Evolving views of obesity raise questions about the role of weight-loss drugs

Contrave
Contrave

Physicians are continuing to learn how to best treat obesity and its associated health issues, which may mean the market for new weight-loss drugs may not be as immediately promising as what pharmaceutical companies would like investors to believe.


During the most recent earnings season, manufacturers that market weight-loss drugs have reported sales growth of those therapies. Arena reported that the number of prescriptions for its weight-loss drug Belviq rose 4% to 149,000 in the fourth quarter of 2014, compared with the third quarter of 2014.


Vivus also reported what appeared to be positive numbers last month, telling investors in a Feb. 24 call that 2014 fourth-quarter sales of Qsymia were $12.7 million, compared with $7.7 million in the fourth quarter of 2013. Orexigen Therapeutics, which began selling weight-loss medication Contrave in October, racked up $6.5 million in fourth-quarter sales.


Vivus CEO Seth Fischer told investors that latter-category entrants like Contrave, which is the only prescription obesity medication listed on the CVS/Caremark preferred drug list, have raised “the noise level about the importance of the treatment of obesity.”

 

But doctors told MM&M they are still struggling with some very basic issues such as broadening the understanding that treating obesity requires more than a prescription. Doctors said they are also dealing with safety concerns that have lingered more than a decade after Meridia and fen-phen were pulled from the market.


“It's more complex than prescribing a single drug,” internal medicine and weight-management physician Dr. Adam Gilden Tsai told MM&M in a phone interview.


Dr. Sue Decotiis, a New York City–based internist and obesity specialist, agreed. She gave a list of additional health issues that can accompany obesity, such as elevated insulin levels and possible nutrient deficiencies that have to be addressed, along with obesity. This is in addition to patients taking on the time commitment that comes with reaching and staying at a healthy weight.


Tsai, who practices in Denver, said this timeframe could include a three- to six-month prescription weight-loss regimen or longer, depending on the patient.


Decotiis noted that getting on a plan requires a support system that is comprised of regular office visits that address a variety of topics, such as tweaking an exercise routine that is part of a long-term weight-management plan. “We're getting them ready for a lifestyle change,” she explained. She also said that support programs, like the food guides that are part of the patient support materials available to Qsymia patients, are helpful, but the reality is that patients may need more dietary support, such as from a nutritionist.


Tsai and Decotiis also noted that there is the matter of getting conversations about weight loss started, particularly at the primary care level. Both are physicians who specialize in obesity, and both recognized that primary care physicians see a wide variety of patients and a number of factors—including time—can crowd out a weight-loss conversation.


Cost is also a major issue. Payers have been slow to cover prescription weight-loss medications. Decotiis mentioned that industry pricing aids, like Arena's financial assistance card, which can limit some prescriptions of Belviq to $75 a month, make the medications less expensive for some patients, but the drugs are still costly.


Although the Endocrine Society's clinical practice guidelines now include provisions for prescription weight-loss medications, Tsai said the 2014 inclusion may not be enough to encourage more payers to cover the drugs.


Tsai called the new guidelines “a big step forward” because they provide a reference point that says “this is a standard of care and this is how I'm supposed to do this.”


Both doctors also noted that safety risks associated with prescription weight-loss drugs that are no longer on the market are a very present medical concern among healthcare providers. “People still think of these drugs as big and dangerous and being like speed,” Decotiis said, referring to older, stimulant-based appetite suppressants. “These medications are actually really safe. There is a very low incidence of phentermine abuse. Nobody gets high on phentermine,” she said, referring to a component in Vivus's Qsymia.

For Tsai, Meridia and fen-phen continue to serve as the go-to prescription reference points. Both were pulled from the market after they were linked with side effects including stroke (Meridia) and heart-valve problems (fen-phen).


“Safety is a major concern for practicing physicians,” Tsai said.