Jeannette Wick , RPH, MBA, FASCP

Discussing smoking cessation with patients can be difficult.

Often patients respond with statements such as “It’s the only pleasure I have” or “I only smoke a few cigarettes a day.” Having a toolkit of talking points can engage patients in cessation efforts or at least start the thought process.

Here are 7 facts that may help convince your patients to give up smoking.

1. The earlier patients try to quit smoking, the more likely it is they will be successful.

 Smoking is a pediatric disease. Most individuals start smoking when they are adolescents.

 For the oldest patients that means they started before the hazards of smoking were fully known and widely disseminated. Older smokers generally have a more severe addiction, a propensity to blame smoking-related health problems on aging, and the belief that smoking’s detrimental effects are reversible.

 In the United States, the average cost for a pack of cigarettes is approximately $7, depending on the state. An individual who smokes 1 pack per day will pay approximately $2555 a year to smoke.

 Ask patients what they would do with the money they’d save by not smoking.

3. Many smokers do not understand that nicotine is not the only dangerous ingredient in cigarettes.

 Cigarettes are highly efficient toxin delivery devices and may contain arsenic, carbon monoxide, formaldehyde, hydrogen cyanide, polycyclic aromatic hydrocarbons, and thiosulfates. All these substances generate free radicals.

4. Nicotine increases norepinephrine levels, which creates a calming effect.

Here, too, cigarettes are extremely efficient. Within seconds of lighting up, patients will feel calmer and less anxious.

 The average smoker needs 20 or more cigarettes a day to sustain smoking’s pleasurable effects.

5. Approximately 70% of smokers are interested in quitting,

 but they believe that it will be too hard or it is too late

. Simply asking patients whether they would like to talk about smoking cessation may not result in immediate agreement but may prompt them to come back later.

6. Individuals who stop smoking can sometimes decrease their pill burden. 

Smoking affects the metabolism of many drugs. 

 lists drugs that are likely to interact with smoking. Primarily, smoking interacts with CYP1A2 substrates.

7. The right smoking-cessation product increases the chances of success. 

There is no best way to quit smoking. Each individual must consider comorbidities, convenience, cost, and the severity of their addiction. Online 

 lists smoking-cessation products and the pros and cons of each. Some patients may need to use 2 smoking-cessation products for best results.

Smoking cessation is tough and abstinence rates are approximately 25% at 1 year, even with treatment.

 Combining nicotine replacement therapy and varenicline is often most successful, but pharmacists can help patients find their best approach and provide ongoing support.

, is the assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

1. Adler G, Greeman M, Rickers S, Kuskowski M. Smoking in nursing homes: conflicts and challenges. 

. 1997;25(4)67-81. doi:10.1300/J01ov25n04_052.

2. Committee on Environmental Health, Committee on Substance Abuse, Committee on Adolescence, Committee on Native American Child. From the American Academy of Pediatrics: policy statement-tobacco use: a pediatric disease. 

. 2009;124(5):1474-1487. doi:10.1542/peds.2009-2114

3. Cigarette prices by state - latest data and trends. Balancing Everything. December 31, 2021. Accessed March 20, 2022. https://balancingeverything.com/cigarette-prices-by-state/

4. Brewer NT, Morgan JC, Baig SA, et al. Public understanding of cigarette smoke constituents: three US surveys. 

. 2016;26(5):592-599. doi:10.1136/tobaccocontrol-2015-052897

5. Hughes JR. Why does smoking so often produce dependence? A somewhat different view. 

. 2001;10(1):62-64. doi:10.1136/tc.10.1.62

6. Dimitriadis K, Narkiewicz K, Leontsinis I, et al. Acute effects of electronic and tobacco cigarette smoking on sympathetic nerve activity and blood pressure in humans.

. 2022;19(6):3237. doi:10.3390/ijerph19063237

7. Simoneau T, Hollenbach JP, Langton CR, Kuo CL, Cloutier MM. Smoking cessation and counseling: a mixed methods study of pediatricians and parents. 

