications can differ from patient to patient just like any other health condition in choosing
35:00 - 35:30 the most appropriate obesity medication we want to consider how it works safety potential side effects tolerability issues contraindications drug interactions mode of administration and thank you so much sue it's my great pleasure to introduce our panelists for today in addition to dr peterson and myself we
35:30 - 36:00 have dr priya manju dr sean wharton and dr arya sharma dr priya manchu is a specialist in internal medicine and endocrinology she is a diplomat of the american board of obesity medicine and a certified hypertension specialist she is co-director of the victoria cardio metabolic collaborative clinic and chair of the science committee in adult obesity or sorry adult clinical committee of obesity canada dr manju has contributed to several national project practice guidelines most recently the
36:00 - 36:30 obesity cpg and the ccs dislocated union guidelines she's on faculty at the university of british columbia and the university of victoria dr wharton the third author on this chapter has his doctorate in pharmacy and medicine he is the medical director of the wharton medical clinic a community-based internal medicine weight management and diabetes clinic he is an adjunct professor at mcmaster university in hamilton and york university in toronto he also works as an internist at women's
36:30 - 37:00 college hospital and the hamilton health sciences dr warton is a researcher and is qualified as a diplomat of the american board of obesity medicine dr wharton's research focuses on bariatric medicine and type 2 diabetes he is the co-chair of the canadian obesity guidelines dr sharma is was recruited from berlin germany in 2002 to a canada research chair in cardiovascular obesity medicine uh at mcmaster university in 2007 he
37:00 - 37:30 accepted a position as professor and chair in obesity research and management at the university of alberta where he's also the medical co-director of the alberta health services provincial obesity program in 2005 he spearheaded the launch of the canadian obesity network now obesity canada which has remarkably transformed the landscape of obesity research and management in canada his research focuses on an evidence-based approach to managing patients living with obesity and includes development of the edmonton obesity
37:30 - 38:00 staging system so we have a number of questions and thanks so much for upvoting them uh so i think we'll lead off with stephen theo and he was wondering about using their glutide in women with obesity [Music] who may become pregnant on treatment and also had some questions with regards
38:00 - 38:30 to [Music] obesity with other comorbidities in this case he was highlighting end-stage renal failure due to polycystic kidney disease um would anybody like to tackle some of these other aspects of use of their blue tie sure so maybe i'll i'll start with the pregnancy question and then maybe someone else wants to take the the other part of that question or the reverse is fine so as far as
38:30 - 39:00 pregnancy there is no safety evidence for any pharmacotherapy in pregnancy or breastfeeding so we want to also make sure that any pharmacotherapy for obesity is stopped prior to any conception attempts there's no data to inform us on exactly how long should it be stop prior to conception attempts we often say six weeks just to make sure that whatever they're on is completely out of their system
39:00 - 39:30 um but if i understood that correctly that patient had um gotten pregnant while taking the regulation three milligrams so as soon as if that patient were to call me and say oh hey i'm on saxenda and i oops i got pregnant i say okay well stop loreglutine and then there's really nothing more to do from there there's no evidence of any known harm of lareglotide when patients who do become pregnant on it but certainly we
39:30 - 40:00 want to be educating our patients who are on pharmacotherapy and are of reproductive potential that they need to stop it six weeks prior to any attempts to get pregnant if this was a patient who had pre-diabetes or type 2 diabetes we also have to watch the sugars very closely because when they stop the regulative being also a diabetes medication sugars could of course go up so we need to be watchful for that okay thanks uh anyone have any
40:00 - 40:30 thoughts with regards to really complex tertiary patient that stephen was sharing with us around who had um underlying end stage renal failure and difficulties with treatment due to excess adiposity arya how would you tackle that well i won't have any primary concern i mean there's not a lot of evidence of the use of these compounds in people with end-stage renal failure
40:30 - 41:00 uh but even with progressive renal failure i think if anything uh you know i would see this as somewhat protective actually because you know there's uh if you're talking about the tide here it does have a you know mild blood pressure lowering effect and maybe other metabolic benefits so i won't be i won't primarily be concerned i also don't think that you need a dose adjustment um but there's very little published literature on this perfect thanks uh yeah
41:00 - 41:30 as shawnee or i can comment on it as well we've been using a lyric bluetooth and glp1 analogs and patients with with that going into into end-stage renal failure and with egfr's lower than 20 in concert with the nephrologist so it's great that arya um spoke up so if you're working with the nephrologist and together you know that there's no toxicity you're monitoring everything then it works out really well it would be the only one out of the list that we currently have right now i would only use the glp1 analogs even though once weekly
41:30 - 42:00 we've actually been been using in in these end stage renal failure patients with the help of the of the nephrologist thanks sean so amanda and steven are asking us both um about duration of therapy and so how long would you maintain patients on these medications are there circumstances when you would recommend stopping them
