Is There a Case for Anti-Obesity Drugs?

This morning, I am presenting at the 23rd Scientific Meeting of the International Society of Hypertension here in Vancouver.

Readers may know that my research career started out in hypertension and it so happens that the first major international conference that I ever attended outside of Germany was the 1988 ISH meeting in Kyoto, Japan. Since then, I don’t believe I have ever missed an ISH meeting, so I guess being here in Vancouver for ISH 2010 is not entirely unexpected.

At this year’s meeting, the Program Committee invited me to present a state-of-the-art overview on the evidence in favor of pharmacotherapy for obesity.

This of course is not a happy chapter, given the past history of anti-obesity drugs and the recent FDA advisories on Qnexa, sibutramine and lorcaserin. Despite pouring billions into anti-obesity drug development, the Holy Grail of highly effective and safe pharmacotherapy for obesity appears elusive.

Some, like the FDA’s Eric Coleman, believe that the biology of ingestive behaviour may simply be so complex and critical to survival that tampering with it is nigh impossible.

I, on the other hand, appear far more optimistic that eventually treatments will be found. They may not work for everyone with excess weight and they will have side effect profiles that require careful monitoring and management, but that only puts them on par with treatments for other complex disorders.

I recall, how when angiotensin converting enzyme (ACE) inhibitors were first introduced, we had to do “captopril tests” in our offices because of the fear of catastrophic kidney failure – none of which eventually posed to be a problem in clinical practice. Once doctors learnt how to use these drugs in the right patients, the medications turned out to be largely unproblematic.

I also remember how the widespread use of nifidipine capsules sometimes resulted in precipitous falls in blood pressure – a problem that essentially no longer exists given the slower onset of action of “modern” calcium antagonists.

Sure, occasionally both companies and regulators will get it wrong, and as in the recent case of Avandia, drugs will be pulled off the market. This is of course far less a problem in diabetes, where we have ample pharmacological alternatives, than for obesity, where we are are limited to only two medications (only one in Europe).

As blogged before, I do not think we will ever have an obesity drug that is as effective for preventing social overeating, mindless eating, homeostatic hyperphagia, food addiction, binge eating disorder, or combatting the obesogenic effects of atypical antipsychotics – but I do think that anti-obesity drugs can be found for some of these distinct indications.

In the meantime it seems that surgeons will continue to have a field day with bariatric surgery, at least for the next decade or so.

Unfortunately, there are no shortcuts in drug development and, if anything, regulatory requirements for anti-obesity drugs are likely to get even tougher.

While I am all for regulation and consumer protection, I also strongly believe that protecting people who misuse treatments not intended for them, should stand behind making effective drugs accessible to those who genuinely need them.

AMS
Vancouver, BC

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