Medicine used in the Treatment of Obesity Elaine Neil Lead Pharmacist North Aberdeenshire LCHP

At one time 3 medicines licensed Orlistat Xenical - POM Alli - OTC

Orlistat Promotes loss of weight by preventing the digestion and absorption of fat Inhibitor of GI lipases acting in stomach and small intestine Reduces absorption of dietary fat by around 25-30% The unabsorbed fat is excreted in the stool.

Contraindications See BNF/SPC Hypersensitivity Chronic malabsorption Cholestasis Breast-feeding Caution in pregnant women The effect of orlistat in patients with hepatic and/or renal impairment, children and elderly patients has not been studied.

Side – effects See BNF/SPC Liquid or oily stools / Oily leakage from rectum Flatulence and Bloating/ abdominal pain Faecal urgency Faecal incontinence Dyspepsia Menstrual disturbances Headache Tooth disorder Anxiety Gingival disorder Fatigue Influenza Respiratory infection Urinary tract infection Hypoglycaemia

Drug Interactions See BNF/SPC Ciclosporin Anti-epileptics Fat soluble vitamins Amiodarone Levothyroxine Warfarin – monitor INR Oral contraceptives – diarrhoea

Orlistat - Xenical Dose 120mg taken with water immediately before, during or up to one hour after main meals. Max dose 360mg daily. Doses above 120 mg three times daily have not been shown to provide additional benefit.

Orlistat Take with calorie controlled diet, 30% calories from fat, distributed over 3 main meals. Omit dose if no main meal taken or no fat content. Increase in faecal fat 24 to 48 hours after dosing, levels return to pre-treatment levels, within 48 - 72 hours.

Eligible Patients BMI 30kg/m2 or greater BMI 28kg/m2 or greater with risk factors diabetes coronary heart disease hypertension hypercholestraemia

Additional “treatment” Orlistat must be prescribed in conjunction with other measures to support weight loss Diet modification Increase in physical activity Behaviour modification Appropriate support and encouragement

Weight Monitoring Serious attempts to lose weight before starting Monitor weight loss during treatment Weight loss – 5% over 3 months (lower in patients with type 2 diabetes)

Weight Monitoring Treatment with orlistat should be discontinued after 12 weeks if patients have not lost at least 5 % of the body weight measured at the start of therapy. Stop therapy if weight loss inadequate May get weight gain on stopping Long-term maintenance of weight loss after a period of obesity is difficult and often unsuccessful, and thus may require sustained support.

Outcomes Pooled data from five 2 year studies with orlistat and a hypocaloric diet showed that 37 % of orlistat patients and 19 % of placebo patients demonstrated a loss of at least 5 % of their baseline body weight after 12 weeks of treatment. Of these, 49 % of orlistat treated patients and 40 % of placebo treated patients went on to lose 10 % of their baseline body weight at one year. Overall, after one year of treatment, the percentage of patients taking 120 mg orlistat who lost 10 % or more of their body weight was 20 % compared to 8 % of patients taking placebo. The mean difference in weight loss with the drug compared to placebo was 3.2 kg.

Xenical – prescription (POM) Xenical 120mg capsules

Alli – over the counter (OTC) Alli 60mg capsules Maximum 60mg three times daily Use for 6 months Discard any capsules stored in the carry case for more than one month.

Costs Orlistat (Xenical) – 120mg x 3 daily 28 days supply £31.63 Alli 60mg x 3 daily 28 days supply £15- £35 Pharmacy or Internet supply

NHS Grampian Spend

NHS Grampian Spend 2010/11 9126 prescriptions £338,643

NHS Grampian Spend

NHS Grampian Spend