42:00 - 42:30 bria do you want to take that one yeah sure uh i think that the all of the studies do show that when patients stop the medications they do regain weight and i think patients have to recognize or one of the things i share with patients is the management of weight is a long-term process um you know it's hard to say to a patient you're going to be on this medication for the rest of your life and and that's not usually the approach that
42:30 - 43:00 i take but i certainly share that there are times where medication is going to be more helpful to them um times when they need that support to maintain the healthy behaviors um and so one of the things i sort of say to patients is let's try let's let's see how you do on the medication first when you get to a point that you feel that you're you're able to sustain these behaviors and these changes there aren't a lot of external pressures we can try weaning it down a little bit and see how
43:00 - 43:30 you do and really it's a discussion with patients in terms of the duration of therapy um so that that's been my approach i also tell patients that um you know there another approach would be intermittent therapy throughout your throughout your life but most of my patients who've been on therapy and have had success on therapy feel that it's a lot easier to maintain the focus on healthy behaviors which is essentially what we're trying
43:30 - 44:00 to do with pharmacotherapy and most of them do not want to stop some do have to stop because of because of financial concerns um and in that situation there are a couple of uh strategies that that i use in terms of helping with samples or doing uh lowering the dose so that the medication can go a little bit further uh arya here so just in terms of intermittent treatment it's important i mean patients often start and stop medication with pretty much any
44:00 - 44:30 medication uh i think all you have to really tell them is that when you stop the medication uh you know at least for a week or longer you might not want to start with the last dose you are on the uptight trade again because otherwise you just get the side effects uh and that and that's happened quite a bit so it's also a question when you have a patient who's been tolerating the medication quite well and then suddenly you know after they've been on it for two or three months certainly you start complaining of side effects you need to ask whether they're
44:30 - 45:00 actually taking it regularly because what people what i've seen people do is that you know when they think they're they've reached a stable weight they actually start increasing the intervals between doses they don't take it every day and then the side effects start coming back i would also add to that that sometimes patients will say um they're nervous about damage to their metabolism or damage to their health somehow if they are to take it for a while and then they stop it like maybe they're afraid that well i don't know if my drug plan is gonna last for the rest of my life so if
45:00 - 45:30 i start this what's gonna happen if i stop so it's important that patients understand that it's not doing any damage to them if let's say they take it for a couple of years and they have good weight management success then they unfortunately lose their job and their drug plan and if they're not able to afford it the weight probably will go back up because as priya said that's what we see clinically and in the clinical trials as well but it's not doing any damage to them to do that and and the other thing i would add also is that
45:30 - 46:00 over time as obesity pharmacotherapy evolves i think it will be more about changing medication rather than you know how long do i take this do i take it for the rest of my life well probably no because probably as as time goes on we expect to see new pharmacotherapies actually probably in the very near future we'll see new treatment options and combination treatment options where it's actually about changing the approach to evolve with updated options for pharmacotherapy
46:00 - 46:30 super thanks guys uh so there's a couple questions here around um you know that we all have made a strong point in these guidelines the outcome isn't uh weighed its health however the point we're making here is that there are medical conditions where the excess adiposity is contributing to to harm to physical and metabolic harm for the person um and the point is being made that the weight loss can be highly variable from person to person
46:30 - 47:00 and some people may you know realize other benefits um regardless of the weight loss and so people are wondering about broadening out the outcome measures and some of these pharmacotherapy studies beyond weight and maybe someone can comment on what's happening in that space yeah i can i can uh i'd like to start with this question if that's okay um i think as we start using more of these agents uh to treat
47:00 - 47:30 uh to help patients achieve their their weight management goals you'll find some patients who say well this medication you know i'm not losing as much weight as i thought i did but it's so much easier to remain focused on the healthy behaviors and and i think that makes things less of a struggle for the patient um and so so that's one of the things that that i consider um very strongly when using a
47:30 - 48:00 medication it's not just you know weight management is is um is what this medication is approved for but we have to have a sue um outlined in the presentation appreciation of how um uh how that medication can affect different facets of of the patient's life so controlling craving may be better um it may be it may have more of an effect on their diabetes management for example with the glp-1 analogs
48:00 - 48:30 there are some studies that are open label studies that look at other parameters of uh well-being with contra those are open level open label studies and they're not the highest quality evidence but i think we'll start seeing more and more of those types of studies coming out looking at different aspects of of behavior and the effect of the medications on on behaviors that are important
