AACE/ACE ALGORITHM FOR THE MEDICAL CARE

OF PATIENTS WITH OBESITY

Patient Screen positive for overweight or obesity Presence of weight-related disease or complication
Presentation BMI ≥25 kg/m2 (≥23 kg/m2 in some ethnicities) that could be improved by weight loss therapy

• Medical history • Physical examination • Clinical laboratory

Evaluation • Review of systems, emphasizing weight related complications
• Obesity history: graph weight vs age, lifestyle patterns/preferences, previous interventions

• Confirm that elevated BMI represents excess adiposity

Anthro- • Measure waist circumference to evaluate cardiometabolic disease risk
Diagnosis

pometric
BMI kg/m2
Diagnosis
<25 25–29.9 OVERWEIGHT | ≥30 OBESITY
NORMAL WEIGHT
<23 Checklist of Obesity-Related Complications
Clinical in certain ethnicities
(staging and risk stratification based on complication-specific criteria)

Diagnosis Waist circumference below

regional/ethnic cutoffs None Mild to Moderate Severe

STAGE 0 STAGE 1 STAGE 2

One or more mild- At least one severe

to-moderate complica- complication or
Diagnostic NORMAL WEIGHT No complications tions or may be treated requires more
effectively with aggressive weight loss
Categories (no obesity)
moderate weight loss for effective treatment

OVERWEIGHT BMI 25–29.9

BMI ≥25 BMI ≥25
OBESITY BMI ≥30

PRIMARY SECONDARY
Phases of TERTIARY
Prevent Prevent progressive
Chronic Disease overweight/obesity weight gain or achieve Achieve weight loss sufficient to
Prevention and weight loss to prevent ameliorate the complications and
complications prevent further deterioration
Treatment Goals

• Healthy meal plan • Lifestyle/behavioral • Lifestyle/behavioral • Lifestyle/behavioral

therapy therapy therapy
Treatment Based • Physical activity
• Consider pharmaco- • Consider pharmaco- • Add pharmaco-
on Clinical • Health education
therapy if lifestyle therapy (BMI ≥27) therapy (BMI ≥27)
Judgment • Built environment alone not effective • Consider bariatric
surgery (BMI ≥35)

• Once the plateau for weight loss has been achieved, re-evaluate the weight-related complications. If the
complications have not been treated to target, then weight loss therapy should be intensified or
Follow-Up complication-specific interventions need to be employed.
• Obesity is a chronic disease and the diagnostic categories for obesity may not be static. Therefore, patients
require ongoing follow-up, re-evaluation, and long-term treatment.

Abbreviation: BMI = body mass index

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 ANTHROPOMETRIC COMPONENT OF THE MEDICAL DIAGNOSIS OF OBESITY
Evidence-based screening and diagnosis for excess adiposity in clinical settings

Screening Annual BMI

• BMI ≥25 kg/m2 • BMI <25 kg/m2

Diagnosis
• BMI ≥23 kg/m2 for • BMI <23 kg/m2 for
(Anthropometric Component)
some ethnicities some ethnicities

1. Clinical interpretation of BMI: Ensure elevated BMI is indicative of excess

adiposity by assessing: age, gender, muscularity, hydration status, edema, third
space fluid collection, large tumors, sarcopenia
2. Waist circumference if BMI <35: Adds information pertaining to Clinical Component
cardiometabolic disease risk; use gender- and ethnicity-specific cut-off values of Diagnosis
3. Can consider body composition technologies: eg, bioelectrical impedance,
air/water displacement plethysmography, or dual-energy x-ray
absorptiometry scan

Abbreviation: BMI = body mass index.

CLINICAL COMPONENT OF THE MEDICAL DIAGNOSIS OF OBESITY

Evaluate for a checklist of weight-related complications. Candidates for weight-loss therapy can present with either excess
adiposity (ie, the anthropometric component) or weight-related complications (ie, the clinical component)

Patients Present with Patients Present with

Candidates for Weight
Overweight or Obesity Weight-Related Disease or Complication
Loss Therapy
(Anthropometric Component) (Clinical Component)

