CASE 1: Orlistat
Q: MK is a 29-year-old woman who is looking for an OTC weight loss supplement. MK mentions that she has recently changed her lifestyle to incorporate more exercise and healthy eating to lose weight and she is looking for a product to help her weight loss in addition to her lifestyle changes. She was reading on the internet about orlistat (alli;Haleon) and wants to know more about the efficacy and safety of the drug. As the pharmacist, what would you discuss about orlistat with MK?
A: Orlistat is a weight loss aid that helps decrease dietary fat absorption. It is important to educate MK that orlistat should be used only if her body mass index (BMI) is at least 30 or if she has 2 comorbidities and a BMI of 27. According to the drug fact label, orlistat can help patients lose another 2 to 3 pounds for every 5 pounds already lost. In clinical trials, subjects lost 10% to 15% of their visceral fat with orlistat after 24 weeks of use. Orlistat should be administered as a single 60-mg capsule with each meal of the day. It is important to use orlistat in conjunction with a low-fat and reducedcalorie diet. Adverse effects of orlistat include loose stool, frequent stools, and gas with discharge, as this medication works to eliminate fat in the stool. Following a low-fat diet can help reduce the incidence of these adverse effects. Orlistat can decrease the absorption of fat-soluble vitamins (vitamins A, D, E, and K); therefore, a multivitamin should be taken at bedtime when using this product.1
CASE 2: Bitter Orange Supplement
Q: LT is a 57-year-old woman who is requesting a consultation with the pharmacist about OTC weight loss supplements. LT has a past medical history of type 2 diabetes, obesity, atrial fibrillation, and hypertension. She is currently taking metformin (Glucophage; Merck), warfarin (Jantoven; Upsher-Smith), and losartan (Cozaar; Merck). She has no known drug allergies. LT wants to purchase a bitter orange supplement but first wants to make sure it is safe for her to take with her prescription medications. As the pharmacist, how would you respond to LT?
A: Bitter orange, also known as Citrus aurantium, is an herbal supplement that increases fat breakdown and the metabolic rate to suppress appetite. Bitter orange contains p-synephrine, which is similar to ephedra. However, ephedra has been banned in the United States by the FDA for causing severe hypertension.2 According to the National Institutes of Health, there is limited evidence to support weight loss with bitter orange.2 Adverse effects of bitter orange include hypertension, tachycardia, chest pain, anxiety, and headaches.3 Because there is little benefit for weight loss and increased risk of hypertension, LT should be educated that using bitter orange is probably not a great option for her.
CASE 3: Healthy Lifestyle
Q: JF is a 60-year-old man who presents to the pharmacy to pick up his prescriptions. He mentions to the pharmacist that he is trying to be healthier and asks for simple recommendations that promote a healthy lifestyle. What counseling points would you give JF to promote a healthy lifestyle?
A: A healthy lifestyle incorporates physical activity and balanced healthy meals. In adult patients, the US Department of Health and Human Services’ guidelines recommend at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week. Muscle-strengthening exercises such as lifting weights, using resistance bands, or yoga should be incorporated throughout the week as part of a physical activity plan. JF should be educated to speak with his doctor before starting an exercise plan if he has any health conditions, such as lung disease, heart disease, or diabetes.4,5 Additionally, the pharmacist should educate JF on the basics of a healthy diet. The 2020-2025 Dietary Guidelines for Americans highlight key dietary principles, including obtaining most nutritional needs from nutrient-dense foods and beverages, choosing a variety of foods from different food groups, and paying attention to portion sizes. Appropriate portion sizes can be determined with the help of nutrition fact labels on which the serving size of a portion is clearly listed in addition to the calorie and percent daily value breakdown.6 If JF is interested in learning more, he may benefit from meeting with a dietician.
CASE 4: Weight Gain
Q: MN is a 30-year-old woman who is looking for an OTC supplement to help her lose weight. She mentions that she has experienced a 10-pound weight gain in the past year. Her medical history includes systemic lupus erythematosus and depression. Her current medications include medroxyprogesterone acetate (Depo-Provera;Pfizer) and mirtazapine (Remeron SolTab;Merck). She started taking mirtazapine about 6 months ago. As the pharmacist, what recommendations would you provide to help MN lose weight?
A: Some medications can cause weight gain, including birth control, antidepressants, antipsychotics, and oral corticosteroids.7 Medroxyprogesterone acetate and mirtazapine may both be contributing to her weight gain. The medroxyprogesterone acetate package insert cites up to 38% incidence of weight gain of more than 10 pounds at 24 months of use.8 The package insert for mirtazapine cites up to a 12% weight gain in short-term clinical trials. Additionally, in a study of patients with psychiatric conditions treated with antidepressants, 88% of patients experienced weight gain with mirtazapine after an average of 13.5 months of therapy.9,10 Although these medications do have evidence of associated weight gain, it is important to educate MN that she should not stop taking her medications. Instead, she can focus on increasing her physical activity and following a healthy diet to help with weight loss. If she is concerned and wishes to stop or change her current medications, she should speak to her health care provider to discuss other medication options with less associated weight gain as an alternative to her current regimen.