ACC recommends medication as first-line treatment for obesity

A new consensus statement from the American College of Cardiology recommends clinicians consider modern obesity medications as a first-line treatment for eligible patients, marking a shift from previous guidance that recommended they try lifestyle interventions before medications.

The clinical guidance focused specifically on the glucagon-like peptide-1 (GLP-1) receptor agonists liraglutide and semaglutide and the GLP-1/glucose-dependent insulinotropic polypeptide receptor agonist tirzepatide. The statement focused on these medications because they fill the treatment gap between lifestyle therapy and bariatric surgery, help address the disease mechanisms of obesity, and are titratable, leaving room to minimize side effects and maximize weight loss, the authors wrote. The concise clinical guidance statement was published by the Journal of the American College of Cardiology on June 20.

The authors outlined several considerations for the clinical decision-making process. Body mass index can be used to determine eligibility for these medications and the threshold “may be the patient's nonpregnant lifetime high, reflecting current understanding around the ‘weight set point’ and in concordance with managing obesity as a chronic disease,” the statement said.

Although the guidance states that patients should not be required to try and fail lifestyle changes before starting pharmacotherapy, clinicians should always offer these interventions in conjunction with medications, the authors noted. Initial encounters with patients should identify any contraindications to the obesity medications and obtain anthropometric and clinical data to better individualize care.

Insurance coverage, availability, and affordability should all be taken into consideration when selecting an agent. “Should a patient miss dosages due to lack of access, published strategies to address this exist and also guide therapeutic interchanges,” the authors wrote, adding that they discourage the use of compounded versions of the drugs.

The impact on cardiovascular risk is another consideration, and all three medications have been shown to reduce the risk of cardiovascular death, myocardial infarction, or stroke in patients with type 2 diabetes at increased cardiovascular risk or with established cardiovascular disease, the statement said.

The authors also noted that patients who take the medications benefit from coordination of care. A team-based approach can involve behavioral therapists, dieticians, and exercise physiologists.

“Clinicians should incorporate shared decision-making into their treatment approach to best balance risks and benefits,” the authors added. “Off-label, but evidence-based, strategies may be considered to mitigate potential harms and optimize health outcomes (eg, lowest therapeutic dose for weight loss maintenance, combination therapies).” Using person-first language can help reduce weight bias and stigma, the authors said. They stressed that the goal of obesity treatment should be tailored to the individual, but a reasonable initial goal is to achieve weight loss of 5% or more from baseline.

Annals of Internal Medicine published two studies on related topics on June 24. In the first, an industry-funded post hoc analysis of a phase 3 randomized trial, patients who lost more weight while taking tirzepatide had greater improvements in cardiometabolic risk factors such as weight circumference and blood pressure. The second, a brief research report, found that nearly one in six U.S. adults with obesity had trouble affording health care, including difficulty paying medical bills, food insecurity, and skipping medication because of cost.