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Blogs by the online BMJ diabetes champions and guests
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In Defence of the "Magic" Anti-Obesity and Diabetic Pill
Hello Fellows:
No, I am not talking about any of those highly promoted, and still unsafe, oral or parenteral, so-called incretin-based anti diabetic drugs. I am talking about a combination pill manufacturaded by a small pharmaceutical company (to which I hold no interest conflict) that early on its therapeutic course of actions make patients loose 5 to 10% of body weight, lower waist circumference, lower blood pressures and lower HBA1C levels, with a quite reasonable safety and side-effects profile. This new drug is a combination of Topiramate with Phentermine. The brand name is Qnexa. The use of both agents provides a treatment option that is more efficacious than anything currently in the market for loosing body weight. There are multiple neuronal and peripheral pathways implicated in the regulation of energy homeostasis, food intake and saciety. This combination pill seems to overcome this complex circuitry. "The combination of phentermine and topiramate is an effective adjunct to diet and lifestyle modification for weight loss and measures of comorbidity in overweight or obese adults with additional metabolic risk factors" Don´t you think we should allow a fair chance for this kind of drug??? All Best, Joey
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1. Have you ever prescribed the two components of Qnexa, Phentermine and Topiramate, for the purposes of weight loss? Why or why not?
No. There are a couple of reasons related to the pharmacology of the agents and the nature of my practice. As regards pharmacology, I am reluctant to use a non-approved combination outside of a clinical trial. More specific is the nature of the two agents in question. Phentermine is a sympathomimetic agent related to the amphetamines. It is relatively contraindicated in persons with hypertension or cardiovascular disease including persons with diabetes. As an Internist with a specialty in diabetes those are the majority of my patients. Additionally, Phentermine is addictive and I am reluctant to use such an agent in a chronic disease such as obesity and diabetes. Topiramate is an agent with a mired of side effects mostly neurogenic. Admittedly these may be avoided by the relatively low dose used in this recommended combination.
2. What are your views on the safety and efficacy of the drugs?
The data presented, if vetted by objective experts, suggest that the combination is efficacious. Given our experience with Phen-Fen, we should be cautious is our use of these agents until larger and longer-term trials are completed.
3. Given the high profile failures of weight loss drugs in the past, how do you think this may be different?
I don't.
4. How do you feel about the availability of options you have to treat patients with weight problems?
They are few and mostly ineffective. As much as I hate to admit it, the only effective option for the chronically morbidly obese patient with other risk factors is bariatric surgery that is not likely to be a universally accepted solution.
5. Any other comments to make?
Every day we discover new pathways and hormones that regulate food intake. In experimental animals adiponectin reduces weight by increasing metabolic rate. Similarly irisin has been shown in mice to convert fat cells into the more metabolically active brown fat cell. I am confident that some day such research will permit us to develop agents that more directly affect food in take. The question is how long and what do we do in there meantime.