. 2021;16(2):e0246231. doi:10.1371/journal.pone.0246231

8. Drug interactions with tobacco smoke. Smoking Cessation Leadership Center. Accessed March 20, 2022. https://smokingcessationleadership.ucsf.edu/sites/smokingcessationleadership.ucsf.edu/files/Documents/FactSheets/Drug%20Interactions%20with%20Tobacco%20Smoke.pdf

9. Martin BA, Wopat MC. Tobacco cessation. In: Kinsky DL, Ferreri SP, Hemstreet B, et al, eds. 

. 20th ed. American Pharmacists Association. 2021:905-929.

10. Chantix (varenicline). Prescribing information. Pfizer Labs; 2009. Accessed April 13, 2022. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/021928s012s013lbl.pdf

11. How to use bupropion SR. CDC. Updated May 24, 2021. Accessed March 20, 2022. https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/quit-smoking-medications/how-to-use-quit-smoking-medicines/how-to-use-bupropion-sr.html

12. Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation. 

. 2000;(2):CD000058. doi:10.1002/14651858.CD000058

13. Gómez-Coronado N, Walker AJ, Berk M, Dodd S. Current and emerging pharmacotherapies for cessation of tobacco smoking. 

. 2018;38(2):235-258. doi:10.1002/phar.2073

Articles

Combining nicotine replacement therapy and varenicline is often most successful, but pharmacists can help patients find best approach.

7 Secrets of Smoking Cessation Can Jump-start the Process

Many community pharmacists work with patients with 

 who are underserved or whose health literacy is low.

Most health care organizations track errors, but the data they collect are often part of their performance and quality improvement programs and are rarely available publicly. Recent discussions with certified diabetes educators identified 8 areas where pharmacists should be more aware about the possibility of error.

1. Injecting insulin after meanls when it should be injected before.

Giving insulin before a meal ensures that its onset matches the absorption of glucose consumed during the meal.

 Clinicians use different types of insulin for mealtime doses. Compared with regular insulin, rapid-acting analog (RAA) insulins aspart, glulisine, and lispro act within minutes of administration. Patients must administer regular insu- lin 30 to 45 minutes before a meal and RAA insulin 5 to 15 minutes before or immediately after they begin eating. They should not wait until they have finished eating.

2. Using mealtime insulin even when they do not eat.

Administering insulin with no food consumption can cause uncontrolled blood glucose and unpredictable glycemic control. Hypoglycemia is a preventable adverse event, and pharmacists should periodically remind patients of that fact.

3. Injecting insulin into the front of the arm, possibly intramuscularly, instead of into the subcutaneous tissue in the back of the arm.

Remembering all the details about insulin can be difficult for patients. They should be reminded that insulin must be injected into the fat just underneath the skin, not into muscle, and that the correct injection sites are the buttocks, rear upper arms, stomach, and thighs.

 These sites have a high fat content. The needle is usually not long enough to reach muscle, but injecting insulin into muscle is painful, and the insulin will be absorbed faster, increasing the risk of hypoglycemia.

4. Reusing lancets and needles for insulin and/or glucagon-like peptide-1 agonists.

The results of an international study showed that on average users of disposable syringe needle devices reused needles 3.3 times

 and on average reused insulin pen devices an 3.6 times. A whopping 26.6% of insulin pen users reused needles more than 5 times.

 The results of a 2021 study in the United States showed that about 50% of individuals reused lancets and needles, with lancet reuse more common than needle reuse.

 Reusing needles reduces copayments, especially for patients who multiple daily injections. But needle reuse for subcutaneous insulin injection is not recommended.

 It may be associated with cutaneous lipodystrophy, infection, and more painful punctures, but little evidence available regarding these adverse events. 

A 2016 meta-analysis that looked at 25 studies showed that infection at injection sites was studied most often, but reusing needles was not associated with local infection.

 Findings showed a statistically significant association between lipohypertrophy and needle reuse but found the data inconclusive because the studies had been structured very differently. Needle reuse was also associated with more pain.