Prediabetes
Metabolic Syndrome
Evaluate for weight-related Type 2 Diabetes
complications Dyslipidemia
Hypertension
Patients present
Cardiovascular Disease
with BMI ≥25 kg/m2,
Nonalcoholic Fatty Liver Disease
or ≥23 kg/m2 in Evaluate for overweight
certain ethnicities, Polycystic Ovary Syndrome
or obesity
and excess adiposity Female Infertility
Male Hypogonadism
Obstructive Sleep Apnea
Asthma/Reactive Airway Disease
Osteoarthritis
Urinary Stress Incontinence
Gastroesophageal Reflux Disease
Depression

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 CHECKLIST OF WEIGHT-RELATED COMPLICATIONS:
SCREENING AND DIAGNOSES IN PATIENTS WITH OVERWEIGHT/OBESITY

Weight-Related Basis for Screening and/or Suggested Secondary Testing When Needed To Confirm
Complication Diagnosis Diagnosis, Stage Severity, or Guide Therapy
Prediabetes Fasting glucose; A1C; If fasting glucose is 100-125 mg/dL, a repeat elevated fasting glucose completes
2-hour OGTT glucose diagnosis of IFG; however, 2-hour OGTT should also be performed to exclude
diabetes and IGT. Fasting and 2-hour OGTT should be performed if initial fasting
glucose is normal and A1C is elevated, or in high-risk patients based on family
history or metabolic syndrome.

Metabolic Syndrome Waist circumference, blood Initial evaluation completes diagnosis; OGTT to test for IGT or diabetes.
pressure, fasting glucose,
triglycerides, HDL-c
Type 2 Diabetes Fasting glucose; A1C; Overtly elevated (i.e., ≥200 mg/dL) or a repeat fasting glucose ≥126 mg/dL
2-hour OGTT glucose; completes diagnosis. If fasting glucose and/or A1C is consistent with prediabetes,
symptoms of hyperglycemia 2-hour OGTT should be performed to test for diabetes. A1C should be performed
to help guide therapy.
Dyslipidemia Lipid panel (total cholesterol, Lipid panel completes diagnosis; lipoprotein subclasses, Apo B-100 may further
HDL-c, triglycerides, LDL-c, define risk.
non-HDL-c)
Hypertension Sitting blood pressure Repeat elevated blood pressure measurements to complete diagnosis; home blood
pressure or ambulatory blood pressure monitoring may help complete testing.
Cardiovascular Disease Physical exam; ROS; history and Additional testing based on findings and risk status (eg, ankle-brachial index,
medical records stress testing, coronary artery calcium score and the MESA risk score calculator,
arteriography, carotid ultrasound)
NAFLD/NASH Physical exam; LFTs Imaging (eg, ultrasound, MRI, elastography) and/or liver biopsy needed to
complete diagnosis.
PCOS and Female Physical exam; ROS; menstrual Hormonal testing (eg, androgen levels, SHBG, LH/FSH, estradiol), ovulation
Infertility and reproductive history testing, imaging of ovaries, may be needed to complete diagnosis.
Male Hypogonadism Physical exam; ROS Hormonal testing (total and free testosterone, SHBG, LH/FSH, prolactin) as needed
to complete diagnosis.
Obstructive Sleep Apnea Physical exam; neck circumference; Polysomnography needed to complete diagnosis.
ROS
Asthma / Respiratory Physical exam; ROS Chest x-ray and spirometry study may be needed to complete diagnosis.
Disease
Osteoarthritis Physical exam; ROS Radiographic imaging may be needed to complete diagnosis.
Urinary Stress Physical exam; ROS Urine culture, urodynamic testing may be needed to complete diagnosis.
Incontinence
GERD Physical exam; ROS Endoscopy, esophageal motility study may be needed to complete diagnosis.
Depression, Anxiety, History; ROS Screening/diagnostic evaluation or questionnaires based on criteria in Diagnostic
Binge Eating Disorder, and Statistical Manual of Mental Disorders; referral to clinical psychologist
Stigmatization or psychiatrist.
Disability Physical exam; ROS Functional testing may be helpful.

Additional Evaluation Relevant to the Differential Diagnosis of Obesity

Interpretation of BMI Physical exam to ensure that Assess muscularity, edema, volume status, pregnancy, third space fluid
BMI value is indicative of excess accumulation, sarcopenia, large tumors, lipodystrohy, etc. Bioelectric impedance,
adiposity air/water displacement plethysmography, or dual-energy absorptiometry scan
may be considered.
Obesity Secondary to Physical exam; ROS TSH for suspected hypothyroidism; salivary/serum/urine cortisol for
Hormonal Disorder hypercortisolism if clinical findings or symptoms present.
Iatrogenic Obesity Review current medications and Follow-up following withdrawal of offending medication and/or substitution with
(e.g., secondary to medication history weight-neutral alternative may be needed to complete diagnosis.
medications)
Genetic Syndrome Physical exam; ROS; family history If clinical findings are suggestive, genetic testing of patient and perhaps family
members may be needed to complete diagnosis.

