Which Weight Loss Drug for this Complex Patient?

Ted W. James, MD

She is 35 y/o with a history of migraine, bipolar disorder, and hypertension. Years of structured diets and nutrition consult have failed. Which agent would you consider?

A 35-year-old woman presents to your office for assistance with weight loss. She has tried structured diets through a registered dietician for the past year with minimal weight loss. She has a history of frequent migraines, bipolar disorder, and hypertension. Her medications include phenelzine, fluoxetine, lithium, lisinopril, and sumatriptan. Currently, her BMI is 32 kg/m2 and her blood pressure is 152/96 mm Hg

Which drug or drug combination would be most appropriate for weight loss in this patient?

A. Orlistat

B. Bupropion-naltrexone

C. Phentermine-topiramate

D. Lorcaserin

E. Liraglutide

Please click here for answer/discussion

Answer: A. Orlistat. Orlistat would be the agent of choice in this situation as it causes maldigestion of dietary fat with a subsequent reduction in available calories from the meal.

  • Lorcaserin is a selective agonist of the serotonin 2C receptor which in turn suppresses appetite. Lorcaserin should not be used alongside selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or triptans.

  • Liraglutide is useful in obese patients who have co-morbid type 2 diabetes, which this patient does not have.

  • Phentermine-topiramate can cause fetal anomalies and is not the drug of choice in women of childbearing age and is also contraindicated in patients with poorly controlled hypertension, bupropion-naltrexone should also be avoided in poorly controlled hypertension.


Suggested reading : Bray GA, Ryan DH. Medical therapy for the patient with obesity. Circulation. 2012;125:1695-703.