 Sometimes, the smallest quantity the pharmacy can dispense is more than the patient will use before it expires. The high cost of the products sometimes force patients to choose between using expired medication or going without. Furthermore, once in use, injectables for diabetes have a finite expiration date, even if the manufacturer’s expiration date is still good. Patients may not know that. Using expired insulin increases the risk of poor glycemic control.

6. Adjusting medication doses without involving the primary care provider.

Although patients can self-adjust some insulins for diabetes, they should not self-adjust all medications for diabetes.

 Clinicians often see patients taking medication once a day when the label says twice daily or taking extra doses when they experience hyperglycemia at the maximum daily dose. Monitoring refill history and questioning patients when they need refills too soon can identify these nonadherence issues.

7.  Not scanning the sensor often enough when using continuous glucose monitoring (CGM).

This prevents the provider from interpreting data and adjusting doses. Higher rates of CGM scanning have been linked to increased time in the glycemic target range and less hyper- and hypoglycemia. Frequent scanning also helps patients see how carbohydrate intake, exercise, illness, medication, or stress
affect blood glucose.

Pharmacists should remind patients to scan at the frequency that their primary care physicians (PCPs) recommend. For complete data capture, they should scan the sensor at least 3 times a day, 8 hours apart.

8. Testing blood glucose with a glucometer because the PCP said to do so, but making no meaningful changes.

Testing for the sake of testing helps no one and wastes money on costly supplies. Patients should know the threshold for checking blood glucose more often, checking ketones, drinking plenty of fluids, restricting carbohydrates, and adjusting insulin. For example, a patient who has a random reading of 400 mg/dL should retest to verify the reading and take medication if that is part of the medication plan or the patient skipped a dose. Taking a walk can sometimes bring the reading down, as can avoiding food and drinking plenty of water.

Knowing common mistakes is a wonderful way to prevent them. Asking a few simple questions when patients pick up refills and stressing points that are apt to cause confusion, such as expiration dates, is helpful for low-literacy patients.

1. Freeman JS. Insulin analog therapy: improving the match with physiologic insulin secretion. 

2. Hartman I. Insulin analogs: impact on treatment success, satisfaction, quality of life, and adherence. 

. 2008;6(2):54- 67. doi:10.3121/cmr.2008.793

3. Fallabel C. Injecting insulin into muscle: do’s and don’ts. Diabetes Strong. April 21, 2021. Accessed February 22, 2022. https://diabetesstrong.com/injecting-insulin-into-muscle/

4. Stewart K. The dos and don’ts of insulin injections. May 5, 2014. Accessed February 22, 2022. https://www.everydayhealth.com/ hs/diabetes-and-insulin-guide/insulin-injection-dos-donts/

5. De Coninck C, Frid A, Gaspar R, et al. Results and analysis of the 2008-2009 Insulin Injection Technique Questionnaire survey. 

. 2010;2(3):168-179. doi:10.1111/j.1753-0407.2010.00077.x

6. Montoya JM, Thompson BM, Boyle ME, Leighton ME, Cook CB. Patterns of sharps handling and disposal among insulin-using patients with diabetes mellitus. 

. 2021;15(1):60-66. doi:10.1177/1932296819882926

7. American Diabetes Association. Insulin administration. Diabetes Care. 2003;26(suppl 1):S121-S124. doi:10.2337/diacare.26.2007.S121

8. Zabaleta-Del-Olmo E, Vlacho B, Jodar-Fernández L, et al. Safety of the reuse of needles for subcutaneous insulin injection: a systematic review and meta-analysis. 

