Response to Letter Regarding Article, “Obesity and Cardiovascular Disease”
We appreciate Dr Hendricks' interest in our recent Clinician Update on Obesity and Cardiovascular Disease.1 We would like to point out that the purpose of the article was not to compare surgical versus medical therapy, but rather educate readers at large of the many options available for the treatment of obesity. We utilized a case vignette of a severely obese individual who underwent gastric bypass surgery and benefited significantly from the intervention. We clearly do not imply that the only effective treatment for obesity is surgical, as this treatment option is reserved for a minority of obese individuals and patient selection should be made on a case-by-case basis, weighing the risk and benefits, and in accordance with NHLBI guidelines for the assessment and treatment of obesity.2
Since the publication of our article, the Food and Drug Administration (FDA) approved the combination of topiramate and phentermine (Qsymia), in combination with diet and exercise, for the treatment of obesity for body mass index (BMI) ≥30 kg/m2 or ≥27 kg/m2 with at least one comorbidity such as hypertension, type 2 diabetes, or dyslipidemia. The recommended daily dose of Qsymia contains 7.5 mg of phentermine and 46 mg of extended-release topiramate. Qsymia will also be available at a higher dose (15 mg phentermine and 92 mg topiramate) for select patients who do not reach target weight loss. It is notable that the dose of phentermine in Qsymia is a fraction of the dose usually prescribed for weight loss in the United States that typically ranges from 30 mg to 37.5 mg daily. Although the phentermine content in Qsymia is lower than prescribed in previous clinical practice, the FDA briefings indicate that Qsymia can increase heart rate and there are lingering side effect concerns that have prompted implementation of several postmarketing studies which include long-term cardiovascular outcomes.3 The FDA also very recently approved lorcaserin (Belviq), a selective serotonin 2C receptor agonist for the treatment of obesity.
We agree with Dr Hendricks that a definitive causal relationship has not been established between phentermine and atrial fibrillation, as its onset in the vignette may have been multifactorial and related directly to obesity itself. It should be noted that the Physicians' Desk Reference indicates that phentermine can be associated with palpitations, tachycardia, hypertension, and overstimulation of the central nervous system. Advanced arteriosclerosis and cardiovascular disease are also listed as contraindications.4 Obesity is a major public health concern and we agree that our patients desperately need effective new treatment options. We maintain that the risks and benefits of all treatments should be carefully considered for each individual to help guide the practitioner in choosing treatment algorithms that include combinations of lifestyle modification, medications, and possible bariatric surgical intervention in select individuals.
Caroline M. Apovian, MD
Noyan Gokce, MD
Boston University School of Medicine
Dr Apovian participates on advisory boards for Allergan, Amylin, Orexigen, Merck, Johnson and Johnson, Arena, and Sanofi-aventis. Dr Gokce reports no conflicts.
- © 2012 American Heart Association, Inc.
- Apovian CM,
- Gokce N
National Heart, Lung, and Blood Institute (NHLBI) and North American Association for the Study of Obesity (NAASO). The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, MD: National Institutes of Health; 2000. Publication No. 00-4084.
FDA approves weight-management drug Qsymia. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm312468.htm. Accessed July 31, 2012.
Physicians' Drug Reference. 66th ed. Montvale, NJ: Thomson PDR; 2012.