Abbreviations: A1C = glycated hemoglobin; BMI = body mass index; FSH = follicle-stimulating hormone; GERD = gastroesophageal reflux disease; HDL-c = high-density lipoprotein
cholesterol; IFG = impaired fasting glucose; IGT = impaired glucose tolerance; LFTs = liver function tests; LDL-c = low-density lipoprotein cholesterol; LH = luteinizing hormone; MRI =
magnetic resonance imaging; NAFLD = non-alcoholic fatty liver disease; NASH = non-alcoholic steatohepatitis; OGTT = oral glucose tolerance test; PCOS = polycystic ovarian syndrome;
ROS = review of symptoms; SHBG = sex hormone binding globulin; TSH = thyroid-stimulating hormone.

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 LIFESTYLE THERAPY
Evidence-based lifestyle therapy for treatment of obesity should include three components

MEAL PLAN PHYSICAL ACTIVITY BEHAVIOR

• Reduced-calorie healthy meal plan • Voluntary aerobic physical activity An interventional package that
• ~500–750 kcal daily deficit progressing to >150 minutes/week includes any number of the following:
performed on 3–5 separate days
• Individualize based on personal • Self-monitoring
per week
and cultural preferences (food intake, exercise, weight)
• Resistance exercise: single-set
• Meal plans can include: • Goal setting
repetitions involving major muscle
Mediterranean, DASH, low-carb, • Education (face-to-face meetings,
groups, 2–3 times per week
low-fat, volumetric, high protein, group sessions, remote technologies)
vegetarian • Reduce sedentary behavior
• Problem-solving strategies
• Meal replacements • Individualize program based on
preferences and take into account • Stimulus control
• Very low-calorie diet is an option
physical limitations • Behavioral contracting
in selected patients and requires
medical supervision Team member or expertise: • Stress reduction
exercise trainer, physical activity coach, • Psychological evaluation,
Team member or expertise:
physical/occupational therapist counseling, and treatment
dietitian, health educator
when needed
• Cognitive restructuring
• Motivational interviewing
• Mobilization of social support
structures
Team member or expertise:
health educator, behaviorist, clinical
psychologist, psychiatrist

WHEN TO INITIATE WEIGHT-LOSS MEDICATIONS IN PATIENTS WITH OVERWEIGHT/OBESITY

INITIATE WEIGHT LOSS MEDICATION AS AN

INITIATE LIFESTYLE THERAPY
ADJUNCT TO LIFESTYLE THERAPY

1. No Complications. 1. Failure on Lifestyle Therapy.

Patients with overweight or obesity who Add medication for patients who have
have no clinically significant weight-related progressive weight gain or who have not
complications (secondary prevention) achieved clinical improvement in weight-related
complications on lifestyle therapy alone.

2. Mild to Moderate Complications. 2. Weight Regain on Lifestyle Therapy.

• Patient with mild to moderate weight- Add medication for patients with overweight
related complications when lifestyle therapy (BMI 27–29.9 kg/m2) or obesity who are
is anticipated to achieve sufficient weight experiencing weight regain following initial
loss to ameliorate the complication success on lifestyle therapy alone.
(tertiary prevention)
• Note: weight loss medications may also be
indicated based on clinical judgment 3. Presence of Weight-Related
Complications.
Initiate medication concurrent with lifestyle
therapy for patients with overweight (BMI 27–
29.9 kg/m2) or obesity who have weight-related
complications, particularly if severe, in order to
achieve sufficient weight loss to ameliorate the
complication (tertiary prevention).

