Alternative Weight Loss Medications to Orlistat

Primary Recommendation: Phentermine

The American Gastroenterological Association suggests phentermine as a cost-effective alternative to orlistat, with a recommended starting dose of 15 mg daily, and careful monitoring of blood pressure and heart rate 1, 2
Phentermine has demonstrated efficacy with 6.0 kg weight loss at 28 weeks and 46% of patients achieving ≥5% weight loss, with a flexible dosing regimen starting as low as 8 mg three times daily or 15-37.5 mg once daily 1, 2

The American Gastroenterological Association recommends starting with low-dose phentermine (8 mg up to 3 times daily or 15 mg once daily) to assess tolerability, particularly in patients with multiple medications 1
Monitoring of blood pressure and heart rate is crucial at baseline and periodically, as phentermine causes mild sympathomimetic effects 1, 3

Naltrexone-Bupropion ER (Contrave) achieves 4.8% weight loss at 56 weeks compared to placebo, and may be beneficial for patients with depression, but requires dose escalation and blood pressure monitoring 5, 2, 3
Phentermine-Topiramate ER (Qsymia) is the most effective option with 6.6-9.8% weight loss at one year, but is more expensive and requires a REMS program due to teratogenicity risk 6, 7, 5

The American Gastroenterological Association advises caution when using phentermine with sertraline, but it is not an absolute contraindication, and phentermine should not be used with MAOIs or other sympathomimetic amines 1, 4
Naltrexone-Bupropion ER (Contrave) is contraindicated in patients with seizure disorders or concomitant opioid medications 2, 3

The American Gastroenterological Association recommends assessing efficacy at monthly intervals for the first 3 months, then every 3 months, and discontinuing medication if <5% weight loss at 12 weeks 5, 2
Monitoring of blood pressure and heart rate is essential with phentermine-containing medications, and patients should continue lifestyle modifications (reduced-calorie diet and physical activity) as medications are adjuncts, not monotherapy 1, 3, 5