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Am Fam Physician. 2011;84(2):149-154

Original Article: Weight Loss Maintenance
Issue Date: September 15, 2010
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to the editor: On behalf of the American Society of Bariatric Physicians (ASBP), I would respectfully like to address several shortcomings of the article by Drs. Grief and Miranda.

Primary care medicine has fostered a bias against the treatment of obesity, and the article in AFP perpetuates such a bias. Although there are numerous drugs available for the treatment of obesity, the article mentions only two: orlistat (Xenical) and sibutramine (Meridia). Since sibutramine has been withdrawn from the market, it is even more pertinent that the article should have included information about alternative anorexants. Medical bariatric experts routinely prescribe older anorectic drugs, including phentermine, diethylpropion, and phendimetrazine. These drugs are prescribed far more often than orlistat and sibutramine. 1 Topiramate (Topamax)—originally approved by the U.S. Food and Drug Administration (FDA) in 1996 to treat epilepsy, but known to be an effective anti-obesity drug—also is used more widely in bariatric clinics than orlistat or sibutramine. 1

Although none of these alternative anorexants have been approved by the FDA for long-term use, experts in obesity treatment have long acknowledged that if an anti-obesity drug is effective for a patient, it should be used long-term for maintenance. 2 Phentermine is the most widely used anti-obesity drug in the United States and is often used long-term for maintenance in medical bariatric programs. 3 Approved in 1959, long before the FDA decided to require two-year clinical trials before approving a new anti-obesity drug, 4 phentermine remains the most popular anti-obesity drug. Its wide-spread use for the past 51 years is a far stronger testament to its effectiveness and safety than any long-term controlled trial. Clearly, obesity treatment experts believe phentermine should be considered as the first choice for any patient on long-term weight loss maintenance.

Long-term pharmacotherapy should be thoroughly considered for every patient during weight loss treatment and maintenance. The ASBP recently published Overweight and Obesity Evaluation and Management guidelines, which address various issues related to the treatment of obesity. 5

in reply: I thank Dr. Richardson for his letter about our article and his concerns regarding the information on pharmacotherapeutic options for weight loss maintenance. As Dr. Richardson points out, there are many non–FDA-approved medications available for treating weight loss. 1 The goal of our article was to provide an update on interventions that succeed in maintaining weight loss; a secondary goal was to share with the physician audience all FDA-approved medications that have been tested, studied, and confirmed to be of utility for long-term usage and for weight loss maintenance, defined as at least one full year of treatment. Off-label use of medications for weight loss was outside the scope of our article. A final goal of the article, albeit a tacit one, was to enhance the partnership and collaborative dialogue between primary care physicians and bariatric surgeons. Therefore, we consulted a bariatric surgeon at our affiliated institution in the preparation of our manuscript. We welcome continued dialogue as to best practices in treating patients for weight loss maintenance and encourage more research on this extremely important topic.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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