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 TREATMENT GOALS BASED ON DIAGNOSIS IN THE MEDICAL MANAGEMENT
OF PATIENTS WITH OBESITY

D I AGNOSI S TREATMENT GOALS

Anthropometric Clinical Intervention/ Clinical Goals
Component Component Weight-Loss Goal

PRIMARY PRE VENTIO N

Primordial BMI ≤25 (≤23 in certain Obesogenic environment • Public education Decreased incidence of overweight/obesity
Prevention ethnicities) • Built environment in populations
• Access to healthy foods

Primary BMI ≤25 (≤23 in High-risk individuals or subgroups based • Annual BMI screening Decreased incidence of overweight/obesity
Prevention certain ethnicities) on individual or cultural behaviors, • Healthy meal plan in high-risk individuals or identifiable
ethnicity, family history, biomarkers, • Increased physical activity subgroups
or genetics

SE CO NDARY PRE VENTIO N

Overweight BMI 25–29.9 (BMI 23–24.9 No clinically significant or detectable • Prevent progressive • Prevent progression to obesity
in certain ethnicities) weight-related complications weight gain or • Prevent the development of weight-
• Weight loss related complications
Obesity BMI ≥30 (≥25 in certain No clinically significant or detectable • Weight loss or Prevent the development of weight-related
ethnicities) weight-related complications • Prevent progressive complications
weight gain

TERTIARY PRE VENTIO N

Overweight BMI ≥25 Metabolic syndrome 10% Prevention of T2DM
or Obesity (≥23 in certain
ethnicities) Prediabetes 10% Prevention of T2DM

T2DM 5% to ≥15% • Reduction in A1C

• Reduction in number and/or doses of
glucose lowering medications
• Diabetes remission especially when
diabetes duration is short

Dyslipidemia 5% to ≥15% • Lower triglycerides

• Raise HDL-c
• Lower non-HDL-c
Hypertension 5% to ≥15% • Lower systolic and diastolic BP
• Reductions in number and/or doses of
antihypertensive medications
Nonalcoholic Steatosis 5% or more Reduction in intrahepatocellular lipid
fatty liver
disease Steatohepatitis 10% to 40% Reduction in inflammation and fibrosis

Polycystic ovary syndrome 5% to 15% or more • Ovulation

• Regularization of menses
• Reduced hirsuitism
• Enhanced insulin sensitivity
• Reduced serum androgen levels

Female infertility 10% or more • Ovulation

• Pregnancy and live birth

Male hypogonadism 5% to 10% or more Increase in serum testosterone

Obstructive sleep apnea 7% to 11% or more • Improved symptomatology

• Decreased apnea-hypopnea index

Asthma/reactive airway disease 7% to 8% or more • Improvement in forced expiratory

volume at 1 second
• Improved symptomatology

Osteoarthritis • ≥10% • Improvement in symptomatology

• 5% to 10% or more • Increased function
when coupled with
exercise

Urinary stress incontinence 5% to 10% or more Reduced frequency of incontinence

episodes
Gastroesophageal reflux disease 10% or more Reduced symptom frequency and severity

Depression Uncertain • Reduction in depression

symptomatology
• Improvement in depression scores

Abbreviations: A1C = hemoglobin A1c; BMI = body mass index; BP = blood pressure; HDL-c = high-density lipoprotein cholesterol; T2DM = type 2 diabetes mellitus.

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 PREFERRED WEIGHT-LOSS MEDICATIONS: INDIVIDUALIZATION OF THERAPY
KEY: PREFERRED DRUG USE WITH CAUTION AVOID

MEDICATIONS FOR CHRONIC WEIGHT MANAGEMENT

CLINICAL CHARACTERISTICS
OR COEXISTING DISEASES Orlistat Lorcaserin Phentermine/ Naltrexone ER/ Liraglutide 3 mg
topiramate ER bupropion ER