. 2016;60:121- 132. doi:10.1016/j.ijnurstu.2016.04.010

9. Thomas K. Drug makers accused of fixing prices on insulin. New York Times. January 30, 2017. Accessed February 22, 2022. https://www.nytimes.com/2017/01/30/health/drugmakers-lawsuit-insu- lin-drugs.html

10. Picchi A. The rising cost of insulin: “horror stories every day.” CBS News. May 9, 2018. Accessed February 22, 2022. https://www.cbsnews.com/news/the-rising-cost-of-insulin-horror-stories-every-day/

11. Kelly B. Nursing interventions for people with type 1 diabetes and frequent hypoglycaemia. 

. 2021;26(11):544-552. doi:10.12968/bjcn.2021.26.11.544

12. Mehta R, Goldenberg R, Katselnik D, Kuritzky L. Practical guidance on the initiation, titration, and switching of basal insulins: a narrative review for primary care. 

. 2021;53(1):998- 1009. doi:10.1080/07853890.2021.1925148

13. Hirsch IB, Nardacci E, Verderese CA. Flash continuous glucose monitoring: implications for use of continuous data in daily diabetes management. 

. 2019;32(4):355-367. doi:10.2337/ds18-0059

14. Blood sugar at 400: what to do, risks & causes. Diabetes Meal Plans. Accessed February 22, 2022. https://diabetesmealplans.com/14776/blood-sugar-at-400/

Here are 8 diabetes areas where pharmacists should be more aware of error.

Monitoring for Mistakes in Patients With Low Health Literacy Is Crucial

 pandemic drags on, Americans are still arguing, debating, and discussing vaccinations.

This is a good time for pharmacists to review the general principles behind the COVID-19 

, extra doses, and booster shots, which are different things.

 First, they should protect against disease and/or infection caused by a pathogen during postvaccination exposure. Second, they should prevent infection transmission, a concept related to herd immunity. Live (attenuated) or nonlive (inactivated) vaccines and protein or polysaccharide antigen(s) have been successful for many years. In response to the pandemic’s dire consequences, pharmaceutical companies developed new vaccines based on nucleic acid (DNA and RNA) and viral vector technology.

After vaccination, 3 biologic activities occur first.1 Dendritic cells activate and present antigens. B cells produce antibodies, T cells work on cellular immunity and immune memory, and T helper cells relay signals that stimulate B cells and cytotoxic T cell production. Finally, cytotoxic T cells kill infected cells.

The most important step is B cell production of circulating antibodies because it drives sterilizing immunity, the situation in which the immune system stops a pathogen completely.

 T cell response is an additional contributing factor. T helper cells can drive cellular immunity, B cell development and antibody production, and mucosal surface immunity. Finally, cytotoxic T cells seem to prevent progression to more severe disease.

 lists other factors that improve protection.

Other factors are vaccine specific. Virologists have examined various measures of efficacy for the COVID-19 vaccines. Although it would be ideal if the vaccines protected from any SARS-CoV-2 infection, it appears that the current vaccines protect from most infections, especially life-threatening and severe ones. Virologists also look at each pathogen’s incubation period and infection process.

 In addition, they examine circulating body concentrations and elimination half-life, with specific attention to whether the amount of antibody varies among individuals.1 Although it usually takes 3 to 4 days for individuals to develop some immune memory or reactivate antibody production, virologists look at each vaccine’s individual profile.

Next, virologists must look at the vaccine’s real-world performance so they can determine whether patients need booster shots or extra doses.

 The decision to recommend either is based on whether patients develop an adequate response to an initial vaccination series, associated with long incubation-period infections, or a less optimal response to an initial vaccination series, associated with short incubation-period infections.

Almost everybody who has been approved for a COVID-19 vaccine needs an additional dose or booster shot to maintain immunity.

 Certain factors drive that need. The circulating SARS-CoV-2 viral variants are relatively resistant to antibody neutralizing activity.

 This means they have an efficient, fast infection process. Virologists have documented declining circulating antibody levels in individuals who have had an adequate response to primary vaccination but who have high-exposure risk, a high risk of severe disease, and/or a low initial response. Another contributing factor has been insufficient herd immunity.

Boosters are recommended when the response to the primary series of any vaccine is sufficient but immunity wanes over time.

Virologists measure waning immunity via declining antibody titers in vaccinated individuals or epidemiologic evidence of increased infections or severe disease.

