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Primary care physicians wouldn't treat a lifelong disease like diabetes with a limited course of drug therapy. Yet they are reluctant to try anti-obesity drugs on their patients or to prescribe them long enough for effective therapy, says G. Michael Steelman, MD, president of the American Society of Bariatric Physicians (ASBP).
At the ASBP 2005 annual meeting in Las Vegas, Steelman presented a session on the judicious use of medication in bariatric practice in an attempt to correct some misconceptions about proper drug therapy.
"Physicians are prejudiced against obese patients and the drugs used to treat them," says Steelman, whose weight-loss practice is in Oklahoma City, Okla. "Appetite suppressants have a bad reputation. The drugs are being held to a higher standard than other drugs."
The Food and Drug Administration (FDA) has approved only a handful of drugs for the treatment of obesity. Commonly prescribed appetite-suppressing drugs include phentermine, diethylpropion (Tenuate, Aventis), and phendimetrazine. Orlistat (Xenical, Roche) is a gastrointestinal lipase inhibitor that blocks the absorption of approximately 30% of dietary fat.
The "new kid on the block," Steelman says, is sibutramine (Meridia, Abbott), which inhibits the reuptake of norepinepherine, serotonin, and dopamine.
Despite an expanding armamentarium, he contends that drugs are not used often enough in treating obesity. A large percentage of the public—and many in the medical community—believe that obesity is a failure of willpower and not a legitimate disorder. In addition, many health professionals mistakenly believe that therapy is a failure if the patient gains weight when the drug is discontinued, Steelman says.
One of the most common problems with anti-obesity therapy is that drugs are not prescribed for a long enough period of time, he says. Appetite suppressants typically are approved for short-term use—8–12 weeks in the case of diethylpropion, while the labeling of phentermine suggests that the drug be prescribed for "a few weeks."
The package insert for sibutramine says physicians should increase the dose or discontinue the drug if the patient does not lose at least 1.8 kg (4 lb) during the first 4 weeks of therapy. Drug information for both orlistat and sibutramine says the safety of drug therapy beyond a 2-year period has not been studied.
Steelman insists that short-term drug therapy is useless in treating obesity. Since the drugs have a comfortable margin of safety and a low potential for abuse, they should be used much longer than indicated on the labeling.
"As a chronic disease, obesity needs therapy as long as the benefits outweigh the risks," he says.
At the ASBP meeting, Steelman reported on a series of 50 patients who have been on anti-obesity medication for an average of 3 years.
Drugs alone are not the answer to obesity, Steelman cautions. Medication "should only be used as part of a multimodal program that includes diet, exercise, and behavioral changes" ("Weight-Loss Drugs More Effective With Lifestyle Change," see page 8).
Patients being considered for drug therapy should have a thorough evaluation and physical exam, particularly looking for hypertension or other conditions that may be made worse by anti-obesity drugs.
To minimize side effects, Steelman suggests starting patients on a low dose
and titrating upward if appropriate. 
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