48:30 - 49:00 to weight management and as we move on in pharmacotherapy research we also now are putting much more focus on studies looking at comorbidities so what about this medication and its benefit in osteoarthritis for example or patients with obstructive sleep apnea that's not well treated so there's really a movement in the obesity pharmacotherapy clinical trial world moving into having
49:00 - 49:30 more focus on the health-related comorbidities we still look at weight of course but we also really are having major focus on okay how does this what percentage of patients with pre-diabetes revert to normal glucose tolerance and questions like that okay great so we have some questions here related questions around people living with type 1 diabetes and obesity so i you know perhaps if there's different
49:30 - 50:00 medication experiences for that group of patients um and questions as well about timing of the medication and uh other medications have approved more for type 2 diabetes such as ozempic do you want to comment uh given your background with diabetes due on on how you might approach this in type 1 diabetes and then your medication choices for people with type 2 diabetes in this space sure so for type 1 diabetes
50:00 - 50:30 unfortunately there is really no clinical trials for patients with type 1 diabetes who are also living with overweight or obesity with regards to weight management pharmacotherapy it's definitely a gap in the literature that needs to be addressed there's lots of people with type 1 diabetes who struggle with weight just like the majority of canadian adults without diabetes also struggle with weight um there is a little bit of data with the regulation
50:30 - 51:00 at the diabetes treatment dose so for victoza in type 1 diabetes showing some reduction in weight there can be an increased risk of hypoglycemia because insulins need to be adjusted appropriately and a small increased risk of diabetic ketoacidosis which is probably not related to the medication so much as just um medication insulin adjustments needing to be done appropriately there's no data for contrave or or
51:00 - 51:30 lestatin type 1 diabetes so and then the type 2 diabetes question so there are as we already went through the data in patients with type 2 diabetes for all of these obesity medications there is also of course medications for type 2 diabetes that are not approved pharmacotherapy for obesity at least not at this time and of course the one that comes to mind is semaglotide which is ozempic at the dose of one milligram once weekly
51:30 - 52:00 and this medication seems to be based on what we know and very much evolving literature that this medication is an excellent medication for weight management in addition to diabetes treatment it's not yet fully uh it's not yet approved anywhere as a weight loss treatment or an obesity pharmacotherapy but it is being studied at actually a higher dose than the diabetes treatment dose diabetes treatment doses one milligram once weekly
52:00 - 52:30 and the obesity pharmacotherapy dose is higher than that and at this point in time there are four key trials which have had high level reports showing very impressive weight loss in the weight management trials but they are not yet published and it is not yet approved um in addition there are also sglt2 inhibitors which is type 2 diabetes treatment of course and now also has indications for treatment of heart failure and we'll also see and we also have good
52:30 - 53:00 data for renal protection now even in people without type 2 diabetes with dopageflozin which just came out and these are weight negative medications as well so this these are medications that can also be beneficial to help that patient with type 2 diabetes with weight management and now those indications are broadening beyond type 2 diabetes as well yeah just to clarify with weight sorry with weight negatives too there you mean uh they negative the weight will go down not that they're adverse oh wait yes correct we will yeah okay
53:00 - 53:30 i'd just like to sort of add um just in regards to patients with type 1 diabetes who are living with obesity it is not it wouldn't be incorrect to have a discussion with them about trying weight loss medications one would just have to be very careful in those patients to monitor for hypoglycemia and also to be very cautious about the risks that sue mentioned particularly dka which again the medications themselves
53:30 - 54:00 don't cause but by reducing the amount of insulin that the patient is taking you might inadvertently trigger that so you know i think a discussion with the patient is very reasonable set expectations choose the patient that you're going to use these medications in very carefully and balance the values and preferences of that patients in the context of the potential side effects but i think those patients do would certainly benefit from weight
54:00 - 54:30 loss medications unfortunately we don't have a lot of data in that area yet but i mean i think it could be done um with careful monitoring yeah and i i agree with pre on that absolutely uh as well and just to make sure that everyone here understands that that's off label um of course on any data yeah yeah so those are really tertiary questions at this point and um so super thanks for the details and
54:30 - 55:00 actually there's another really important i think tertiary question here which is um in people who are taking these medications for chronic chronic condition of obesity if they're admitted to hospital with different uh presentations would be would there be times where it would be really important to hold the medications uh or how would you manage uh recommend managing these medications in the in-patient setting john do you want to take that one
