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Ask a Pharmacist: Weighing Weight Loss Options for People with HIV

, by Jennifer Cocohoba, PharmD, AAHIVE

Bathroom weight scales, flat designMany people—both those with and without HIV—may be interested in losing some extra weight so they look and feel great. There are a lot of medication options out there, both prescription and over-the-counter, but not all are equally safe and effective. In this column, I’ll give an update on my popular 2012 article about diet pills for people with HIV. We’ll explore a few over-the-counter weight loss supplements that are trending now, discuss prescription weight loss pills, and talk about what is known about commercial diet plans so that you can make an informed decision about which weight loss strategy might be right for you.

Au natural…?

Dietary supplements and herbs can be found in pharmacies, grocery stores, vitamin shops and other retail locations. Because they are available without a prescription and vary widely in how effective they are, they tend to gain (and lose) their popularity very quickly. Two supplements you might have heard about recently are Garcinia and green coffee bean extract.

Garcinia cambogia is a plant found in the topics that has a chemical called hydroxycitric acid (HCA) in its fruit and rind which is thought to help people lose weight by interfering with the way the body stores fat. Some studies have shown that garcinia has helped people lose a small amount of weight.

Here’s what we know about how well garcinia does in clinical trials. One randomized controlled study looked at the effects of garcinia in 89 women who weighed and average of 166 pounds and were 10-50 pounds over their ideal body weight. The group of women who took 2.4 grams of garcinia every day lost an average of 2.9 pounds more than the group of women who only took placebo over the course of the study. But—and this is important—the study lasted for a total of 12 weeks, so the weight loss over time in people who took garcinia wasn’t dramatic.

Another study on garcinia was conducted with 60 people who were classified as clinically obese. People who took a garcinia-based extract reduced their body mass index (BMI) on average by 5-6% over eight weeks. That would equate to a 300 pound person losing about 15 pounds across the eight weeks. People who didn’t take the garcinia extract didn’t have any average change in BMI after eight weeks.

Although these studies look promising, three other studies demonstrated no change in weight after taking garcinia. This is where you get to decide—there seems to be very modest weight loss when using garcinia, but it may not be worth spending your dollars on. Plus, there’s a small risk that people who take garcinia and also take some commonly used antidepressants may develop a serious condition called serotonin syndrome. Just because you can buy this supplement over the counter doesn’t mean you can proceed without caution!

Green coffee bean extract.  Coffee beans are green before they’ve been roasted.  They contain a chemical called chlorogenic acid which may help people regulate how their bodies handle sugar and then lose weight. In two different studies, people taking green coffee bean extract lost approximately four and a half pounds over six to eight weeks. Green coffee bean extract is pretty well tolerated, so there aren’t many strong reasons to avoid this supplement other than it may not be as effective as you hope. If you have an anxiety disorder, high blood pressure, or bleeding disorder you may want to talk with your doctor or pharmacist before taking this supplement. People who are sensitive or allergic to caffeine should avoid using green coffee bean extract.

A prescription for weight loss

Prescription medications now exist that can help people who are obese—as measured by body mass index (BMI)—lose weight. The Endocrine Society guidelines say that you might be a good candidate for a prescription weight loss medication if you meet one of these criteria (calculate your BMI here):

  • Your BMI is 25 or greater and you’ve had trouble losing weight by modifying your diet and exercising;
  • You have a BMI of 27 or greater and also have a comorbid condition such as high blood pressure, high cholesterol, diabetes or sleep apnea; or,
  • Your BMI is 30 or greater.

Here are a couple of examples that will give you a rough idea of who might qualify for a prescription weight loss medication. A 5 foot 10 inch man with diabetes weighing more than 185 pounds and a 5 foot 4 inch woman with no other health conditions over 180 pounds both meet the Endocrine Society guidelines.

Prescription medication options

Phentermine. This medication helps people lose weight by changing the balance of chemicals in the brain that suppress appetite. Short-term studies show that people who took phentermine lost more weight than those who took placebo.  People with heart disease and certain other conditions like hyperthyroidism, glaucoma or agitation shouldn’t take this medicine.

Another medication called topiramate, which is most commonly used to treat seizures and prevent migraines, is sometimes prescribed along with phentermine to raise the levels of phentermine in the blood and increase its effectiveness.  

Diethylpropion. This medication helps people lose weight by reducing appetite, but shouldn’t be used by people who have very high blood pressure, hardening of the arteries, hyperthyroidism or glaucoma.

Lorcaserin. This medication changes the levels of a chemical in the brain called serotonin to regulate appetite. In clinical trials, more people who took loracaserin and started a diet and exercise routine lost between 5-10% of their body weight over one year compared to people who only used diet and exercise.