Diabetes Prevention Insufficient data for Insufficient data for

(metabolic syndrome, T2DM prevention T2DM prevention
prediabetes)
Type 2 Diabetes
Mellitus
Hypertension Monitor heart rate Monitor BP and heart Monitor heart rate
rate.
Contraindicated in
uncontrolled HTN
Cardiovascular CAD Monitor heart rate Monitor heart rate, BP Monitor heart rate
Disease Arrhythmia Monitor for bradycardia Monitor heart rate, Monitor heart rate, Monitor heart rate,
rhythm rhythm, BP rhythm
CHF Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data
Chronic Kidney Mild
Disease (50–79 mL/min)
Moderate Do not exceed Do not exceed
(30–49 mL/min) 7.5 mg/46 mg per day 8 mg/90 mg bid
Severe Watch for oxalate Urinary clearance of Urinary clearance of Urinary clearance of Avoid vomiting and
(<30 mL/min) nephropathy drug metabolites drug drug volume depletion
Nephrolithiasis Calcium oxalate stones Calcium phosphate
stones
Hepatic Impairment Mild-Moderate Watch for cholelithiasis Hepatic metabolism Do not exceed Do not exceed Watch for
(Child-Pugh 5–9) of drug 7.5 mg/46 mg per day 8 mg/90 mg in AM cholelithiasis
Severe Not recommended Not recommended Not recommended Not recommended Not recommended
(Child-Pugh >9)
Depression Insufficient safety data Avoid maximum dose: Insufficient safety data
15 mg/92 mg per day
Avoid combinations of Avoid in adolescents
serotonergic drugs and young adults
Anxiety Avoid max dose:
15 mg/92 mg per day
Psychoses Insufficient data Insufficient data Insufficient data Insufficient data Insufficient data
Binge Eating Insufficient data. Insufficient data. Insufficient data. Insufficient data
Disorder Possible benefit based Possible benefit based Possible benefit based on
on reduction in food on studies with studies with bupropion
cravings topiramate
Avoid in patients with
purging or bulimia
nervosa
Glaucoma Contraindicated, may May trigger angle
trigger angle closure closure
Seizure Disorder If discontinue at dose Bupropion lowers
of 15 mg/92 mg, taper seizure threshold
slowly
Pancreatitis Monitor for symptoms Monitor for symptoms
Avoid if prior or current
disease
Opioid Use Will antagonize opioids
and opiates
Women of Pregnancy Use contraception and Use contraception and Use contraception Use contraception and Use contraception and
Reproductive discontinue orlistat discontinue lorcaserin and discontinue discontinue naltrexone discontinue liraglutide
Potential should pregnancy occur should pregnancy occur phentermine/topiramate ER/bupropion ER should 3mg should pregnancy
should pregnancy pregnancy occur occur
occur (perform monthly
pregnacy checks to
identify early pregnancy)
Breast-feeding Not recommended Not recommended Not recommended Not recommended Not recommended
Age ≥65 years * Limited data available Insufficient data Limited data available Insufficient data Limited data available
Alcoholism/ Might have abuse Insufficient data. Avoid due to seizure
Addiction potential due to Topiramate might exert risk and lower seizure
euphoria at high doses therapeutic benefits threshold on bupropion
Post-Bariatric Insufficient data Insufficient data Limited data available Insufficient data Data available at
Surgery 1.8 – 3.0 mg/day

* Use medications only with clear health-related goals in mind; assess patient for osteoporosis and sarcopenia.
Abbreviations: BP = blood pressure; CAD = coronary artery disease; CHF = congestive heart failure; HTN = hypertension; T2DM = Type 2 Diabetes Mellitus.

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 DIAGNOSIS AND MEDICAL MANAGEMENT OF OBESITY

DIAGNOSIS COMPLICATION-SPECIFIC STAGING AND TREATMENT

Anthropometric Clinical Component Disease Stage Chronic Suggested Therapy
Component Disease Phase (based on clinical judgment)
(BMI kg/m2) of Prevention

<25
<23 in certain ethnicties Normal • Healthy lifestyle:
waist circumference weight Primary healthy meal plan/
below regional/ (no obesity) physical activity
ethnic cutoffs

25–29.9 Evaluate for presence or Overweight Secondary • Lifestyle therapy:

absence of adiposity- stage 0 Reduced-calorie healthy meal
23–24.9 in certain
related complications plan/physical activity/
ethnicities (no complications)
and severity of behavioral interventions
complications
≥30 • Metabolic syndrome Obesity Secondary • Lifestyle therapy:
stage 0 Reduced-calorie healthy meal
≥25 in certain • Prediabetes
plan/physical activity/
ethnicities • Type 2 diabetes (no complications) behavioral interventions
• Dyslipidemia • Weight-loss medications:
• Hypertension Consider after lifestyle therapy
• Cardiovascular fails to prevent progressive
disease weight gain. (BMI ≥27)
• Nonalcoholic fatty
≥25 liver disease Obesity Tertiary • Lifestyle therapy:
stage 1 Reduced-calorie healthy meal
≥23 in certain • Polycystic ovary plan/physical activity/
ethnicties syndrome (1 or more behavioral interventions
• Female infertility mild-moderate
complications) • Weight-loss medications:
• Male hypogonadism Consider after lifestyle therapy
• Obstructive sleep fails to achieve therapeutic
apnea target or initiate concurrent
• Asthma/reactive with lifestyle therapy. (BMI ≥27)
airway disease
≥25 • Osteoarthritis Obesity Tertiary • Lifestyle therapy:
stage 2 Reduced-calorie healthy meal
≥23 in certain • Urinary stress plan/physical activity/
ethnicties incontinence (at least 1 severe behavioral interventions
• Gastroesophageal complication)
• Add weight-loss medication:
reflux disease
Initiate concurrent with lifestyle
• Depression therapy. (BMI ≥27)
• Consider bariatric surgery:
(BMI ≥35)