55:00 - 55:30 yeah this is sean here right um so i have seen that a number of patients have stopped their medications when they have they've gone into the hospital and i don't i i don't see it as a necessary step this is not an sglt team they have never when we're talking about the glp analogs i don't even think contrary if they're not in hospital or something that is specific to the medication i.e um excessive nausea and vomiting where there is a dehydration setting or there is a pancreatitis
55:30 - 56:00 i'm studying abdominal pain abdominal issues then those are conditions where you you would actually stop the the medication otherwise if they're in hospital for um for other reasons um that don't have to do with with medication i think there's a question there about a open open open fracture so um i i would be careful with with with the glc analogues if the dietary
56:00 - 56:30 interventions have changed and with the patient if they're not taking things orally for a period of time um stopping the medication for surgery would be necessary like any other hypoglycemic agent that could potentially cause hypoglycemia although this typically doesn't but if they're on very very low low amounts of calories that would be the issue there so normally i would not stop them for the majority of cases but i would in certain cases be that clinical doctor
56:30 - 57:00 in the hospital and make the appropriate call right another question guys just just so many good questions here when we talk about yo-yo dieting and arya you've certainly talked about this a lot and sort of the adverse effect of the on people in terms of their basal metabolic rate kimberly is asking whether or not there's any adverse effects from pausing these medications and restarting them will that reduce the effectiveness the next time that they take the medication
57:00 - 57:30 um and uh i don't know the answer to that so i'm hoping one of you guys does arya do you want to take that one sorry i was distracted just go ahead yeah just we're talking about yo-yoing and the risks of yo-yoing in terms of impact on basal metabolic rate and people's challenges with future weight loss and kimberly is asking the question about in in the case of medications if people take medications
57:30 - 58:00 and it already breaks yeah i mean there's always a risk that that you know you get metabolic adaptation anytime you lose weight now there's not a lot of literature on how long it lasts and how severe it is and there's certainly a lot of individual variability in how much people adapt uh so again it's something you want to be concerned about or or monitor carefully uh you know i wouldn't go as far as to advise that people actually measure metabolic rates but it's certainly one of those things that one needs to be cautious about uh we do know it happens with extreme weight cycling so when you
58:00 - 58:30 if you remember the people from the biggest loser who lost really enormous amounts of weight uh there was no doubt that there was a lot you know once a lasting effect but there certainly seems to be a long-term effect on metabolic adaptation uh you know whether smaller changes in body weights would have the same effect and whether that effect would last long or over time is is really not clear yeah i think i think the final sorry it's very small i'm just mindful of time because i would you want to wind up in a couple of minutes but i just wanted to barb's
58:30 - 59:00 been patient and has had her question at the top of the list for a while just around coverage because this is such a barrier to patients and there has been such work at obesity canada around trying to advocate for this uh can anyone give us a little bit of a summary um about health plans which cover or work that's going on with regards to advocacy for coverage yeah i mean this is a this is a moving target of course but as it stems right now about 20 of medical private medical plans cover
59:00 - 59:30 obesity pharmacotherapy meaning of course 80 do not so there's a major gap there and there's no public reimbursement so we as you said denise we really hope that these guidelines can serve as an important advocacy tool in order to improve access i mean for imagine not having the same situation in the diabetes world or the hypertension world that would be unacceptable so why should that be any different for this chronic medical
59:30 - 60:00 condition excellent okay well i'm i'm mindful that we're getting to the close and thanks to everyone so much for your questions um there are a number of um questions here that get into some of the other topics that would be great for the timed right group so i encourage you to um to join that group and carry on with these conversations between sessions i really want to thank all of our attendees today as well as all of our panelists and zoo
60:00 - 60:30 particularly for a great presentation uh all the guideline authors especially for this pharmacal therapy chapter which really is is so very important so we really appreciate your feedback for these sessions so there's a form that's up on your screen right now with a link or a qr code please give us your feedback and let us know how we are addressing your questions i'm glad that we triaged to make a separate bariatric surgery session because
60:30 - 61:00 obviously this was a rich and full session to the last minute today so thanks so much to everyone for your interest and look forward to seeing you online on the time break community thank you so much sue so on the panel this evening in addition to dr peterson and myself we have dr priya manju dr sean wharton and dr arya sharma dr priya manju is a specialist in internal medicine and endocrinology she's a diplomat
61:00 - 61:30 of the american board of obesity medicine and a certified hypertension specialist she's co-director of the victoria cardio metabolic collaborative clinic and chair of the science committee and adult clinical committee of obesity canada dr manages contributed to several national practice guidelines most recently the obesity clinical practice guidelines and the ccs dyslipidemia guidelines she's known faculty at the university of british columbia and the university of victoria