Additional doses are recommended when the patient’s immunity is inadequate or the response to the originally designed primary series of the vaccine is insufficient.

 In the former case, epidemiologic evidence indicates that vulnerable populations have no or limited protection from infections or severe disease or that patients have low or unmeasurable antibody titers.

 lists factors that influence response to the initial vaccine series.

Immunizers should be aware of the CDC’s recommendations for additional doses of mRNA vaccines. As of January, the CDC recommends additional doses for moderately to severely immunocompromised people, meaning individuals who are actively taking high-dose corticosteroids or immunosuppressants, are receiving active cancer treatment, have advanced or untreated HIV infection, have a moderate to severe primary immunodeficiency, or received a stem cell transplant within 2 years or an organ transplant and are taking immunosuppressants.

Patients who mount no detectable serum anti-body response to the COVID-19 vaccines still have an approximately 50% protection from infection compared with unvaccinated individuals.

 CDC recommendations change, and the astute immunizer should bookmark CDC pages and visit them often. Research is evolving continually, and the need for a booster shot does not mean these vaccines do not work; they work well.

1. Pollard AJ, Bijker EM. A guide to vaccinology: from basic principles to new developments. 

. 2021;21(2):83-100. doi:10.1038/s41577-020-00479-7

2. Rey GU. T cell responses to coronavirus infection are complicated. Virology blog. November 5, 2020. Accessed January 10, 2022. https://www.virology.ws/2020/11/05/t-cell-responses-to-coronavirus-infection-are-complicated/

3. Kourtis AP, Read JS, Jamieson DJ. Pregnancy and infection. 

. 2014;370(23):2211-2218. doi:10.1056/NEJMra1213566

4. Kelly DF, Pollard AJ, Moxon ER. Immunological memory: the role of B cells in long-term protection against invasive bacterial pathogens. 

. 2005;294(23):3019-3023. doi:10.1001/ jama.294.23.3019

5. Mbaeyi S, Oliver SE, Collins JP, et al. The Advisory Committee on Immunization Practices’ interim recommendations for additional primary and booster doses of COVID-19 vaccines - United States, 2021. 

. 2021;70(44):1545- 1552. doi:10.15585/mmwr.mm7044e2

6. Rodda LB, Netland J, Shehata L, et al. Functional SARS-CoV-2-specific immune memory persists after mild COVID-19. 

. 2021;184(1):169-183.e17. doi:10.1016/j.cell.2020.11.029

7. Goswami ND. Clinical considerations for use of an additional mRNA COVID-19 vaccine dose after a primary mRNA COVID-19 vaccine series for immunocompromised people. CDC. August 13, 2021. Accessed January 10, 2022. https://www.cdc.gov/vaccines/ acip/meetings/downloads/slides-2021-08-13/03-COVID-Goswa- mi-508.pdf

8. GilbertPB,MontefioriDC,McDermottAB,etal.Immunecorrelates analysis of the mRNA-1273 COVID-19 vaccine efficacy clinical trial. 

. 2022;375(6576):43-50. doi:10.1126/science.abm3425

Explain to patients that research Is continually evolving and the need for booster shots does not mean the vaccinations do not work.

Change Is the Operative Word When Discussing COVID-19 Vaccines

The traditional formula for weight loss is simple: induce a negative energy balance by increasing physical activities and reducing caloric intake.

 Yet obesity is not a simple health problem. Individuals who struggle with obesity report difficult life changes, few ways to lose weight and keep it off, and yo-yo dieting.

Guidelines call weight loss of at least 5% from baseline clinically significant, indicating that it improves cardiometabolic risk factors.

 That seems like good news. For instance, that would mean a 200-lb individual who loses just 10 lb should see significant improvements. However, most 1 individuals with obesity lose little weight with lifestyle changes alone. Approximately one-third who lose more than 5% of their weight return to their original weight within 1 year. More than half return to their starting weights at 2 years and almost all do so within 5 years.

When lifestyle interventions are unsuccessful, most obesity control guidelines recommend adjunct medication.