a. All patients with BMI ≥25 have either overweight stage 0, obesity stage 0, obesity stage 1, or obesity stage 2, depending on the initial clinical
evaluation for presence and severity of complications. These patients should be followed over time and evaluated for changes in both
anthropometric and clinical diagnostic components. The diagnoses of overweight/obesity stage 0, obesity stage 1, and obesity stage 2 are not static,
and disease progression may warrant more aggressive weight-loss therapy in the future. BMI values ≥25 have been clinically confirmed
to represent excess adiposity after evaluation for muscularity, edema, sarcopenia, etc.
b. Stages are determined using criteria specific to each obesity-related complication; stage 0 = no complication; stage 1 = mild-to-moderate;
stage 2 = severe.
c. Treatment plans should be individualized; suggested interventions are appropriate for obtaining the sufficient degree of weight loss generally
required to treat the obesity-related complication(s) at the specified stage of severity.
d. BMI ≥27 is consistent with the prescribing information mandated by the US Food and Drug Administration for weight-loss medications.
Abbreviation: BMI = body mass index.

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 AACE OBESITY CARE MODEL

• Obesity care legislation

• Health public policy
HEALTHY BUILT ENVIRONMENT • Health messaging
• Promotes healthy lifestyle

• Payment reform
• Preventive care paradigm
REFORMED HEALTH
• Optimize drug pipeline
CARE SYSTEM • Education/research
• Patient access to therapy

• Decision support
• Self-management • Delivery system design
• Empanelment PREPARED • Informatics/registries
ACTIVATED
• Patient-team partner OBESITY • Leadership/behaviors
• Activated community PATIENT • Continuity of care
PRACTICE
• Access to information • Enhanced access to care
• Coordinated care

• Clinical research design

• Relevant metrics
IMPROVED POPULATION-BASED • Improved overall health
OUTCOMES • Economic outcomes
• Feedback to revise
Clinical Care Model

• Technology-driven
FUTURE INNOVATIONS • Outcome-driven

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 WEIGHT-LOSS MEDICATIONS APPROVED BY THE FDA FOR LONG-TERM TREATMENT OF OBESITY

Anti-obesity Mechanism of Action, Dose Common Side Effects Contraindications, Cautions, Monitoring and Comments
Medication Study Name, and Safety Concerns
(Trade Name) Study Duration: % TBWL 9Contraindication
Year of FDA Approval Greater Than Placebo • Warning, Safety Concern

Orlistat Lipase inhibitor 120 mg PO TID (before • Steatorrhea 9Pregnancy and breastfeeding Monitor for:
meals) • Fecal urgency 9Chronic malabsorption syndrome • Cholelithiasis
(XenicalTM) XENDOS • Incontinence 9Cholestasis • Nephrolithiasis
OTC: 60 mg PO TID • Flatulence 9Oxalate nephrolithiasis
(AlliTM) – OTC - Recommend standard multivitamin (to include vitamins A, D, E,
1 yr: 4.0% (before meals) • Oily spotting • Rare severe liver injury
4 yr: 2.6% • Frequent bowel and K) at bedtime or 2 hours after orlistat dose
1999 • Cholelithiasis - Eating >30% kcal from fat results in greater GI side effects
movements • Malabsorption of fat-soluble vitamins
• Abdominal pain - FDA-approved for children ≥12 years old
• Effects on other medications: - Administer levothyroxine and orlistat 4 hours apart
• Headache • Warfarin (enhance)
• Antiepileptics (decrease)
• Levothyroxine (decrease)
• Cyclosporine (decrease)

Lorcaserin Serotonin 10 mg PO BID • Headache 9Pregnancy and breastfeeding Monitor for:

(5HT2c) receptor agonist • Nausea 9Serotonin syndrome or neuroleptic • Symptoms of cardiac valve disease
(Belviq®) • Dizziness malignant syndrome • Bradycardia
BLOSSOM • Fatigue • Safety data lacking in patients who • Serotonin syndrome
BLOOM • Xerostomia have depression • Neuroleptic malignant syndrome
2012 • Dry eye • Depression
• Concomitant use of SSRI, SNRI, MAOI,
1 yr: 3.0%-3.6% • Constipation bupropion, St. John’s wort as may increase • Severe mood alteration, euphoria, dissociative state
2 yr: 3.1% • Diarrhea risk of developing serotonin syndrome • Confusion/somnolence
• Back pain • Uncontrolled mood disorder • Priapism
• Nasopharyngitis • Cognitive impairment • Leukopenia
• Hyperprolactinemia • Avoid in patients with severe liver injury • Euphoria at high doses could predispose to abuse
or renal insufficiency • Hypoglycemia in patients having T2DM treated with
• Caution with patients with bradycardia, insulin and/or sulfonylureas
heart block, or heart failure
• Unproven concern for potential
cardiac valvulopathy
• Leukopenia

Phentermine/ NE-releasing agent Starting dose: • Headache 9Pregnancy and breastfeeding Monitor for:
(phentermine) 3.75/23 mg PO QD • Paresthesia (topiramate teratogenicity) • Increased heart rate
Topiramate ER for 2 weeks • Insomnia 9Hyperthyroidism • Depressive symptomatology or worsening depression
GABA receptor • Decreased bicarbonate 9Acute angle-closure glaucoma especially on maximum dose
(Qsymia®) modulation (topiramate) Recommended dose: • Xerostomia 9Concomitant MAOI use (within 14 days) • Hypokalemia (especially with HCTZ or furosemide)
7.5/46 mg PO QD • Constipation • Tachyarrhythmias • Acute myopia and/or ocular pain
2012 EQUIP • Nasopharyngitis • Decreased cognition • Acute kidney stone formation
CONQUER Escalation dose: • Anxiety • Seizure disorder • Hypoglycemia in patients having T2DM treated with
SEQUEL 11.25/69 mg PO QD • Depression • Anxiety and panic attacks insulin and/or sulfonylureas
• Cognitive impairment • Nephrolithiasis
1 yr: 8.6%-9.3% on Maximum dose: (concentration and - Potential for lactic acidosis (hyperchloremic non-anion gap) in
• Hyperchloremic metabolic acidosis combination with metformin
high dose; 6.6% on 15/92 mg PO QD memory) • Dose adjustment with hepatic and
treatment dose • Dizziness - MAOI (allow ≥14 days between discontinuation)
renal impairment

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• Nausea - 15 mg/92 mg dose should not be discontinued abruptly
• Concern for abuse potential (increased risk of seizure); taper over at least 1 week
2 yr: 8.7% on high dose; • Dysgeusia • Combined use with alcohol or depressant
7.5% on treatment dose - Health care professional should check ßHCG before
drugs can worsen cognitive impairment initiating, followed by monthly self-testing at home
- Monitor electrolytes and creatinine before and during treatment
- Can cause menstrual spotting in women taking birth control
pills due to altered metabolism of estrogen and progestins
 Anti-obesity Mechanism of Action, Dose Common Side Effects Contraindications, Cautions, Monitoring and Comments
Medication Study Name, and Safety Concerns
(Trade Name) Study Duration: % TBWL
Year of FDA Approval Greater Than Placebo

