Today’s post comes from Maryam Kebbe. Maryam is a PhD Candidate in the Department of Pediatrics at the University of Alberta. She is also the current Chair of the University of Alberta’s OC-SNP chapter and Communications Director of the OC-SNP National Executive.
For many adolescents with obesity, lifestyle interventions alone are insufficient to achieve and maintain long-term weight loss, and additional therapeutic approaches such as pharmacotherapy or bariatric surgery may be required. Specifically, anti-obesity medications are an option to offset the adaptive changes in appetite and energy expenditure that favour the promotion of weight gain ; these are classified as belonging to one of three primary targets: (i) nutrient processing, (ii) enteric hormonal regulation, and (iii) central modulation of appetite, satiety, and food behaviors [2,3]. While experts believe that obesity pharmacotherapy should be reserved for children and adolescents 12-16 years of age with a high body mass index and who demonstrate an obesity-related comorbidity (e.g., dyslipidemia, hypertension, insulin resistance, fatty liver disease, obstructive sleep apnea) [4,5], the counterargument is that potential benefits may outweigh potential risks among those who already manifest complications of excess weight .
Current pediatric anti-obesity agents [2,3] are limited in both number and availability (especially in Canada), with many being used off-label and not being covered by government agencies. Due to limited efficacy in monotherapy, there is also growing movement toward combination pharmacotherapy.
Approved for adolescent and adult obesity:
- Orlistat (Xenical®)
Approved for adult obesity:
- Naltrexone/bupropion (Contrave®)
- Liraglutide, high dose 3mg (Saxenda®)
Off-label use* – common examples include:
- Metformin (various trade names) for diabetes mellitus
- Exenatide (Byetta®, Bydureon®) for diabetes mellitus
- Topiramate (Topamax®) for epileptic seizures and migraine headaches
*Use of non-approved drug combinations for obesity treatment should be limited to clinical trials, and adolescents need to be made aware of the status of these drugs if used alone or in combination.
The scientific literature on weight reduction drugs, including randomized controlled trials (RCTs) on effectiveness, are far fewer in adolescents compared with adults, partly owing to changes in developmental growth affecting nutritional requirements and concerns about adverse health consequences . Further, pediatric drug trials tend to suffer from short intervention periods, high attrition rates, and inadequate description of methods and conduct of analyses. This calls for future trials that minimize these issues with example considerations for high-quality RCTs outlined by Kelly and colleagues (2017) . If obesity pharmacotherapy is to improve in the adolescent area, a number of drug classes should be investigated.
Precision medicine strategies are growing in momentum, and pediatric obesity pharmacotherapy is an attractive field for which to uncover patient profile characteristics and biomarkers for a successful response to specific treatments using pharmacogenetics, eating behavior phenotyping techniques, metabolomics, and other predictive factors . In the array of existing and new obesity management approaches, the goal is to provide patients with the therapeutic option that is deemed most effective with the lowest risk of side effects.
- Greenway FL. Physiological adaptations to weight loss and factors favouring weight regain. Int J Obes. 2015;39:1188–96.
- Coles N, Birken C, Hamilton J. Emerging treatments for severe obesity in children and adolescents. BMJ. 2016;354:i4116.
- Sherafat-Kazemzadeh R, Yanovski SZ, Yanovski JA. Pharmacotherapy for childhood obesity: present and future prospects. Int J Obes. 2013;37:1.
- Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatr. 2007;120: S164–S92.
- Yanovski JA. Intensive therapies for pediatric obesity. Pediatr Clin North Am. 2001;48:1041–53.
- Kelly AS, Fox CK, Rudser KD, Gross AC, Ryder JR. Pediatric obesity pharmacotherapy: current state of the field, review of the literature and clinical trial considerations. Int J Obes. 2016;40:1043.
- Kelly AS, Fox CK. Pharmacotherapy in the Management of Pediatric Obesity. Current Diab Rep. 2017;17:55.