 Because central and peripheral hormonal signaling controls energy intake,

 investigators have targeted numerous mechanisms to develop medications. FDA-approved antiobesity medications for chronic weight management include 5 options. Potential mechanisms for obesity medications include appetite/energy intake reduction, calorie absorption reduction, and promotion of energy expenditure.

Glucagon-Like Peptide 1 Receptor Agonists

The FDA approved the injectable glucagon-like peptide 1 (GLP-1) receptor agonists liraglutide (Saxenda) in 2014 and semaglutide (Wegovy) in 2021
for long-term weight management (Table

). GLP-1 regulates blood glucose after meals by inhibiting glucagon secretion and enhancing insulin secretion from pancreatic β-cells in a glucose-dependent manner.

 It induces postprandial satiety and fullness, reduces appetite and food consumption, and slows gastric emptying.

 Three randomized controlled trials (RCTs) found weight loss of 4.7% to 8% in liraglutide-treated patients.

 In clinical trials, semaglutide treated was associated with an approximate 15% weight loss over a 68-week period.

Naltrexone/bupropion (Contrave) combines an opioid antagonist with an antidepressant. Four large RCTs documented weight loss of 5% to 6.1%
in naltrexone/bupropion-treated patients.

 Contraindications include abrupt alcohol discontinuation, anorexia or bulimia nervosa, benzodiazepines, monoamine oxidase inhibition during the first 14 days of use, seizure, uncontrolled hypertension, and use of antiepileptic drugs or barbiturates. This medication also requires gradual dose escalation, starting with 1 tablet (8 mg/90 mg) for 1 week, and ultimately reaching 2 tablets twice daily (the maximum dose) at week 4. Common adverse effects (AEs) include constipation, dizziness, dry mouth, headache, nausea, and vomiting.

 Clinicians should monitor for depression or suicidal ideation.

The FDA approved orlistat (Xenical) in 1999, and it is available as an OTC formulation (Alli) for individuals 12 years or older.

 Orlistat inhibits gastrointestinal and pancreatic lipases, blocking absorption of approximately one-third of consumed fatty acid and triglyceride hydrolysis but having no effect on appetite.

 In a large RCT, participants had a total body weight loss of 2.4% after 4 years. Orlistat decreased type 2 diabetes (T2D) risk in the treatment arm (9%) compared with the placebo arm (6.2%).

 It also improved blood pressure, insulin sensitivity, and lipid profiles.

Patients should take orlistat with or within 1 hour of meals.

 Because nonabsorbed fats remain in the intestine, almost all patients will report some fecal incontinence, flatus with discharge, frequent bowel movements, and steatorrhea. Using a fiber-contain- ing supplement such as psyllium, can reduce gas- trointestinal AEs. Orlistat prevents the lipid-soluble vitamins from being absorbed, so patients may need vitamin A, D, E, and K supplementation with long-term use.

The FDA approved phentermine/topiramate extend- ed release (Qsymia), a schedule IV-controlled sub- stance, for long-term obesity management in 2012. It suppresses appetite through mechanisms that remain unclear. Three RCTs found significant mean weight reduction ranging from 7.8% to more than 10% over 1 to 2 years. It was also associated with improved blood pressure, fasting glucose and insulin levels, lipid profiles, and waist circumference.

Patients take phentermine/topiramate once daily in the morning to avoid drug-related insomnia. Clinicians gradually escalate the dose from 3.75 mg/23 mg for 2 weeks to 7.5 mg/46 mg in the following weeks. After 3 months, they may increase the dose to 15 mg/92 mg if patients have not lost 3% of baseline weight. If patients lose less than 5% of weight or are intolerant to the drug, clinicians should gradually discontinue phentermine/topiramate to avoid seizure risk.

 Common AEs are constipation, dizziness, dry mouth, dysgeusia, insomnia, and paresthesia. Clinicians must periodically monitor creatinine, electrolytes, and heart rate.