Naltrexone ER/ Opiate antagonist Titrate dose: • Nausea 9Pregnancy and breastfeeding Monitor for:
(naltrexone) • Headache 9Uncontrolled hypertension • Increased heart rate and blood pressure
Bupropion ER Week 1: • Insomnia 9Seizure disorder • Worsening depression and suicidal ideation
Reuptake inhibitor of DA 1 tab (8/90 mg) • Vomiting 9Anorexia nervosa • Worsening of migraines
(Contrave®) and NE (bupropion) PO QAM • Constipation 9Bulimia nervosa • Liver injury (naltrexone)
• Diarrhea 9Severe depression • Hypoglycemia in patients having T2DM treated with
2014 COR-I Week 2: • Dizziness 9Drug or alcohol withdrawal insulin and/or sulfonylureas
COR-II 1 tab (8/90 mg) • Anxiety 9Concomitant MAOI (within 14 days) • Seizures (bupropion lowers seizure threshold)
COR-BMOD PO BID • Xerostomia 9Chronic opioid use
- MAOI (allow ≥14 days between discontinuation)
• Cardiac arrhythmia - Dose adjustment for patients with renal and hepatic
1 yr: 4.2%-5.2% Week 3: • Dose adjustment for liver and kidney
2 tabs (total 16/180 mg) impairment
impairment - Avoid taking medication with a high-fat meal
PO QAM and 1 tab • Narrow-angle glaucoma
(8/90 mg) PO QHS - Can cause false positive urine test for amphetamine
• Uncontrolled migraine disorder - Bupropion inhibits CYP2D6
• Generalized anxiety disorder
Week 4: • Bipolar disorder
2 tabs (total 16/180 mg) • Safety data lacking in patients who
PO QHS have depression
• Seizures (bupropion lowers seizure
threshold)

Liraglutide 3 mg GLP-1 analog Titrate dose weekly • Nausea 9Pregnancy and breastfeeding Monitor for:
by 0.6 mg as • Vomiting 9Personal or family history of medullary • Pancreatitis
(Saxenda®) SCALE Obesity & tolerated by patient • Diarrhea thyroid cancer or MEN2 • Cholelithiasis and Cholecystitis
Prediabetes (side effects): • Constipation 9Pancreatitis • Hypoglycemia in patients having T2DM treated with
• Headache 9Acute gallbladder disease insulin and/or sulfonylureas
2014
1 yr: 5.6% 0.6 mg SC QDt • Dyspepsia • Gastroparesis • Increased heart rate
1.2 mg SC QDt • Increased heart rate • Severe renal impairment can result from • Dehydration from nausea/vomiting
1.8 mg SC QDt vomiting and dehydration • Injection site reactions
2.4 mg SC QDt • Use caution in patients with history
3.0 mg SC QD - Titrate dose based on tolerability (nausea and GI side effects)
of pancreatitis
• Use caution in patients with cholelithiasis
• Suicidal ideation and behavior
• Injection site reactions

Abbreviations: BID = twice daily; DA = dopamine; FDA = US Food and Drug Administration; GI = gastrointestinal; • For liraglutide 3 mg:
HCTZ = hydrochlorothiazide; MAOI = monoxidase inhibitor; MEN2 = multiple endocrine neoplasia type 2; If the patient has not lost at least 4% of body weight 16 weeks after initiation, the medication should
NE = norepinephrine; OTC = over-the-counter medication; % TBWL = percent total body weight loss from baseline be discontinued.
over that observed in the placebo group; PO = oral; QAM = every morning; QD = daily; QHS = every bedtime;
SC = subcutaneous; SNRI = serotonin–norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake References:
inhibitor; TID = 3 times a day; T2DM = type 2 diabetes mellitus. 1–4 and package inserts for each medication

FDA indication for all medications: BMI >30 kg/m2 or BMI ≥27kg/m2 with significant comorbidity. 1. Wyatt HR. Update on treatment strategies for obesity. J Clin Endocrinol Metab. 2013;98(4):1299-1306.
2. Garvey WT, Garber AJ, Mechanick JI, Bray GA, Dagogo-Jack S, Einhorn D, et al. American Association of Clinical
After 3 to 4 months of treatment with antiobesity medication: Endocrinologists and American College of Endocrinology position statement on the 2014 advanced framework
• For naltrexone ER/bupropion ER and lorcaserin: for a new diagnosis of obesity as a chronic disease. Endocr Pract. 2014;20(9):977-989.
If the patient has not lost at least 5% of their baseline body weight at 12 weeks on the maintenance dose, the 3. Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review.

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medication should be discontinued. JAMA. 2014;311(1):74-86.
• For phentermine/topiramate ER: 4. Fujioka K. Current and emerging medications for overweight and obesity in people with comorbidities.
Continue medication if the patient has lost >5% body weight after 12 weeks on recommended dose (7.5 mg/42 Diabetes Obes Metab. 2015;17(11):1021-1032.
mg); if the patient has not lost at least 3% of body weight after being on the recommended dose for 12 weeks
then the medication should be discontinued, or the patient can be transitioned to maximum dose (15 mg/92
mg); if patient has not lost at least 5% after 12 additional weeks on the maximum dose, the medication should
be discontinued.