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In my practice as a weight management physician, I routinely see patients with medication lists that are a mile long. This is not entirely unexpected. With obesity comes comorbid disease, and with disease often comes pharmacotherapy. In fact, it’s not unusual to see people on 10 or more medications when they first walk into my office. As a result, one of the first questions I usually ask myself is not, “What new medication can I start this patient on?”, but rather, “What old medication(s) can I stop?”
Many commonly used medications are notorious for either promoting weight gain or impeding weight loss. These include some classes of antidepressants, seizure medications, insulin, beta blockers, and even something as benign-sounding as antihistamines. While there are patients for whom these medications are absolutely necessary despite their risk of weight gain (e.g. prednisone in a patient with active rheumatologic disease, metoprolol in a patient with coronary artery disease), there are also countless examples of patients who are needlessly left on weight-gain promoting medications when alternative, weight-neutral (or even weight-loss promoting!) options are available.  

Although there are now several FDA-approved medications for weight loss, many physicians and patients remain hesitant to initiate therapy with these agents. A long history of horror stories from drugs like Fen-Phen, Sibutramine and others has sensitized the medical profession to the idea that some drugs may harm more than they help, especially when it comes to weight management. For patients and physicians sharing these hesitations, an alternative strategy might be to put both a patient and his/her medication list on a diet. A careful review of the patient’s history of weight gain, examining for coincident initiation of medications, is a good place to start (e.g. “It looks like you’ve gained about 30 pounds since starting on Paxil. What about a trial of Wellbutrin instead?”).  Asking about over-the-counter medication use (e.g. “Are you taking Zyrtec every day?”) is also important.

Clearly, for most patients, these kinds of changes will not result in dramatic weight loss. However, they may remove unrecognized barriers to the impact of behavior changes like diet and physical activity. Helping patients start to see results from their efforts at cutting calories and getting more exercise can be incredibly motivating. For physicians treating patients with obesity, the take-home message should be, “If you’re not comfortable starting a new drug, how about stopping one instead?”

 


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