Orlistat. This medication blocks the body’s ability to absorb fats and then causes them to be excreted. It’s been sold under the brand name Xenical since 1999 as a prescription, but has been recently made available in a lower dose over-the-counter under the brand name Alli. In clinical trials, more people (57%) who took orlistat lost 5% of their body weight compared to those who took placebo (17%) after one year.

There is one report of a person with HIV having an increase in viral load after taking orlistat. Because it’s possible that this medication may change absorption of antiretrovirals, it is probably safer for people with HIV to avoid this medication, especially if they’re taking protease inhibitors.

Naltrexone/bupropion. It’s not well understood why the combination of these medications helps people lose weight. Clinical trials have shown that people who took naltrexone/bupropion, reduced their calorie intake and engaged in an exercise routine were more likely to lose at least 5% of their body weight after 56 weeks of treatment (42% of people), compared to those who used diet and exercise alone (17% of people). If you regularly take opioid pain medications you should not use naltrexone/bupropion because it may cause withdrawal.

Liraglutide. This injectable medication is also used to treat diabetes. In clinical studies, 75% of people who took 3 mg of liraglutide daily lost at least 5% of their body weight compared with 29% of people taking placebo.  Two case reports of people with HIV and diabetes describe liraglutide as being safe and effective when used to treat diabetes.

If you are curious about prescription weight loss medications, talk with your doctor and your pharmacist.  Each medication has different advantages and disadvantages, so medications must be very carefully selected based on your current weight, goals, other health conditions and other medications you’re taking, especially if you are taking HIV medications.

Commercial Diet Plans

If you’re not that keen on using medications to help you lose weight, you may have looked into one of the many commercially available diet plans.  There is evidence that some of these plans help people lose weight—even if research has not specifically been done with people living with HIV.  A systematic review of high-quality, published clinical trials of popular plans showed that the most effective plans were Jenny Craig (4.9% increased weight loss compared to a control group after 1 year), Nutrisystem (3.8% increased weight loss compared to a control group after 3 months) and Weight Watchers (2.6% greater weight loss compared to a control group).

Partners in health

However you decide you’re going to take charge of your weight—whether it is through an exercise and diet plan, with herbs and dietary supplements, or with prescription medications—it can help to have a support team in place. This team can include your family and friends in addition to your doctor and pharmacist. Together, they’ll help you be successful in losing weight safely and with your health in mind.

Jennifer Cocohoba, PharmD, is an associate clinical professor in the School of Pharmacy at the University of California, San Francisco (UCSF). Since 2004, she has worked as the clinical pharmacist for the UCSF Women’s HIV Program, where she provides adherence support and medication information to patients and providers.

The opinions expressed in this article are those of the author alone. They do not reflect the opinions or positions of BETA Blog or of San Francisco AIDS Foundation. BETA Blog serves as a resource on new developments in HIV prevention, evolving approaches to HIV treatment, and strategies for living well with HIV. Our goal is to inform, empower, and inspire conversation.

Selected sources.

Preuss, H.G. and others. Effects of a natural extract of (-)-hydroxycitric acid (HCA-SX) and a combination of HCA-SX plus niacin-bound chromium and Gymnema sylvestre extract on weight loss. Diabetes, Obesity and Metabolism. 2004.

Mattes, R.D. and Bormann, L. Effects of (-)-hydroxycitric acid on appetitive variables. Physiology & Behavior. 2000.

Melendez-Rosado, J. and others. Acute hepatitis induced by pure garcinia cambogia. Journal of Clinical Gastroenterology. 2015.

Onakpoya, I. and others. The use green coffee extract as a weight loss supplement: a systematic review and meta-analysis of randomised clinical trials. Gastroenterology Research and Practice. 2011.

Thom, E. The effect of chlorogenic acid enriched coffee on glucose absorption in healthy volunteers and its effect on body mass when used long-term in overweight and obese people. Journal of International  Medical Research. 2007.

U.S. Department of Health and Human Services Food and Drug Administration.  Dietary supplements. 2015.

Mayo Clinic.  Over the counter weight loss pills.  2015.

Apovian, C.M. and others. Pharmacological management of obesity: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism. 2015.

Kent, S.J. Loss of control of HIV viremia associated with the fat malabsorption drug orlistat.  AIDS Research and Human Retroviruses. 2012.

Gudzune, K.A. and others. Efficacy of commercial weight-loss programs: An updated systematic review.   Annalso of Internal Medicine. 2015.

 

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