A common concern people have before starting one of the new generation highly effective chronic weight management medications is that they will need to take them indefinitely. Is it true that there are only two possible realities, that you need to either take the medication forever or you will have weight recurrence after you stop it?
I think that it is not that simple, and a little more context and background here is helpful. When I quit my job in 2014 to hang a shingle and open a private practice to treat obesity full-time, I was a little on the fringe of the current standard of care because, until then, most medications used for weight management were labeled for “weight loss” and FDA approved to use for 12 weeks. So, the usual experience of a patient was to be prescribed a medication for weight loss, experience that weight loss, only to be told they should not take the medication anymore because they were no longer losing weight, it was not “good” to take long-term, and they should balance their calories in with their calories out and maintain their weight loss that way. Well, it is known now that metabolic adaptation to weight loss, genetics, environment, and many other potential factors make weight recurrence common, especially without expert counseling on what strategies have actually been shown to work. Many people would experience weight recurrence. Due to misinformation, weight stigma and bias, this would be interpreted as more evidence to not treat weight in the first place, and it was very rare for a doctor to prescribe and manage medications for weight loss and people were left to mostly seek options elsewhere.
Now that the physiology of weight regulation is better understood, the FDA does not approve medications for weight loss, only for chronic weight management. This means that the manufacturer must demonstrate that the drug is safe and effective not only for weight loss but also for chronic weight management. This means it must not only cause weight loss, but it must keep the weight off, and it must do so safely. This means it has been shown that, after two years, the initial weight loss is still sustained if the patient keeps taking the medication. They also have to monitor for cardiovascular health to ensure it is safe to keep taking. This new paradigm of chronic weight management versus weight loss is important for several reasons. It means people don’t have to weight cycle because their medication was stopped when they stopped losing weight. It is also important for things like insurance reimbursement of the medications when a BMI reaches a “normal” range. It is also important simply for the normalization of taking a medication for weight management over time. After all, if someone is taking a medication for high blood pressure, and their blood pressure gets into the normal range, does their doctor tell them they should stop taking their medication? Of course not, so why was it always different for weight management medication? On the other hand, sometimes people need to stop their blood pressure medication, and so do people sometimes stop their weight management medication. But, the conversation about weight management has shifted to reflect the understanding of the physiology of weight regulation. I counsel people that they now have the option to take the medication as long as needed for them individually for their personal health goals. It is known to be safe and effective (within the label’s parameters), for as long as they need it, and their doctor should not stop prescribing it and their insurance should not stop paying for it.
When I talk to an individual, I try to personalize this information for them. This is the essence of shared decision making, and something you can only do with a healthcare provider with whom you have a patient-physician relationship. For some people, they feel they do not need to take a weight management medication long term. They may have experienced temporary circumstances that led to weight gain, such as a lifestyle change, family change, or medical event. Their experience is that in the current situation, a medication is needed, but expect that things will change. On the other hand, for some people, taking this one medication can prevent the need for several others and likely prevents many other complications. For example, someone may have had excess weight much of their life and now been diagnosed with high blood pressure, high blood sugar, arthritis, and sleep apnea. Taking this medication can lead to a 20% weight loss, which can lead to remission of these other conditions. So, essentially, they are taking one injection a week instead of three daily medications, wearing a CPAP at night, and having mobility limitations. In this situation, one medication to treat the underlying cause of many conditions and prevent the need for many other medical interventions, is their preferred option.
Another consideration when considering whether to take these medications temporarily even if you do not intend to take them long term is the concept of “adiposopathy.” Adiposopathy is the concept that adipose (fat) is an active endocrine organ, not just inert storage of energy. Adipose secretes “adipokines” which are chemical messengers that affect the functioning of other tissue, promoting further weight gain and metabolic dysfunction. This may be visceral fat or white fat that is resistant to simple diet and exercise. Using medication to treat this metabolically dysfunctional adipose may lead to a place with less metabolic dysfunction to maintain.
I think the message when considering these medications is:
They are used as an adjunct to diet and exercise.
Shared decision making is crucial. This requires a patient and health care provider to work together to make a decision, taking into account evidence-based information, the provider’s knowledge and experience, and the patient’s values and preferences. This can not be done ordering these from a questionnaire online.
These medications are a tool, and, like any tool, they can be used wisely or imprudently.
If these medications are discontinued after successful weight loss, the recommendation is to wean the dose and monitor for weight recurrence.
Maintaining weight loss without medication or surgery typically requires specific diet, exercise, and habits, including monitoring calorie intake, tracking weight at home several times per week, and making exercise a routine part of most days.
As these medications have been in use for a few years now, the data from sources available show that many people are discontinuing these medications in real use. The cause is not certain, but I have found that proper counseling on how to get started and titrate them while adjusting to side effects and seeing the results expected, can require adjustments and personalization along the way.
And, if you are taking one of these medications and want to stop it, don’t go it alone. Be sure you have an expert on your side. Losing weight is hard, and keeping it off can be even harder.
In conclusion, make this decision with a healthcare provider with training and experience in this specialty who takes into account your complete medical history and data and your personal goals and values. There is not one right path. Your health journey is unique and your own.
Take Back Your Healthcare Decisions,
Valerie Hope-Slocum Sutherland, MD
Thank you for this, an interesting informative read.