61:30 - 62:00 dr wharton has his doctorate in pharmacy and medicine he's the medical director of the wharton medical clinic a community-based internal medicine weight management diabetes clinic he is an adjunct professor at mcmaster university in hamilton and york university in toronto he also works as an internist at women's college hospital in the hamilton health sciences dr wharton is a researcher and has qualified as a diplomat of the american board of obesity medicine dr wharton's research focuses on bariatric medicine and type 2 diabetes he is the co-chair of the canadian
62:00 - 62:30 obesity guidelines dr sharma was recruited from the humboldt university in berlin germany in 2002 to a canada research chair tier 1 and cardiovascular obesity and management at mcmaster university in 2007 he accepted a position as professor and chair and obesity research and management at the university of alberta where he is also the medical co-director of alberta health services provincial obesity program in 2005 he spearheaded the launch of the canadian obesity network now obc canada which has remarkably transformed the landscape of obesity
62:30 - 63:00 research and management in canada his research focuses on an evidence-based approach to managing patients living with obesity and includes development of the edmonton obesity staging system so welcome everyone and thank you to everyone attending this evening i'm excited to see that the q a session is starting to heat right up so please upvote the questions you want answered and type in your questions and julius is kicking us off and asking about whether or not pharmacotherapy is a lifelong commitment
63:00 - 63:30 and whether there's any evidence that the accurate nucleus located uh weight set point can be reset after maintaining a lower weight over time uh so who on our panel wants to kick us off with that sean yes hello hi this is sean orton here thank you terrific question and i'm going to answer it very in a very succinct manner so you can get on to a lot of the other great questions so there is this is a very unfortunate um answer there is no evidence that the
63:30 - 64:00 accurate nucleus gets better there's no evidence that the second point gets better so when we think of um of of weight management you have to think of it as if the if the patient gets the weight down and um and the weight is stained down that's because they're keeping their foot on the gas that you take your foot off of the gas which is any behavioral intervention that you're doing any um uh uh any one of those three pillars that you happen to be doing things will go back to previous because
64:00 - 64:30 the arcuate nucleus and the scar tissue and the hormonal changes never change so they always want to go back to the previous weight so the only way you're keeping the weight off is by keeping your hair on the actual gas so that sometimes means going from one pillar to another pillar sometimes you're on the pharmacotherapy pillar then you introduce the psychological pillar or you use both of them together or you flip to bariatric surgery and the reason we have to use all of them all the time interchangeably
64:30 - 65:00 is because of this point that it doesn't go back to normal and the hormones keep on radiating did you want to chime in on that one yes i i think sean um described it really very very nicely and uh i i think uh sharing that with your patient uh sharing to them that it's not uh obesity is a chronic disease it is not a um it is not a disease of volition
65:00 - 65:30 it is a re it has a real neural biology that sort of makes it very hard to lose weight really the cert the the definition of survival is to achieve and maintain your highest weight and uh unfortunately our environments have changed and the arcuate nucleus doesn't function um as well in this environment as it did um in when uh when food sources etc were
65:30 - 66:00 less uh less available i mean that's a very simplistic way of of describing it but um i think the the goal of pharmacotherapy is to as sean put it make it easier for patients to keep the foot on the gas to keep those healthy behaviors going despite the pull and tugs of pharmacotherapy and you know there is some i myself have often wondered about this there is no evidence that that this set point can change but
66:00 - 66:30 i do sort of wonder about plasticity of the brain and again you know in younger patients i i'm always a little bit more aggressive in trying to get that weight down in a younger person because um one of the things we have to remember is that at whatever weight you attempt weight loss um and you attempt healthy behavior change you know there is a limit on how low you can go so it on average it's about five to fifteen
66:30 - 67:00 percent some people are as strong calls them winners and they can go further but if you start this process at 220 pounds we're looking at five to fifteen percent if you started at 300 pounds you're looking at five to fifteen 15 so the sooner we engage people in this process the easier it is to sort of uh achieve a lower weight sean what do you think about that yeah i really like the way that you
67:00 - 67:30 stated that it is that much so the higher they start at the less chance you'll get to getting to let's say a quote-unquote reasonable weight or weight that a person may want to actually be at so starting early is important and um and we really really know that so we should we should we shouldn't wait until their 60s and their 70s we should we we're looking at adolescents um starting really early because it's important we know also that there is an inflammatory process that happens
67:30 - 68:00 in the hypothalamus which is the appetite regulating center the fundamental basal regulation of weight in our brain and the longer you have obesity the more you have this inflammatory process that can lead to essentially scarring of that area and causes that hypothalamus to not function properly which is part of the the what defines that new set point so it also maybe helps us to understand why if someone has a um something in their
