Rebuttal: Should family physicians prescribe medication for obesity?

I have 3 main concerns with regard to the points made in the yes argument.¹

First, I am concerned about my opponents’ worry that the weak recommendation from the Canadian Task Force on Preventive Health Care (CTFPHC)² against pharmacotherapy will dissuade primary care providers from routinely using medication to treat obesity. Considering the state of the evidence (which has not changed, despite Health Canada’s recent approval of liraglutide for obesity), routine use of medication to treat obesity is inappropriate. Based on the GRADE (grading of recommendations, assessment, development, and evaluation) framework, a weak recommendation implies an informed discussion about the benefits and risks of the proposed intervention. Following this discussion, the primary care provider might still prescribe under individual circumstances. It is important to remind readers that the CTFPHC mandate is to “support primary care providers in delivering preventive health care”³ and that none of the guideline authors had any pharmaceutical industry affiliation.

My biggest concern is the reliance on the Endocrine Society clinical practice guideline.⁴ The strength of their recommendation to use pharmacotherapy for patients who have failed lifestyle management is also weak, but with low-quality evidence. As a reminder, the CTFPHC weak recommendation not to prescribe was based on moderate-quality evidence. In addition, the guideline specifically states “the weight loss effects of these medications are only sustained as long as they are taken” with “gradual weight gain typically occurring when medications are stopped.”⁴ In contrast to the CTFPHC guideline, 3 of 8 authors on the Endocrine Society guideline (including the principle author) have potential conflicts of interest related to significant association with the pharmaceutical industry.

Finally, an informed discussion implies an understanding of the risks as well as the benefits. There is a lack of information presented concerning the potential risks of medication (particularly liraglutide, for which these might be substantial^5,6) and no mention of the lack of long-term efficacy or safety data.

Obesity is a risk factor for chronic disease. We should require a higher benefit-to-risk ratio, particularly in asymptomatic patients, before we use pharmacotherapy to treat what is predominantly a lifestyle condition. This bar has not been met. If we wish to prescribe, let us use an exercise prescription, for which there is evidence to support improved quality of life—one of our main goals in chronic disease management.⁷

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