HYPERTENSION AND OBESITY (E REISIN, SECTION EDITOR) Pharmacologic Treatment Options for Obesity: What Is Old Is New Again Donna H. Ryan & George A. Bray Published online: 28 April 2013 # Springer Science+Business Media New York 2013 Abstract After a long period of failure in development, two new medications (phentermine/topiramate ER – Qsymia™ and lorcaserin – Belviq®) have been approved by the US Food and Drug Administration for long-term weight management in persons with obesity (BMI ≥ 30 kg/m 2 ) or in overweight persons (BMI ≥ 27 kg/m 2 ) with comorbidities. Another medi- cation, bupropion/naltrexone, is undertaking a cardiovascular outcomes trial and an analysis in 2014 will determine its approval and release. The most widely prescribed drug for obesity, phentermine, used since 1959 for short-term weight management, has been released in a new formulation. This paper reviews these new medications, and other important events in the landscape for management of obesity, with an eye to the interests of physicians who manage hypertension. All the new drugs under discussion are re-fittings of old agents or fresh approaches to old targets; thus, what is old is new again in the pharmacotherapy of obesity. Keywords Obesity . Hypertension . Pharmacotherapy . Obesity treatment . Medications for obesity . Phentermine . Topiramate . Topiramate ER . Lorcaserin . Naltrexone . Bupropion . Qsymia . Belviq . Contrave . Suprenza Introduction Recent events have changed the landscape for managing obesity. First, there is a growing appreciation that modest weight loss (5–10 % from baseline) is achievable, sustainable and is associated with health benefits. With observation of more than 2,500 diabetic subjects in a intensive lifestyle intervention, Look AHEAD has demonstrated the ability to produce modest weight loss and sustain it over four years [1, 2]. That weight loss had benefits regarding risk factors [1, 2], sleep apnea [3], urinary incontinence [4], mobility [5] and symptoms of depression [6]. Further, the intervention reduced medication use and costs [7]. In response to a grow- ing appreciation of the impact of obesity on morbidity and health care costs, and the health and potential cost benefits of modest weight loss, the Center for Medicare Services (CMS) announced in 2012 that reimbursement would be provided for up to 14 sessions of intensive behavioral therapy for obesity, when delivered by primary care physicians [8]. Surgery for obesity is being more widely implemented across the US; The Swedish Obese Subjects study has shown that compared to usual care, bariatric surgery is associated with long-term reduction in overall mortality, and decreased incidence of diabetes, myocardial infarction, stroke and cancer in women [9]. The diabetes remission or “reversal” rate following vari- ous types of bariatric surgeries has garnered attention [10–12] in the face of a diabetes epidemic, and this treatment may be implemented more often for patients with that disease. And, finally, at long last, there appears to be a new appreciation of the need for medications to aid patients in their attempts to achieve weight loss and related health benefits and the US Food and Drug Administration (FDA) approval and release of two new medications for weight loss in 2012. Medications for the treatment of obesity have an unfortu- nate history that has been a barrier to rapid development of safe and effective drugs [13]. The “halo” around using medications to help patients lose weight has been tarnished on account of these events. Sibutramine was removed from the market in 2012 because of increased risk for cardio- vascular events in patients with pre-existing cardiovascular disease. Fenfluramine and dexfenfluramine were associated with cardiac valvulopathy and removed from the market in 1997. Many drugs failed in development for lack of efficacy D. H. Ryan : G. A. Bray (*) Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA 70808, USA e-mail: brayga@pbrc.edu D. H. Ryan e-mail: ryandh@pbrc.edu Curr Hypertens Rep (2013) 15:182–189 DOI 10.1007/s11906-013-0343-6