68:00 - 68:30 life where they gain some weight really quickly and temporarily like uh due to a new um like let's say they're on prednisone or in pregnancy or something like that that it may be easier to lose that weight that has only been present for the short term because it hasn't had that chronic inflammatory fibrotic effect yet so i completely agree with that with sean then and priya that we want to intervene earlier um we want to do what we can to help patients get weight down before that trajectory goes
68:30 - 69:00 up and up and up and persists over the long long term because the longer it goes on and the higher the weight the harder it is to have successful weight management doesn't mean we can't but it does make it more challenging the longer it's gone super so we have some questions here about sort of emerging therapeutics and um i would highlight to all the webinar attendees that there is a section in therapics chapter on emerging therapies we are very careful with the cpg to only endorse things that actually
69:00 - 69:30 have robust evidence but with that as a caveat nicole and teresa are asking about the status of clinical trials related to semiglutid and perhaps clinical experience with that perhaps in your patients with type 2 diabetes priya did you want to take a step at that one sure um i uh i i think um i'll uh i i do know that there have been uh very promising studies
69:30 - 70:00 showing uh the benefits of semiglutid in the for the role of weight management specifically i personally feel that there is a lot of off-label use and i think as long as you know we can't advocate off-label use um but i think if you're going to do that and you have a discussion with the patient that this is off-label we're not here there yet in terms of
70:00 - 70:30 approval for uh weight management but those trials are definitely coming if if you have an informed discussion with the patient and you document that they've been told it's an off-label use they're okay with that then i think that's that's a reasonable thing uh that's a reasonable approach again you know you may not get coverage for it there is no uh behavioral program or patient support programs um that that uh are associated
70:30 - 71:00 with drugs that are approved for weight management so uh sexenda or laragliotide has a patient support program contrave has a patient support program um so so i think those are just some of the things to consider but certainly you know it's semi-glutide is cheaper so it's certainly um i have myself had to do that in the best interest of my patient but i have uh discussions about that with them um sue i think is involved in some of
71:00 - 71:30 the the trials uh of some glue tight i think sean is as well and maybe i'll have them uh chime in sure yeah so uh so the the step program is the phase three clinical program for cement glutathide as an obesity treatment and it will be at a higher dose than what we're familiar with for type 2 diabetes so for type 2 diabetes the dose of ozempic is a maximum of one milligram weekly uh semiglutid for obesity will be 2.4 milligrams
71:30 - 72:00 weekly um the four key clinical trials from that step program have been completed uh they're not yet published we're working on publication and writing them up right now but the um data that has been released to the public is that it in some of the trials they've seen 16 to 18 weight loss at that dose so quite quite impressive versus about six percent on placebo so this will this is certainly the medication that is the next closest to
72:00 - 72:30 becoming the next approved obesity medication but i agree with priya in our patients with type 2 diabetes where we use it very regularly on label we see really nice weight loss results in the vast majority of patients super thank you so much and so that's a good segue into jody's question who's talking about the struggles with getting coverage for these medications and uh to make treatment more accessible
72:30 - 73:00 and um arya i'm wondering if you want to comment on the work that obesity canada has been spearheading uh in that direction well this is of course a big issue for uh you know for canadians living with bc and the last report card published by obc canada last year uh i mean it was clear that only about 20 of people of canadians have access to these medications and all of those are through private uh benefit plans and not even all private benefit plans cover obesity
73:00 - 73:30 medication so this really is an issue currently none of these medications perhaps with the exception of uh allistad or any of the public formularies uh and so that acts as really really difficult now in terms of advocacy i mean our own experience has been that sometimes when patients uh you know write a lot of letters make phone calls to speak to supervisors etc uh sometimes letters of support from the physician can help not always but we always advise that patients you know directly contact uh you know
73:30 - 74:00 the benefit provider and we've seen exceptions made so there are certain professional categories that appear to have really good coverage in some provinces so in the province of alberta for example all of the nurses uh have coverage all of the teachers have coverage um the rcmp has coverage uh the city police does not so you know there are wide swaths of you know professionals who do have coverage through their plans but it's very sketchy
74:00 - 74:30 and uh you know it continues to be that most canadians don't have access to these medications thanks arya yeah um there's a um a great question here from carfu about the use of pharmacotherapy and people who have had bariatric surgery as well as a two-part question also around the use of this in people who are older and sort of taking into account sarcopenic obesity and the application of these
74:30 - 75:00 medications um sean do you want to take a stab at that so great so in terms of patients post bariatric surgery so arya sharma has written an article and i've written an article on it when where we looked at research patients who have presented to our clinic post bariatric surgery who have gained weight we looked at them before lyric glue tied the first medication really to come out after
