Other Medications and Herbal Supplements

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Many agents have as an unintended side effect weight loss. These include metformin, a biguanide used to treat type 2 diabetes, acarbose, an alpha-glucosidase inhibitor also used to treat type 2 diabetes, and topiramate an anti-epileptic drug. It should be noted that these agents do not have an FDA indication for the treatment of obesity and trials, including those specifically in some cases designed as weight loss trials have shown a lack of efficacy or an unfavorable risk benefit ratio. Therefore their use can not be routinely recommended.

Dietary supplements and herbal preparations are not prospectively reviewed by the FDA for safety or efficacy. These agents are only reviewed if they are shown to present a "significant or unreasonable risk", as has been the case with ephedra supplements. Herbals and supplements include chitosan, chromium picolinate, conjugated linoleic acid, ephedra alkaloids (ma huang) and garcinia cambogia. There is insufficient data on these agents except for ephedra alkaloids and caffeine, which do have randomized, controlled trials that indicate efficacy in promoting weight loss. Chromium picolinate, an essential trace mineral and cofactor to insulin, which improves insulin action and is available as an over the counter supplement. A meta-analysis of 10 double-blind randomized clinical trials with this supplement found a relatively small weight reduction of 1.1-1.2 kg (0.08-0.2 kg/wk) compared with placebo during a treatment period of 6-14 wk in patients with an average BMI of 28-33, without any appreciable side effects. Thus the risk benefit ratio for weight loss appears as favorable, if not more so, than with other herbal or pharmacologic medications.

Figure 6.2. Mechanisms of action of orlistat. Adapted from: Yanovski SZ, Yanovski JA. Obesity. N Engl J Med 2002; 346(8):591-602.

Figure 6.2. Mechanisms of action of orlistat. Adapted from: Yanovski SZ, Yanovski JA. Obesity. N Engl J Med 2002; 346(8):591-602.

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