 Contraindications observed are uncontrolled cardiovascular disease, chronic kidney disease, glaucoma, hypertension, hyperthyroidism, and inhibition of monoamine oxidase within 14 days. Women of childbearing age should avoid pregnancy, as the drug is linked to fetal oral clefts.

With 5 drugs available to manage obesity, clinicians should consider each drug’s mechanism of action before prescribing. Orlistat is more suitable for individuals who tend to eat fatty foods. The GLP-1 receptor agonists have no neuropsychiatric safety concerns and may be options for patients with comorbid mental disorders or T2D.

1. Canuto R, Garcez A, de Souza RV, Kac G, Olinto MTA. Nutritional intervention strategies for the management of overweight and obesity in primary health care: a systematic review with meta-analysis. 

. 2021;22(3):e13143. doi:10.1111/obr.13143

2. Seo MH, Lee WY, Kim SS, et al. 2018 Korean Society for the Study of Obesity guideline for the management of obesity in Korea. 

. 2019;28(1):40-45. doi:10.7570/jomes.2019.28.1.40

3. Hall KD, Kahan S. Maintenance of lost weight and long-term management of obesity. 

. 2018;102(1):183-197. doi:10.1016/j.mcna.2017.08.012

4. Bhat SP, Sharma A. Current drug targets in obesity pharmacotherapy - a review. 

. 2017;18(8):983-993. doi:10.2174/1389450118666170227153940

5. Wegovy. Prescribing information. Novo Nordisk; 2021. Accessed January 1, 2022. 

https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/215256s000lbl.pdf

6. Saunders KH, Umashanker D, Igel LI, Kumar RB, Aronne LJ. Obesity pharmacotherapy. 

. 2018;102(1):135-148. doi:10.1016/j.mcna.2017.08.010

5. Pilitsi E, Farr OM, Polyzos SA, et al. Pharmacotherapy of obesity: available medications and drugs under investigation. 

. 2019;92:170-192. doi:10.1016/j.metabol.2018.10.010

6. Velazquez A, Apovian CM. Updates on obesity pharmacotherapy. 

. 2018;1411(1):106-119. doi:10.1111/nyas.13542

7. Pi-Sunyer X, Astrup A, Fujioka K, et al. A randomized, controlled trial of 3.0 mg of liraglutide in weight management. 

. 2015;373(1):11-22. doi:10.1056/NEJMoa1411892

8. Davies MJ, Bergenstal R, Bode B, et al. Efficacy of liraglutide for weight loss among patients with type 2 diabetes: the SCALE diabetes randomized clinical trial. 

. 2015;314(7):687-699. doi:10.1001/jama.2015.9676

9. Wadden TA, Hollander P, Klein S, et al. Weight maintenance and additional weight loss with liraglutide after low-calorie-diet-induced weight loss: the SCALE maintenance randomized study. 

. 2013;37(11):1443-1451. doi:10.1038/ijo.2013.120

12. Allison DB, Gadde KM, Garvey WT, et al. Controlled-release phentermine/topiramate in severely obese adults: a randomized controlled trial (EQUIP). 

. 2012;20(2):330-342. doi:10.1038/oby.2011.330

13. Gadde KM, Allison DB, Ryan DH, et al. Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomised, placebo-controlled, phase 3 trial. 

. 2011;377(9774):1341-1352. doi:10.1016/S0140-6736(11)60205-5

14. Garvey WT, Ryan DH, Look M, et al. Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL): a randomized, placebo-controlled, phase 3 extension study. 

. 2012;95(2):297-308. doi:10.3945/ajcn.111.024927

15. Smith SM, Meyer M, Trinkley KE. Phentermine/ topiramate for the treatment of obesity. 

. 2013;47(3):340-349. doi:10.1345/aph.1R501

16. Patel DK, Stanford FC. Safety and tolerability of new-generation anti-obesity medications: a narrative review. 

. 2018;130(2):173-182. doi:10.1080/00325481.2018.1435129

Increasing physical activities and reducing caloric intake isn’t always enough to conquer obesity.