75:00 - 75:30 xenocow to see what type of weight loss we could get when we just implemented them to um to eat a little bit better go on a diet try to do their behavioral changes at that stage what they did was they gained 0.5 kilos so they stopped gaining weight and they kind of maintained so that was good but then when we got the introduction of medication they actually lost six kilos so we went from just maintaining to losing weight and every single other um clinical evidence in in in aria's series of patients there's
75:30 - 76:00 other ones in um other countries showing that the introduction of pharmacotherapy post bariatric surgery after patients have regained weight shows a positive impact it's not usually as great as we get with the patients who have not had previous bariatric surgery where we should get about 10 weight loss or so here we're getting about six kilos about six six percent weight loss maybe seven so it isn't it isn't bad and it's um it's it's much better than them continually gaining weight when it comes to the elderly um the majority of our patients
76:00 - 76:30 that come to our clinic are actually elderly and the majority of patients in many clinical trials um are quote-unquote older older than than 60 or in their 50s to 60 to 70. so patients do very well on pharmacotherapy many of these patients have elevated weight the same way a 35 year old or 45 year old does so they're no different now when it comes to sarcopenia or problems because um then that would not be something if if they're having a medical problem
76:30 - 77:00 because they are older because they have cancer because there's other things going on and that's not the time to use the the medication if they're adiposes causing a medical condition then we use it um and um and to battle some of the sarcopenia i would recommend of course um a lot of a number um doing doing resistance training which for a lot of ugly people they need to do yeah um this is uh priya hair just to
77:00 - 77:30 to chime in there i think um when you're also as sean rightly said you have to look at when you're looking at obesity pharmacotherapy you always have to weigh the risks and benefits so um your if your patient has a compelling even if that is an elderly patient who has a compelling reason for reducing weight and and there are there are certain uh situations whether it be um related to musculoskeletal issues or
77:30 - 78:00 um benign intracranial hypertension or their overall metabolic risk then you really do have to take that into consideration um if there is uh another reason why they're losing weight then then you also have to sort of put that into context like if the person does have cancer you know you're and there is weight loss for another reason you have to sort of uh decide if that's if if putting them on pharmacotherapy is
78:00 - 78:30 important um but in and of itself when you do lose weight um you do lose some muscle and there are some things that you can do to maintain that muscle so physical activity uh is important for example making sure in the elderly that they're getting enough protein to meant to end and having adequate nutrition as well as physical activity to maintain the muscle mass are some of the things that you can do to to offset that sarcopenia thank you priya um i i
78:30 - 79:00 just wonder if anybody has any other things to comment on that or will pivot to the question about binge eating disorder okay sue um do you want to just comment on your experience with um treatment with binge eating disorder so julius is is is bringing that up which is really excellent because we we haven't really discussed it um and is wondering also about whether there could be broader application of some of the medications used for that condition in in other patients living with obesity yeah so i i
79:00 - 79:30 see that the question is whether the some of the weight loss from binge eating disorder treatments is through just appetites is it appetite suppression is it treating the um impul impulsivity aspect and and it's it's i'm sure it's both and actually um vyvanse for binge eating disorder actually uh also has the um it has an indication for treatment of binge eating disorder and is also can be very effective to help those patients lose weight as well because of
79:30 - 80:00 the adrenergic properties as well mhm yeah yeah yeah so so the importance of recognizing impulsivity uh and it's not actually not just binge eating disorder it's also attention deficit disorder so these patients have i have problems with impulse control uh and it's it's it's really extremely difficult for these patients to follow meal plans to plan meals to keep food diaries to uh you know that's just part of part of their situation and that's where we find that medications that are indicated for
80:00 - 80:30 attention deficit disorder or in the most specific case as was mentioned by vance for the specific indication of binge eating disorder is extremely helpful not so much because these medications actually cause weight loss but because they allow patients to do the things that they need to be doing uh and uh so you know in the same way so i look at a lot of these medications similar as i look to the depression medication if you have a patient who's got severe depression you're not going to get anywhere in terms of weight management because someone who has depression is simply not
80:30 - 81:00 doesn't have the motivation doesn't have the energy it doesn't have the focus uh you know to do all the things that would be necessary to actually you know make those lifestyle changes take the medication and show the initiative uh and uh so you have to treat the depression first in order to actually make progress here and i think when you talk about someone with a binge eating disorder or or adhd it's a similar situation you have to kind of treat that condition first so that the patient can then do what is necessary uh to better control their their obesity
81:00 - 81:30 thanks hurry up did you want to chime in on that one um just to say that that often binge eating disorders are associated with other um behavioral diagnoses so specific psychiatric diagnoses and uh you know screening that patient for depression getting getting and getting a mental health uh profession involved to help you as needed is important it's not just a matter of treating it with a drug i think the drug is one part of it but there's a lot of
81:30 - 82:00 other aspects of the disease process that has to be considered and management so it's one of those one of those again it highlights the importance of a multi-disciplinary approach thanks priya that's a great note to end on so for leslie um uh he's got a great question here just around practicalities in your experience with treating patients with um obesity with pharmacotherapy and and
82:00 - 82:30 you know what kind of side effects and intolerances you may be experiencing and how you work around it so uh specifically was wondering about how often you might find patients intolerant to the lyric illusion at three milligrams um subcutaneously so sue do you want to chime in on on lindsay's question so the red glue tide and caught and contrary so saxena and contrary both of them are titratable medications and for both of them the recommendation for titration gets
82:30 - 83:00 you to the therapeutic full dose after about a month so both of them you increase the dose usually by uh once a week until you get to the full dose most people tolerate those rates of titration very well without any problems but sometimes people will experience so the question here is for regular types we'll focus on that some people experience some gastrointestinal side effects because the regulation transiently delays uh slows gastric emptying which
83:00 - 83:30 is a transient phenomenon that usually goes away after a patient has been on medication for a couple of months um so if a person is struggling with those kinds of side effects i would suggest a few things one is you can slow the rate of titration it's not a sprint it's a marathon so some people will take a few months to get up to the full dose that's totally okay so we can back off if they get to let's say 1.8 milligrams which is the third titration step oh no i don't feel so good okay go back to 1.2 we'll do that for a little longer
83:30 - 84:00 you can even count up clicks between clicks between doses on the on the pen and work your way up even more slowly the second thing that i recommend is looking at the dietary pattern avoiding spicy food during the titration phase anecdotally can help making sure that the meals are smaller because sometimes it um it's that um habitual process that a person has of this is how much food i should be eating this is how big my breakfast is this is helping my lunches this is how it's been their whole adult
84:00 - 84:30 life and now their body is telling them stop i'm not i don't want this much food but the um habitual nature of it maybe they try to keep eating that and then they don't feel good so smaller meals and also lower fat during the titration phase can help to mitigate some some of those side effects and with all of those strategies most people will tolerate the photos super thanks to arya did you want to chime in on that uh no that was a pretty
84:30 - 85:00 comprehensive answer okay great well then our last question is from marie claude who's wondering about with binge eating disorder whether you might um come do a combination of psychostimulant plus weight loss medication is wondering about contrave together with five amps is that something that anybody's ever tried before certainly i'm sure there's no studies about it but yeah i'm showing shawn morton here yeah i would be a little hesitant with
85:00 - 85:30 by that's a contrave as a combination we know that contrary does have a lot of interactions with a number of medications does it have an irrational vibrancy i actually looked it up once um recently and uh it said no that there wasn't really a interaction um with with the vitamins but we do know that you're dealing with a um uh the that the where when we look at at the bu program component there's an adrenergic component to it which is why the bupropion is usually called a booster so you have an antidepressant that usually
85:30 - 86:00 works like um ciprolex or something then you put the and the person's mutus isn't quite high enough so you give them this adrenergic agent norepinephrine um dopamine mean we uptake inhibitor and um and it ends up boosting things a little bit so you combine that with vivants i don't know where things are going to go so sometimes is combined by vans with the glp-1 analogs and because there i i i there's not an interaction that i am aware of that would cause a problem that's what i tend to do yeah and um
86:00 - 86:30 yeah i think just just to add to that i i think uh again as sean highlighted with bupropion uh there are interactions with um the cytochrome uh uh p450 system so the drug is both metabolized by and affects other cyclo um uh systems in the liver uh i think um what sean mentioned about the excitability uh
86:30 - 87:00 and of having new two neural stimulants i would worry a little bit about increasing the seizure potential as well because um uh both uh bupropion and bupropion can lower that seizure threshold a bit so one of the contraindications is patients who have a history of of seizures um and vivance can do the similar things so so that would be one of the concerns um i think i would in that situation opt for as sean said uh using a glp-1
87:00 - 87:30 analog super well thanks so much to all of our panelists and especially sue for the wonderful presentation and to all of the attendees participating today um i really encourage you to join the timed right community where there's lots of opportunity to have further dialogue uh between webinars it's getting very dynamic lots of things going on so um please uh sign in and check that out uh and also we really do appreciate your feedback so if you could provide us some
87:30 - 88:00 feedback and perhaps some experiential evidence from your own clinical practice in our qr code that would be tremendous as well